he weekend quiet of the ICU was broken by the
familiar loud series of beeps and buzzes. The respiratory therapist looked at
her watch. ''He's not going to make it for even 10 minutes today.'' She strode
quickly into the room. A young man lay in the bed surrounded by equipment. His
face gleamed with sweat; his large abdomen heaved. A monitor showed that his
heart was beating rapidly. His breaths were fast and harsh-sounding as he
struggled to get air through the ''trach'' -- the white plastic tube that
protruded from his throat. His wife looked up at us, tired, worried.
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The respiratory therapist moved quickly to reattach the man to the
ventilator, which immediately took over his breathing. We had been trying, once
again, to see if the young man could be weaned from the vent -- if he could
breathe without the help of the machine on which he had depended since he came
to the hospital a few weeks earlier.
''I can't breathe,'' he whispered the day he arrived at the emergency room.
He'd had a cold and a cough, but now he felt out of breath. ''Like I ran up the
stairs,'' he gasped, ''but all the time.'' He had no fevers, no chills; just a
headache and this difficulty breathing. And he was tired, really tired. He
hadn't slept well for several months. But these last few days, he couldn't stay
awake. ''I couldn't even drive here today,'' he admitted softly.
He was just 23 years old. He had no doctor -- he didn't think he needed one.
He worked as a mechanic and lived with his wife and new son. As he told his
story to the medical team, his eyes closed. The young E.R. doctor shook his
shoulder. ''I'm sorry,'' he stammered. ''I just can't stay awake.''
The patient was quite obese. He was average height, maybe 5-foot-7, but he
probably weighed 350 pounds. He had curly dark hair and a sweet face, round and
smooth. His plaid, short-sleeved shirt was drenched with sweat.
Investigation
On examination, his heart was beating rapidly, and he breathed with quick,
noisy breaths. Despite his effort, the meter on his finger showed that the
oxygen in his blood was low, at 88 percent (100 percent is normal). His lungs
were clear at the top two-thirds but silent at the bases: was it an infection or
just his size that kept him from breathing deeply? Blood tests suggested that it
was an infection, and a chest X-ray confirmed that he had pneumonia in both
lungs.
A third test explained his unusual sleepiness. It showed that the patient had
high levels of carbon dioxide in his blood. Normally, you breathe in oxygen and
breathe out carbon dioxide. Elevated levels of carbon dioxide make you sleepy.
Our patient had what is quaintly called Pickwickian syndrome, so named after a
character in Charles Dickens's ''Pickwick Papers.'' Those with this syndrome,
like Joe, the character in the book, and like our own patient, are obese and,
because of that, can't clear their lungs of carbon dioxide. Also known as
obesity hypoventilation syndrome, it was first described in the medical
literature in the 1950's and is now a widely recognized complication of morbid
obesity.
It was clear to us that the pneumonia was making his Pickwickian syndrome
worse. His body was working hard to fight the infection. But the harder the body
works, the more carbon dioxide it makes, so the sleepier the patient became. If
his pneumonia didn't resolve quickly, he would need a ventilator to help him
breathe. Sure enough, after two days, he was intubated.
Slowly, with the help of antibiotics and the ventilator, he came through a
terrible pneumonia. His fever came down, his blood pressure came up and finally
his lungs began to clear. But now it seemed his recovery was at a standstill. He
should have been able to come off the ventilator. Yet he couldn't. Moreover, he
continued to run a low-grade fever. Clearly, something else was going on. That
morning on rounds, we considered the possibilities.
Infection was certainly the most likely cause of his fever, but his lungs
were working better. Did he now have another infection? If so, where? Or could
it be something else? Drugs can cause a fever as part of an allergic type of
reaction, and he was on many. Tumors can as well, though we had no reason to
think that this young man had a tumor.
Blood clots are always a risk in those who have extended illnesses. Although
our patient had been on blood thinners throughout his hospital stay to prevent
these clots, they remained a possibility. Finally there was atelectasis, a
partial collapse of the lung. This is a common concern in hospitalized patients
whose immobility and pain discourage them from taking the deep breaths that keep
lungs working well. Still, atelectasis didn't usually cause a fever like the one
our patient had.