Respiratory Cases I


22 yo male, spinal fracture


Patient Chart
VC is a 22-year-old male who suffered a C3 spinal cord fracture three years ago as a result of a diving accident. Following the diving accident, VC spent a month in an acute care hospital. Once his condition stabilized, he was transferred to a rehabilitation facility for four months. He currently resides in a long-term care facility that specializes in quadriplegic care.

He has a #8 cuffed tracheostomy tube with an inner cannula. Throughout the day, the cuff is maintained as deflated so he can vocalize. He is on a portable ventilator with following settings: Mode: volume control-assist/control Rate: 14 Tidal volume: 650 mL FiO2: .21 He has been maintained on these settings for more than a year without incident. However, over the past two days, his condition has changed. He is complaining of shortness of breath and ‘uneasiness.’ His heart rate is 106 (high for him) and his temperature is 101.6o F. His SpO2 in 88%. Current assessment reveals an anxious young adult male with rhonchi on exhalation in both bases. His principal caregiver reports that she has been suctioning him for moderate amounts of thick, dark yellow sputum.
Heart Rate:
Blood Pressure: /

Auscultation:




Diagnosis
Which of the following is KB’s most likely diagnosis?