Respiratory Case Study

Here's another case study from the archive vault at the hospital I worked at for so many years. Again, I want to stress these are typical for people who smoke for several years. I saw thousands of patients just like this one.

We had a 62 year-old male present with coronary artery disease. He had just returned from the OR where he had coronary artery bypass surgery (CABG) X 4 arteries. We weaned him off the ventilator within a few hours of arriving to the ICU. He had no family history of heart disease, led an active lifestyle but became fatigued with exertion in the last couple of years, and smoked about a pack of cigarettes per day for 40 years.

Once he came off life-support, we began therapy designed to help his chest get used to taking deep breaths. It's important for the post-op patient to take deep breaths, otherwise they can get a nasty case of pneumonia. This patient did fairly well, he could take a pretty deep breath for someone who just had his chest completely opened up a few hours earlier.

He was eventually discharged to the cardiac ward. However, the next day, his oxygen requirements increased greatly. He began to wheeze and became short of breath. We realized his heart was in some kind of failure, so we put him on a breathing machine that would help him breathe during the day and night, but it didn't require a breathing tube. It fit on his face via tight fitting mask. This is called "bipap" therapy.

After about 4 days, things started to normalize. But not before he had utilized $100,000's in cardiopulmonary services, pharmaceuticals, physican expenses, hospital procedures and the like. What was supposed to be a non-complicated bypass surgery had turned into a nightmare for him and his family.

So why was he in this boat to begin with? What was the initial cause of his coronary artery disease? You guessed it, his smoking. He had no other contributing risk factors, no family history, no high cholesterol, nothing. He just smoked.

Think of it this way. Lets say each pack of cigarettes cost him on average $2.50 over that 40 year time period. Now multiply that by 356 days and then by 40 years. You get $35,600. Now add in the $300,000 in hospital expenses that were incurred and you get an average price per pack of $23.00. If smoking were that expensive would people buy them? Sure some would, but not as many. That is what you call the hidden cost of cigarettes. Now add in the lost productivity, pre-surgical testing and physician office visits, along with the post-surgical rehab he had to go through and the cost goes up even more.

Again, this isn't a fringe example of how smoking affects a person's health. It is very common place, albeit, most bypass surgeries aren't complicated. Despite this, even the uncomplicated bypass surgeries are costly and carry with them great risk. Why add that risk to your health profile? Better to just quit now and not take any further chances.

Pulmonary Case Studies

I have been asked by many to start including actual case studies from my personal hospital experience. I will limit these cases to those that just involve patients who had smoking related diseases, although, I may venture off every once in a while to talk about very unusual to interesting cases. I may even ask questions to see if you can figure out what may have happened to the patient.

Here's a quick case study off the top of my mind. We had a 58 y/o white male present with shortness of breath. His lung sounds included lots of crackles and wheezing, with a prolonged expiratory phase. His respiratory rate was > 25. He quit smoking 1 year prior to this admission, but had smoked 1 - 1.5 packs of cigarettes per day for 40 years. He had spiked a temperature at 101.4 F the night before. His ankles had 1+ edema (swelling). He had a history of 2 previous heart attacks (AMI). He was not a candidate for heart surgery, due to his poor baseline respiratory status. He was diagnosed with Stage 4 emphysema and was dependent on a multiple of inhalers, as well as, continuous nocturnal bipap.

This gentleman was the nicest guy around. We loved seeing him in the hospital but were sad because we only saw him as a patient, rather than a visitor. He is what you call a "frequent flyer". In other words, he found himself in our ER frequently throughout the year with the same old symptoms. His hospital stays would typically last about 10 days. His diagnosis was always the same:

1) COPD (emphysema)
2) Community acquired pneumonia
3) Congetive heart failure
4) Ischemic heart disease
5) Hypertension (high blood pressure)
6) Acute respiratory failure
7) Chronic respiratory failure

Here is an example of someone's body not tolerating the effects of a 40 pack year smoking history very well. I could also give you an example of someone who smoked just as much, but didn't have nearly the physiological devastation that this man had.

But the point is, you never know how your body will respond over time to the smoking. Which person will you turn into? Patient A who needed a machine at night to ensure he didn't stop breathing when he was asleep and continuous oxygen the rest of the time, or the other patient whose body faired a little better?

Hard core smokers are quick to point out lots of patient B examples, and tend to ignore or even deny the existence of the over couple hundred thousand patients a year that die due to smoking related illnesses. It's important to drive home the realism of smoking related disease, as often times, this is the only thing people will listen to.

I hope to share even more real life case studies in the future to offset the hum-drum nature of literature review.