Possible silent hypoxemia in a COVID-19 patient: A case report

Abstract

Introduction: It has been hypothesized that silent hypoxemia is the cause of rapid progressive respiratory failure with severe hypoxia that occurs in some COVID-19 patients without warning.

Presentation of case: A 60-year-old male presented cough without any breathing difficulty. Vital signs showed blood pressure 130/75 mmHg, pulse 84x/minute, respiratory rate (RR) 21x/minute, body temperature 36.5C, and oxygen saturation (SpO2) 75% on room air. RT-PCR for COVID-19 were positive. On third day, he complained of worsening of breath shortness, but his RR was still normal (22x/minute) with SpO2 of 98% on 3 L/minute oxygen via nasal cannula. On fifth day, he experienced severe shortness of breath with RR 38x/minute. He was then intubated using a synchronized intermittent mandatory ventilation. Blood gas analysis showed pH 7.54, PaO2 58.9 mmHg, PaCO2 31.1 mmHg, HCO3 26.9mEq/L, SaO2 94.7%, FiO2 30%, and P/F ratio 196 mmHg. On eighth day, his condition deteriorated with blood pressure 80/40 mmHg with norepinephrine support, pulse 109x/minute, and SpO2 72% with ventilator. He experienced cardiac arrest and underwent basic life support, then resumed strained breathing with return of spontaneous circulation. Blood gas analysis showed pH 7.07, PaO2 58.1 mmHg, PaCO2 108.9 mmHg, HCO3 32.1mEq/L, SaO2 78.7%, FiO2 90%, and P/F ratio 65 mmHg. Three hours later, he suffered cardiac arrest again and eventually died.

Discussion: Possible mechanisms of silent hypoxemia are V/Q mismatch, intrapulmonary shunting, and intravascular microthrombi.

Conclusions: Silent hypoxemia might be considered as an early sign of deterioration of COVID-19 patients, thus, physician may be able to intervene early and decrease its morbidity and mortality.

Keywords: ARDS; COVID-19; Early sign of deterioration; Respiratory failure with severe hypoxia; Silent hypoxemia.

Fig. 1

Chest x-rays: a) on the admission day indicated bilateral pneumonia, which is not compatible with the relatively slight clinical manifestations of patient, b) on the third day, and c) on the eight day also showed bilateral pneumonia.

Fig. 2

Clinical picture and disease progression of case. ROSC, return of spontaneous circulation; iv, intravenous; †, died. Y-axis scale: SBP, systolic blood pressure (mmHg, violet triangle); HR, heart rate (times/min, red circle); RR, respiratory rate (times/min, green circle); T, temperature (°C, blue circle); SpO₂, oxygen saturation (%, yellow circle). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)