66-Year-Old Patient Recovers from Lung Injury with Effective Medication for Cough, Phlegm, and Shortness of Breath

Medical Disclaimer: This article is intended solely for educational and informational purposes. To protect patient privacy, all identifying details have been altered or anonymized. The content reflects a real-world clinical scenario but has been adapted to ensure confidentiality.

Overview: Recovery from Diffuse Lung Disease in an Elderly Patient

A 66-year-old male presented with persistent cough, excessive phlegm production, and increasing shortness of breath that had begun to severely disrupt his daily routine and sleep quality. After thorough diagnostic evaluation at the First Affiliated Hospital of Harbin Medical University in March 2022, he was diagnosed with diffuse bilateral lung disease—a common form of pulmonary injury often linked to infection or environmental exposure. With timely intervention including oxygen therapy and targeted medications, the patient experienced significant symptom relief and steady recovery over a 10-day inpatient treatment period.

Patient Profile & Clinical Diagnosis

Age & Gender: 66-year-old maleDiagnosis: Bilateral diffuse lung lesions (pulmonary injury)Hospital: First Affiliated Hospital of Harbin Medical UniversityTreatment Period: March 2022Treatment Plan: Oxygen supplementation, intravenous cefoxitin sodium, and nebulized ambroxol hydrochlorideDuration of Care: 10 days inpatientOutcome: Marked improvement in respiratory symptoms and overall health status

Initial Assessment: Recognizing the Signs of Pulmonary Damage

The patient reported experiencing a worsening cough accompanied by thick white frothy sputum—approximately 100 mL per day—for about one week prior to admission. He also described progressive shortness of breath, especially during physical activity, along with right-sided back pain triggered by deep breathing or coughing. Nighttime discomfort disrupted his sleep, and fatigue became increasingly noticeable.

Chest CT imaging revealed consolidation in the lower right lung, indicating localized inflammation or infection contributing to broader lung dysfunction. Based on these findings, clinicians suspected an infectious origin leading to diffuse alveolar damage—a condition where widespread inflammation impairs gas exchange and respiratory efficiency.

Comprehensive Treatment Approach

Upon admission, the patient appeared fatigued with visible cyanosis around the lips, suggesting low blood oxygen levels. A bronchoscopy confirmed the presence of abundant white foamy secretions in the airways, reinforcing the diagnosis of active pulmonary involvement.

Arterial blood gas analysis showed decreased oxygen saturation, while laboratory tests indicated elevated white blood cell and neutrophil counts—clear markers of systemic infection. Given this evidence, the medical team concluded that the diffuse lung changes were likely infection-driven.

Therapeutic Strategy

To stabilize the patient's condition, a multi-modal treatment plan was implemented:

Oxygen Therapy: Administered continuously to correct hypoxemia and support vital organ function.
Intravenous Antibiotics: Cefoxitin sodium was prescribed to target bacterial pathogens commonly associated with respiratory infections.
Nebulized Mucolytic Therapy: Ambroxol hydrochloride solution was used via inhalation to thin mucus, ease expectoration, and improve airway clearance.

This combination addressed both the underlying infection and the symptomatic burden of retained secretions, providing a foundation for faster healing.

Positive Treatment Outcomes

Within days of starting therapy, the patient began to show measurable improvements. His energy levels increased, lip cyanosis diminished, and breathing became noticeably easier. The intensity of chest discomfort reduced significantly, and family members observed a return of appetite and better nighttime rest.

After 10 days of consistent care, follow-up lab work showed normalization of white blood cell and neutrophil counts, indicating resolution of acute infection. Imaging reassessment supported clinical progress, showing partial regression of lung infiltrates. With improved functional capacity and stable vitals, the patient was discharged with clear instructions for ongoing self-care and monitoring.

He expressed high satisfaction with the treatment outcome and reported feeling more confident in managing his health moving forward.

Ongoing Care Recommendations

While the patient achieved excellent recovery, long-term wellness depends on proactive lifestyle choices and vigilance. Key recommendations include:

Avoid Environmental Irritants: Steer clear of secondhand smoke, polluted air, dust, and chemical fumes that can irritate the lungs.
Maintain Nutritional Balance: Focus on a diet rich in fresh fruits, vegetables, whole grains, and lean proteins. Avoid spoiled or processed foods, and limit intake of greasy, spicy, or heavily seasoned meals.
Support Immune Health: Engage in moderate exercise such as walking or light aerobic activities tailored to individual fitness levels. Regular physical activity enhances lung capacity and immune resilience.
Monitor Symptoms: Be alert for any recurrence of cough, phlegm production, wheezing, or breathlessness. Early medical consultation can prevent minor issues from progressing into serious complications.

Clinical Insights: The Importance of Early Intervention

This case highlights how untreated or delayed treatment of lung infections can lead to extensive pulmonary damage, particularly in older adults who may already have compromised respiratory reserves. The development of diffuse lung lesions underscores the vulnerability of aging lungs to inflammatory processes.

Early detection is critical. Routine check-ups, especially for seniors or individuals with a history of respiratory conditions, allow for prompt identification of abnormalities. Persistent cough, unexplained fatigue, or changes in breathing patterns should never be ignored—they may signal the onset of a treatable but potentially serious condition.

With appropriate diagnostics and a well-coordinated treatment strategy, even advanced cases of lung injury can see substantial recovery. Empowering patients with knowledge and preventive tools remains a cornerstone of effective pulmonary care.