Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive dyspnea, orthopnea, and morning headaches. History significant for ALS with recent decline in bulbar and limb function. Reports increased fatigue, nocturnal awakenings, and daytime somnolence. No acute chest pain or fever. Symptoms consistent with ventilatory pump failure secondary to neuromuscular weakness.
Clinical Examination Findings
General: Patient appears fatigued, tachypneic at rest, using accessory muscles for respiration. Respiratory: Shallow breathing pattern, paradoxical abdominal movement noted in supine position. Auscultation: Decreased breath sounds bilaterally, no wheezing or crackles. Neurological: Significant proximal and distal muscle atrophy, fasciculations present, weak cough reflex. Vital signs: SpO2 [X]% on room air, RR [X] bpm, tachycardia noted.
Treatment Protocol
Initiate non-invasive ventilation (NIV/BiPAP) to support respiratory effort. Monitor arterial blood gases (ABG) and nocturnal pulse oximetry. Consider early discussion regarding goals of care, including invasive mechanical ventilation and tracheostomy. Referral to pulmonology and palliative care for symptom management. Ensure aggressive pulmonary hygiene and cough assist protocols.