challenging cases in pulmonary yright (and critical care)

Education is at the heart of patient care.

A teaching hospital of Harvard Medical School

ChallengingCasesinPulmonary(andCriticalCare)

RichardM.Schwartzstein,MDChief, Division of Pulmonary, Critical Care and Sleep Medicine

Beth Israel Deaconess Medical CenterEllen and Melvin Gordon Professor of Medicine

Harvard Medical School

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A teaching hospital ofHarvard Medical School

Case1A21yearoldcollegestudentcomestoseeyouaboutapositivePPD.OneofherroommateswasdiagnosedwithM.Tuberculosiseightweeksago.AthirdroommatehadanegativePPDwithapositivecontrol.Shewantstoknowwhatthepositiveskintestmeansandwhatsheneedstodoaboutit.

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Case1- continuedThepatientfeelscompletelywell.

Herphysicalexamisnormal.

TheCXRisnormal.COPYRIG

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Youtellthepatientthat:1. ShewasexposedtoTBandneedstobetreated

prophylacticallywithINH.2. ShewasinfectedwithTBandneedstobetreated

withINHtocuretheinfection.3. ShewasexposedtoTBanddoesnotneedtobe

treated.4. ShewasinfectedwithTBandneedstobetreated

withthreedrugs.

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Case2A20yearoldcollegestudentpresents6hoursafteringestinganunknownquantityof“extra-strengthTylenol”tablets.Sheiscomplainingofmildnausea.

Onexamsheissomnolentbutcanbearoused.Vitalsignsarenotablefor:BP=110/70, HR=110,RR=14.Theabdomenissoftandwithoutguardingortenderness.

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Case2- Continued• Thereisaconcernthatshemayhavealsotakenvaliumprescribedforafriend.Thepatientisnotbeingverycooperativere:answeringquestions.Shejustbrokeupwithherboyfriendandkeepsmutteringthatshe“wantstodie.”

• ElectrolytesandLFT’sarenormalCOPYRIG

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Yourapproachatthistimeshouldbe:1.Sendtoxicscreenandawaitacetaminophen levelbeforeproceedingfurther

2.LavagestomachwithEwaldtube3.Administer Ipecac4.Administeractivated charcoal5.AdministerN-acetylcysteine

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Case3A40yearold“weekendwarrior”injureshiskneeplayingbasketballwithhisson.Hecollidedwithhissondrivingtothebasketandhitthegroundhard.Hehasright-sidedchestwalltendernessandaswollenleftkneethathurtswhenhewalksonit.

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Case3- Continued• HeisbroughttotheemergencydepartmentofhislocalhospitalwhereaCXRistakenandshowsbilateralhilaradenopathy.ACTscanofthechestandabdomenrevealsnootherabnormalities.

• Onphysicalexam,therearenoenlargedperipheralnodes.Bloodchemistries,LFT’sandCBCareallwithinthenormalrange.

• Untiltoday’sgame,thepatientstateshewasin“perfecthealth.”

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Youshouldadvise:1.ObservationwithrepeatCXRinthreemonths

2.Bronchoscopy3.Mediastinoscopy4.PPD

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Case4A28yearoldmancomestotheemergencydepartmentwithacomplaintof1weekofshortnessofbreathandmildpleuriticchestpain.Hehasahistoryofasthma,butdenieschesttightness.Hefiguredhehadpulledamuscle.

Onexam,therearediminishedbreathsoundsontheright,butnowheezes.CXRshowsalargerightpneumothorax.O2satis97%withoutsupplementaloxygen.

Achesttubeisinsertedtore-expandthelung.

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Case4- ContinuedThirtyminutesafterthelungisre-expanded,thepatientdevelopsacutedyspnea;O2satis85%.

Onphysicalexam,therearediminishedbreathsoundsontheright,althoughbetterthanbeforethechesttubewasinserted.

CXRshowstherightlungisre-expandedbuthasadiffusealveolaropacity.

Thehematocritis39.Thereisnobloodcomingfromthechesttube,andnoapparentairleak.

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Atthispoint,youshould:

1. Intubatethepatientandstartmechanicalventilation

2. Getthepulmonologisttodoabronchoscopytoassessforpulmonaryhemorrhage

3. Givesupplementaloxygenandobservethepatient

4. CheckcardiacenzymesandadministeradiuretictothepatientCOPYRIG

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Case5A62yearoldmanwithCOPDpresentstotheemergencydepartmentwithincreasingshortnessofbreathfortwodays.Duringthistimehehadincreasedcough,wheezing,andsputumproduction.

Onphysicalexamination,heisusingaccessorymusclesofventilationandhisRR=32.Therearediffusewheezesandrhonchi.ABGonroomair:PO2=45,PCO2=55,pH=7.34.

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Case5- ContinuedAsyoudiscussingnebulizertreatmentswiththerespiratorytherapist,thenursecomesuptoyouandsaysshewouldliketoputstartthepatientonsupplementaloxygenbymask.

Therespiratorytherapistlookshorrified.

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Atthispointyoushould:

1.Administersupplementaloxygenalongwithbronchodilators

2.Avoidoxygenbecausethepatientisrelyingupon“hypoxicdrive”tobreathe

3.Immediatelyintubatethepatientandbeginmechanicalventilation

4.PrescribeAtivanfortherespiratorytherapist

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Case6A30yearoldwomanpresentswiththeacuteonsetofshortnessofbreathfourhoursago.Shehasmildchestdiscomfortondeepbreathing.Shesmokescigarettes,hasahistoryofasthma(usuallyassociatedwithexposuretoallergens),andbrokeheranklesixweeksago.

Onexam,sheisanxiousandinmildrespiratorydistress.RR=26, temp.=100.5° Chestrevealsscatteredwheezes.Thepulseoximetershowsasaturationof94%.

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Case6- Continued• ABGonroomair:PO2=70,PCO2=28,pH=7.49.

• TheCXRisclear,althoughthelungsappearhyperinflated.

• AV/Qscanwasperformedbecausepatienthasallergytoradiographiccontrast,anditdemonstratesmultiplesubsegmentalperfusiondefectsontherightandisreadas“lowprobability.”

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WiththeresultsoftheV/Qscaninhand,youshould:

1.Initiatebetaagonistsandsteroids2.Obtainlowerextremityultrasound3.Pre-treatherwithsteroidsandproceedwithacontrast-CT scan

4.Beginanti-coagulation

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Case7A62yearoldmanisbeingtreatedwithPrednisoneandCytoxanforidiopathicpulmonaryfibrosis.HehasshownimprovementinhisCXR,oxygenation,andpulmonaryfunctionoverthecourseofthreemonths.

Sixweeksagoyoubegantotaperhissteroidsfrom40mgqdto20mgqod.COPYRIG

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Case7- ContinuedInthepastweekhehasbeguntocomplainofanon-productivecoughandincreaseddyspnea.

Hedeniesfeverandchestpain.

Onexam,heappearstobeinmildrespiratorydistress.Temp99,BP140/90,HR100,RR22.Chestauscultationisnotableforbibasilarrales,whichhehashadonpriorvisits.

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Case7- ContinuedOxygensaturationis85%onroomair(downfrom92%)andaCXRshowsdiffuseinterstitialmarkings,whichareincreasedcomparedto6weeksago.COP

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Atthispoint,youshoulddowhichofthefollowing:

1.Beginonbroadspectrumantibiotics2.Performabronchoscopy3.Performathoracoscopicbiopsy4.Increasethedoseofsteroids.

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Case8A35yearoldmanpresentswithdyspneaonexertion.Hehasbeeningoodhealthwithnochronicmedicalproblems.Heisactiveandjogs3-4timesaweekfor30minutesatatime.Overthepastseveralmonths,hehasnotedincreasedshortnessofbreathonhisrunsandoccasionallywhencarryingpackagesupstairs.

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Case8- ContinuedOnphysicalexam,thepatientisthinandwellappearing.Hisvitalsignsarenormal.Theoralexamisnotableforafewwhitepatchesonthebuccalmucosa.Thereareafewenlarged,non-tenderposteriorcervicalandaxillarylymphnodes.Thechestisclearwithgoodairmovementbilaterally.CardiacexamrevealsapronouncedP2.Thereisnoperipheraledema.

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Case8- ContinuedAnechocardiogram isperformedandshowsanormalaorticandmitralvalveandleftventricularfunction.Thereismoderatetricuspidregurgitationwithanestimatedpulmonaryarterysystolicpressureof60mmHg.Therightventricleismildlydilated.

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Thepatient’spulmonaryhypertensionismostlikelydueto

1. Elevatedpressuresintheleftheart2. Hypoxemia3. Anacutebloodclotinthelungs4. Changesinthestructureofthepulmonary

arterioles

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Case9Youareprovidingcareforapatientwithpneumonia,cirrhosisandascites.Inthefirst24hoursofthehospitalization,thepatientrequired6LofcrystalloidtosustainanadequateBP.Inthepastday,urineoutputhasdeclinedandthecreatinineisrising.

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Case9- ContinuedAdministrationofa500ccbolusofnormalsalinedoesnotincreaseurineoutput.

Onphysicalexam,BP=100/60,HR90.Theabdomenhasbecomeincreasinglyfirm,butisnon-tender.Thereis2+pittingedemaofthelegs.

TheINRis2.5andthealbuminis1.8.

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1. Administeradiuretic

2. Administeralbumin

3. Performaparacentesis

4. Transfusefreshfrozenplasma(FFP)COPYRIG

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Case10Apatientwithbronchiectasis, worseninglungfunctionandchestradiograph, increasedcough,andweight losscomestoyouforevaluation.

Onphysicalexam,thepatient isthinbutappearscomfortable. BPandHRarenormal;respiratory rateis20.Chestauscultation revealsbilateralrhonchi.

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Case10- continuedHeundergoessputuminduction.ThesputumculturegrowsMycobacteriumaviumcomplex(MAC)onthreeoccasions.

HetellsyouhehadanegativePPD10yearsago.

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1.PlaceaPPD

2.Assumetheorganismisa“colonizer”andignorethefindings

3.Refertopulmonaryforabronchoscopy

4.BegintherapyforMAC

5.Placethepatientinisolationpendingdeterminationofsensitivityoftheorganismtovariousanti-tuberculosisdrugs.

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Case11A65yearoldmancomestoseeyouforfollow-upofchronicdyspnea.Hehasa60pack-yearhistoryofsmokingandanFEV1thatis30%ofpredictedandusessupplementalO2athome.Healsosuffersfromchronicsystolicheartfailureandwasrecentlydiuresedforthiswithsomeimprovementinhisshortnessofbreath.Laboratoryresultslastweekshowed:ABG(2LnasalO2):PaO270,PaCO253,pH7.45.SerumK3.7,Bicarbonate33.Youareconcernedabouthisalkalemiaandeffectonhisbreathing.

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Case11- continued


1. PrescribeCPAPorBiPAP

2. Startacetazolamide(Diamox)

3. Replaceserumpotassium

4. Startprogesterone

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Case12A60yearoldmancomestoseeyouforfollow-upofchronicdyspnea.Hehasa60pack-yearhistoryofsmokingandanFEV1thatis30%ofpredictedandusessupplementalO2athome.Healsosuffersfromchronicsystolicheartfailure.

Laboratoryresultslastweekshowed:ABG(2LnasalO2):PaO270,PaCO234,pH7.41.

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Youconclude:

1. ThelowPaCO2suggestshisexertionaldyspneaismostlikelyduetoheartfailure.

2. ThelowPaCO2suggestshisexertionaldyspneaismostlikelyduetohisCOPD.

3. ThelowPaCO2suggeststhereisaninteractionbetweentheCOPDandheartfailure.

4. Heneedsahigherdoseofsupplementaloxygen

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Case13Oneofyourpatientsis56yearsoldand

asksyouaboutgettingaCTscantoscreenforlungcancer.Hehassmokedcigarettes1packperdayX20years.COP

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Youreply:

1. Yes,Iwillscheduleit.

2. No,ithasnotbeenproventosavelives.

3. No,theextraradiationoutweighsanybenefit.

4. No,itistooexpensive.

5. No,youhaven’tsmokedenoughcigarettestoqualify.

6. Yes,Idoanythingmypatientswant(ittakestoolongtoexplainwhytheyshouldn’thavethetest).

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Case14A22yearoldcollegestudentwithapositivePPDcomestoseeyouabouttreatment.Hehasheardthatheneedstotakeadrugforninemonthstotreatthis,andisdemandingashortercourseoftherapy.

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Yourecommend:

1. Findanotherdoctor.

2. DoublethedoseofINHandtreatfor4months

3. Giverifampinat600mg/dayfor4months

4. GiverifampinandINHfor4months.COPYRIG

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Question15Youarecalledasamedicalconsultanttoseea58yearoldPortuguesespeakingwomanundergoingaliverbiopsy(forpossibleliverabscess)intheinterventionalradiologydepartment.ShehassuddenlydevelopedacuteshortnessofbreathandtheO2sathasdroppedto92%withhighflowoxygenbymask;shedenieschestpain.Onexam,sheappearsveryanxiouswithuseofaccessorymusclesofbreathing.Shehaswheezesonexamwithgoodbreathsoundsbilaterally.

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Case15- continuedAtthispoint,youshould:

1. Intubatethepatient

2. Givemorphineandbronchodilators

3. Startantibiotics

4. GetaCTscanofthechest

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Question16A45yearoldmanisadmittedtoyouwithadiagnosisofpossiblesepsis.Hehasbeenhealthyotherthanforahistoryofhypertension.HerecentlyflewbackfromabusinessmeetinginCalifornia,andhassomeheadcongestion.YoutellhimtogototheEDwhereyouevaluatehim:BPis85/60whichimprovessomewhatwith2Loffluid;BPnow95/70.CXRisclear.WBCis6,000,Hct35.BUN/Creatbeforefluidwas40/1.5.O2satis95%withoutsupplementaloxygen.

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Case16- continuedThenextbestcourseofactionisto:

1. Givesupplementaloxygen

2. Givemorefluid

3. Placeannasogastrictube

4. Getarenalconsult

5. ObtainachestCTscan

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Case17Youareseeinga75yearoldwomanwithahistoryofcoloncancerandlongstandinghypertensionwhocomestoyourofficewith2daysofshortnessofbreathandaswollenleftleg.Onexam,shehasapalpablecordandapositiveHoman’ssign;BPis120/85mmHgwithHR110/min.

Yousendherforaquickechocardiogram,whichshowsanestimatedPApressureof70mmHg.ACTAconfirmssegmentalpulmonaryemboli.

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Case17- continuedOnadmissiontothehospital,youshouldbeconsidering:

1. Thrombolytic therapy

2. Rightheartcatheterization

3. PlacementofanIVCfilter

4. Diuresis

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Case18A69yearoldmanwithCOPDandchronichypercapnia(baselinePCO2=55mmHg)hasbeenintubatedandventilatedfor10daysbecauseofhypercapnicrespiratoryfailureinthesettingofacutebacterialpneumonia.Hehasbeentreatedwithantibioticsandbronchodilators.

Youarenowassessinghimforpossibleremovalfromtheventilatorandsubsequentextubation.

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Heisplacedonpressuresupportventilationof5cmH2OwithanFIO2of0.4andobservehim.Thebestpredictorofhisabilitytobesuccessfullyextubatedis:

1.PaO2>60mmHg

2.PaCO2<50mmHg

3.Tidalvolume>5ml/kg

4.Respfrequency/tidalvolumeratio<100

5.Maximalinspiratorypressure>-25mmHg

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Case19Yesterday,youadmitteda78yearoldmanwithaRLLpneumonia.Helivesinanursinghomeandhasbeennotedtoaspirateperiodically.

Despiteantibiotics,hisoxygenationisworseningandyoutransferhimtotheICUforintubationandinitiationofmechanicalventilation.

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Case19- ContinuedTheCXRshowsbilateralalveolarinfiltratesandhisPaO2witha100%non-rebreathingmaskinplaceisonly50mmHg.

Thepatientisnowintubatedandtherespiratorytherapistsuggeststhatyouneedtobecarefulaboutcausinglunginjurywiththeventilator.

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Inconsideringthesettingsfortheventilator,youmustbemostawareof(i.e.,concernedabout):

1.Overdistentionofalveoli(volumetrauma)2.Highpeakairwaypressures(barotrauma)3.Rapidrespiratoryfrequencies4.Highcarbondioxidelevels5.PEEP(positiveend-expiratorypressure)above5cmH2O

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Case20A37yearoldmanisadmittedtotheICUfromtheEDwithpresumedsepticshock.Bloodculturesarepositiveforstreppneumonia.Heiswarmwithgoodcapillaryrefillintheextremities,butthebloodpressurehasdroppedto70mmHgsystolicandurineoutputis<20cc/hr.

CVP=7cmH2O.HereceivedoneliteroffluidintheEDandispresentlyreceivinghighdosenorepinephrine.

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Youshouldadvise:1.Beginaphenylephrine(neosynephrine)infusion.

2.Beginadopamineinfusion.3.Beginavasopressininfusion.4.Givemorefluids.

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Case21A22year-oldcollegestudent isadmitted tothehospitalwithincreasingcough,shortnessofbreath,nausea, andageneralfeelingofbeingunwell.HisO2satis84%withsupplemental oxygenbymask(FIO20.8)andheisabouttobeintubated.CXRshowsbilateralpulmonary infiltrates.WBCis12,000.

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1. Startantiviralmedicationsforinfluenza

2. Beginonbroadspectrumantibiotics

3. Inquireaboutvaping

4. Getanechocardiogram

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PathologyofVaping-AssociatedLungInjuryNEJM(17patients- Buttetal.,onLine– October2,2019)Bronchiolitis Mucosal edema,

epithelial sloughing

Foamy macrophage DAD

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Case22A75yearoldwomanisadmittedtoyoufromtheemergencydepartmentwithhypotension.Shehasafeverto103degrees,BPwas80/40mmHginitially.TheUAshowsmanyWBCsandbacteria.SerumlactatelevelincreasedfromonemeasurementtoanotheronthreeoccasionswhileshewasintheED.Bloodpressureisnow100/60withthepatientreceivingadopamineinfusionat6micrograms/kg/min.

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Basedontherisingserumlactatelevels,youshould:

1. Tellthefamilythatherriskofdyingisincreased

2. Tellthefamilythatshewillneedtobeintubated

3. Tellthefamilythatoncealactateleveliselevated,furtherriseisnotimportant

4. AskthefamilyifshehasbeentakingillicitdrugsCOPYRIG

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challenging cases in pulmonary yright (and critical care)

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