A case of critical management of ILD

M. Bakyalakshmi¹, Subadhra Devi², Maha Lakshmi

¹Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

A 41-year-old male with underlying comorbidities, including type II diabetes mellitus, presented with progressive dyspnea on exertion, chest discomfort, and episodes of hemoptysis. During referral, the patient underwent bronchoscopy with bronchoalveolar lavage for diagnostic evaluation. On admission, radiological investigations revealed diffuse reticular opacities with interstitial septal thickening and traction bronchiectasis involving bilateral lung fields, showing subpleural and lower lobe predominance, along with reactive mediastinal lymphadenopathy. The patient developed significant respiratory compromise, necessitating admission to the intensive care unit and initiation of non-invasive ventilatory support. This case highlights the importance of early recognition, comprehensive diagnostic evaluation, and prompt respiratory support in patients presenting with severe interstitial lung involvement and acute respiratory distress.

Introduction

Interstitial Lung Disease (ILD) refers to a heterogeneous group of disorders characterized by inflammation and/or fibrosis of the lung interstitium, the tissue surrounding the alveoli and pulmonary capillaries. These conditions lead to impaired gas exchange, reduced lung compliance, and progressive respiratory dysfunction. ILDs may result from known causes such as occupational and environmental exposures, autoimmune diseases, drug toxicity, infections, or maybe idiopathic, as seen in idiopathic pulmonary fibrosis. Clinically, patients often presented with progressive dyspnea, dry cough, and reduced exercise tolerance. Early recognition and appropriate management are essential to slow disease progression and improve quality of life.

A 41-year-old male with a known history of type II diabetes mellitus presented with progressive dyspnea on exertion, chest discomfort, and episodes of hemoptysis. During transit, he underwent bronchoscopy with bronchoalveolar lavage for diagnostic evaluation. On admission, radiological investigations revealed reticular opacities with interstitial septal thickening and traction bronchiectasis involving bilateral lung fields, predominantly in the subpleural regions and lower lobes, along with reactive mediastinal lymphadenopathy. Owing to worsening respiratory status, the patient required intensive care management with non-invasive ventilatory support.

Social History

He does not have any social history of cigarette smoking or alcohol addiction.

Allergies

No known medicine or environmental allergies

Past Medical History

Type II Diabetes Mellitus

Physical Examination

Vital signs:

Temp: 101.3-degree F
HR: 126/min
RR: 50/min
BP: 130/70 mmHg
Spo2: 94%With 40%

A: On NIV Support

B: Dyspneic, Tachypneic, Tachycardia, Skin eruption noted on anterior chest, PEEP and FiO2 titrate to adequate oxygenation

C: All peripheral pulse present.HR 126/min BP 130/700 mm Hg, No pallor, icterus, or pedal edema

Neurological Examination: Assessed the level of consciousness, pain

Sedation and analgesia: Titrate for comfort and safety.

Relevant Investigation

Alanine Aminotransferase (ALT/SGPT)	21.8 U/L
Calcium Serum	8.7 mg/dL
Creatinine	0.61 mg/dL
NT Pro BNP (N - Terminal B Type)	246.4
D Dimer	600 g/dl
Glucose	193 mg/dL
Indirect Bilirubin	0.75 mg/dL
K +	6.5 mmol/L
Magnesium	1.91 mg/dL
Phosphorous	3.6 mg/dL
Potassium	4.21 mmol/L
Sodium	140 mmol/L
Total Protein	5.38 g/dl
Urea Serum	14.98 mg/dL
Control (PT)	11.3 Seconds
Hematocrit	32 %
Hemoglobin	12.0g/dl
Packed Cell Volume (PCV)	37.3 %
Platelet Count	136000 cells/µl
Test (PT)	31.2 Seconds
Total RBC Count	3.37 10^9/cumm
INR	2.79
CA++(7.4)	0.95 mmol/L
Total Bilirubin	2.83 mg/dL

Imaging examination

CT Thorax

Reticular opacity with interstitial septal thickening with traction bronchiectasis in bilateral lung fields with subpleural and lower lobe predominance, Reactive mediastinal lymphadenopathy

Diagnosis

Acute Exacerbation of Progressive Intestial Lung Disease Respiratory Failure

Management

On admission the patient was tachypneic, dyspneic, tachycardia, SpO2: 96% with NIV. He was shifted to IMCU for further management. CT scan pulmonary angiogram showed no evidence of pulmonary thromboembolism, dilated main pulmonary artery. His respiratory failure was managed with non-invasive ventilation support. He was treated with bronchodilators, analgesics, nebulization, PPI, corticosteroids and other supportive measures.

Outcome

The patient is conscious, afebrile, dyspneic, and tachypneic. Vital signs show a heart rate (HR) of 130 beats per minute and an SpO₂ of 96% on 40% FiO₂. The patient is on non‑invasive ventilation (NIV) support. ECMO / Lung transplantation / high risk mortality was explained to patient attenders. Patient condition, nature of the disease, progressive illness, referral to higher centers

Discharge Advice medication

S. No	Drug	Dose
1	Tab. Pantocid	40 mg
2	Tab. Taxim o	200 mg
3	Tab. Ursocol	300 mg
4	Tab. N. Taur	500 mg
5	Tab. Nodosis	500 mg
6	Tab. Bunpro forte

Medical Aspects

Elsewhere bronchoscopy was performed and Acinetobacter grew in culture. He was diagnosed with fibrotic interstitial lung disease (ILD) and treated with steroids. A rheumatologist’s opinion was obtained, and analgesics were started, which the patient did not tolerate. As his symptoms progressed along with low oxygen saturation,

Infection Control

Antibiotics – Broad-spectrum antibiotics to cover biliary pathogens.

Supportive Care

Fluid management – Careful fluid resuscitation to maintain organ perfusion.

Organ support – Support for liver and renal dysfunction.

Nutritional support – Adequate nutrition to support recovery.

Skilled Nursing Care Plan

Comprehensive Monitoring and Assessment

Vital Signs: Hourly monitoring of temperature, BP, HR, RR, and SpO₂.
Neurological Checks: Regular GCS assessment for altered sensorium.
Cardiac Monitoring: Continuous ECG monitoring post-arrest.
Renal Function: Monitor urine output; report oliguria/anuria.
Lab Review: Ongoing assessment of WBC, LFTs, RFTs, ABG, and coagulation profile.

Medication and IV Therapy

IV Antibiotics: Timely administration as per prescription.
Fluid Resuscitation: Administer IV fluids/blood products per protocol.
Vasopressors/Inotropes: Administer and titrate if ordered for hemodynamic support.
Pain and Fever Management: Administer antipyretics and analgesics as needed.

Infection Prevention and Control

Aseptic Technique: Strict during all procedures (e.g., catheter care, IV lines).
Isolation Precautions: If required due to infection risk.
Wound/Line Site Monitoring: Inspect for signs of local infection.

Supportive and Specialized Care

Respiratory Support: Oxygen therapy, suctioning, or ventilator care if intubated.
Nutrition: Monitor for NPO status or initiate enteral/parenteral nutrition.
Renal Support: Monitor for dialysis needs and assist during procedures.

Patient Safety and Psychosocial Support

Fall Prevention: Use of side rails, bed alarms for altered sensorium.
Family Education: Communicate patient status and care plan clearly.
Emotional Support: Reassure patients (if conscious) and provide holistic care.

Conclusion

The patient’s clinical course reflects a rapidly progressive and life-threatening condition, likely ascending cholangitis complicated by sepsis, multi-organ dysfunction, and cardiac arrest. Despite the severity of the presentation, the preservation of cardiac function post-arrest and timely identification of biliary obstruction provided a critical opportunity for targeted intervention.

Early recognition, aggressive antibiotic therapy, biliary decompression, and comprehensive supportive care are essential to improving outcomes in such complex cases. This case underscores the importance of prompt multidisciplinary management in patients with signs of systemic infection and biliary obstruction.

A case of critical management of ILD

A case of critical management of ILD

M. Bakyalakshmi1, Subadhra Devi2, Maha Lakshmi

Nightingale Journals

M. Bakyalakshmi¹, Subadhra Devi², Maha Lakshmi