Interstitial densities following radiotherapy.
After admission on June 30, R.D. remained intubated, and he continued on i.v. steroids, heparin, and warfarin. Nutritional needs were met with a nasointestinal feeding tube and nutritional preparations. He was alert and oriented and communicated appropriately with family and staff via written notes. The patient and his wife wanted to try a ventilator for a period of time before considering a "No CPR" order. His chest wound continued to be open but was healing slowly. Over the next few days, R.D. became more hypoxic with increased respiratory effort and required sedation and assist-control ventilator settings. On July 1, he required more sedation to keep him comfortable, but remained alert and oriented and continued to communicate with his family. On July 3, he sat in a chair for 1.5 hours. On July 4, he developed a large right pneumothorax and a chest tube was placed. He continued to indicate that he was short of breath. The patient remained very anxious and was started on a propofol drip. Later that day, his wife had a discussion with the healthcare team; the decision was made not to resuscitate the patient. On July 5, R.D.'s agitation increased and he was started on additional propofol for sedation, vecuronium bromide to facilitate breathing, and lorazepam i.v. push for relaxation. R.D.'s oxygenation-ventilation status declined through the night. After a discussion between the family and the physician on July 6, life support was withdrawn, and R.D. died later that day. Some of the factors that may have led to R.D.'s radiation-induced pneumonitis include his prior history of smoking as well as his former occupation as a coal miner. He received 15 radiation treatments to his chest area. He also received chemotherapy, including the drug paclitaxel; this combination may have contributed to his radiation-induced pneumonitis. The pneumonitis led to his immunosuppressed condition. R.D.'s superior vena cava syndrome led to the formation of clots for which he received heparin and coumadin. He received steroids to reduce the inflammation from the mediastinoscopy site and in his lung tissues. All of these factors contributed to R.D.'s outcome.
McManamen
Lynd
L
Deaconess Billings Clinic, Billings, MT, USA. lmcmanamen@billingsclinic.org
D002289:Carcinoma, Non-Small-Cell Lung / Q000532:radiotherapy*; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D017564:Radiation Pneumonitis / Q000000981:diagnostic imaging / Q000209:etiology*; D011859:Radiography; D011879:Radiotherapy Dosage