A 55-year-old Caucasian man is brought into the Emergency Department by his wife because of increasing shortness of breath. Symptoms developed gradually over the past few months are exacerbated by exertion, and are associated with a chronic dry cough. The patient’s medical history is significant for hypertension and rheumatoid arthritis, and he takes hydrochlorothiazide and daily NSAIDs. He has smoked 2 packs of cigarettes daily for the past 15 years and drinks alcohol moderately. His temperature is 36.7°C, blood pressure is 142/88 mmHg, heart rate is 94 beats per minute, respiratory rate is 24 breaths per minute, and oxygen saturation is 91% on room air. The physical examination is notable for bibasilar dry crackles, a right ventricular heave, clubbing of the digits, and mild pitting edema around the ankles. There is also some tenderness to palpation in the epigastric area. Testing the stool for occult blood is positive.
Which of the following could have prevented the development of this patient’s lung disease?
Smoking cessation. In the setting of rheumatoid arthritis, the symptoms/signs of dyspnea on exertion, chronic dry cough, clubbing, and bibasilar dry crackles are indicative of rheumatoid arthritis-associated interstitial lung disease. This complication typically presents around the age of 50 to 60 and typically affects the lower lungs. Risk factors for developing this complication include male gender, severity of disease (correlates with a high rheumatoid factor level), and smoking. In addition to the presentation, other findings that suggest this diagnosis are a restrictive pattern on pulmonary function tests and reticular or ground glass changes on a CT scan. Smoking cessation is the best preventive measure, and is always a good answer choice for the shelf examination. (C) Early initiation of DMARDs such as methotrexate, azathioprine, rituximab, calcineurin inhibitors, and tumor necrosis factor blockers is a good answer choice since they have been a major improvement in the treatment of patients with rheumatoid arthritis and can slow down disease progression. However, there is less of a correlation between the development of interstitial lung disease and DMARD initiation than other disease features (e.g., joint destruction). Smoking cessation is still the best option for preventing interstitial lung disease associated with rheumatoid arthritis.
(A) Hypertension would not produce the lung findings seen in this patient, and the patient’s current blood pressure is only mildly elevated. The findings of a right ventricular heave and peripheral edema may be signs of pulmonary hypertension and early right heart failure (cor pulmonale) from the patient’s lung disease. (D) The findings on examination are more consistent with interstitial lung disease (dry crackles) than with COPD (wheezes, hyperinflated lungs). (E) The epigastric pain with occult blood in the stool is likely a result of a bleeding peptic ulcer from chronic NSAID use, not colon cancer. Metastatic disease to the lungs from colon cancer would not produce bibasilar dry crackles.
A 68-year-old man undergoes a left hip replacement and is recovering in the hospital afterward. As he stands up to walk with the physical therapist, he suddenly collapses. He undergoes initial resuscitation and is intubated, but he remains hypotensive despite heavy fluid resuscitation. The patient is tachycardic, but the rest of his cardiac and pulmonary examinations are normal. IV heparin is started and a CT angiogram is performed (Figure below).
What is the next step in management?
Thrombectomy. This patient experienced a massive pulmonary embolism, and a “saddle embolus” affecting the pulmonary trunk and arteries is seen on the CT angiogram. Patients undergoing surgical procedures (especially orthopedic surgery) are at an increased risk of clot formation and pulmonary embolism. The initial management of a pulmonary embolism depends on whether the patient is stable or unstable. If the patient is stable and there is a high suspicion for pulmonary embolism, then IV anticoagulation should be started during the workup (e.g., heparin, enoxaparin, fondaparinux, etc.). If a patient has a DVT discovered but is asymptomatic, then the answer is still IV anticoagulation. If the patient is unstable, then they need to be resuscitated and stabilized with ventilation, blood pressure support, and empiric anticoagulation (as long as pulmonary embolism is highly suspected and there are no serious contraindications). (C) Persistent hypotension is an indication for fibrinolytic therapy (alteplase); however, recent surgery within 10 days is a contraindication to this therapy. Other contraindications to fibrinolytics include the presence of an intracranial tumor, recent intracranial surgery or trauma, previous hemorrhagic stroke (or nonhemorrhagic stroke in the past 2 months), internal bleeding within the past 6 months, bleeding diathesis, severe hypertension, and a platelet count <100,000/mm3 . Thrombectomy is an option if the patient fails fibrinolytic therapy or has a contraindication to systemic fibrinolysis, and it can be performed surgically or with a catheter. This is the best option for this hemodynamically unstable patient that has a contraindication to fibrinolysis.
(A) The immediate concern is the massive pulmonary embolism on CT, not diagnosing coronary artery disease. (B) Though the patient had recent surgery and therefore is at a higher risk of bleeding, IV anticoagulation is still warranted and the benefits outweigh the risks. Enoxaparin is preferred over heparin by some; however, heparin has already been started and only one agent should be used. (E) An IVC filter is a good option for patients with a confirmed DVT or pulmonary embolism that have a contraindication to anticoagulation (failure of previous anticoagulation, serious bleeding with previous anticoagulation, or high bleeding risk; although recent surgery is a risk factor for bleeding, high risk typically means there are 2 or more risk factors). However, this is not a good option since it will prevent future pulmonary emboli but will not address the current life-threatening embolism!
A 57-year-old man is involved in a motor vehicle collision and undergoes operative repair of several fractures. He does well during the procedures and his only complaint is postoperative pain. An arterial blood gas shows a PaO2 of 70 mmHg and a PaCO2 of 65 mmHg. He has a history of hypertension and stage 2 chronic kidney disease. His regular medications include aspirin and lisinopril. He appears drowsy on examination but his lungs are clear to auscultation bilaterally.
Which of the following is the most likely cause of this patient’s abnormal blood gas?
Medication effect. Many patients in the hospital are treated with opioids for pain control, which can cause oversedation and hypoventilation. In a patient without pre-existing lung disease, acute hypoxemia with hypercapnia suggests hypoventilation (either a low tidal volume, a low respiratory rate, or both). Besides opioids, other causes of a decreased respiratory rate include sedatives (e.g., benzodiazepines), hypothyroidism, stroke, and metabolic alkalosis. Causes of a decreased tidal volume include obesity, obstructive sleep apnea, COPD, interstitial lung disease, neuromuscular disease (diseases affecting the nerves, neuromuscular junction, or muscles), and chest wall deformities (e.g., severe scoliosis). Diffusion impairment from interstitial lung diseases can also cause hypoxemia and hypercapnia, but not as a result of hypoventilation. (B, C, D) Pulmonary embolism, atelectasis, and hospital-acquired pneumonia cause V/Q mismatch leading to hypoxemia without hypercapnia, since patients will increase ventilation in response to hypoxemia.
A 73-year-old nursing home resident complains of severe difficulty breathing. The nursing home staff reports that she has had several episodes of pneumonia since she has been there and is often delirious during the night. She has a history of hypertension, diabetes, dementia, and chronic cough with daily sputum production. Her medications include metformin, hydrochlorothiazide, over-the-counter cough suppressants, and haloperidol as needed. She has a 10 packyear smoking history and quit 30 years ago. She has a temperature of 38.3°C, blood pressure of 104/62 mmHg, heart rate of 91 beats per minute, respiratory rate of 26 breaths per minute, and oxygen saturation of 94% on room air. The patient’s CT scan is shown below (Figure below).
Which of the following is the most likely cause of this patient’s lung findings?
Recurrent aspiration events. Bronchiectasis is a destructive process of the airways caused by recurrent infections without the ability to adequately respond to the infections. The inadequate response may be caused by processes such as airway obstruction, immunosuppression, or impaired drainage from the site of infection. Bronchiectasis may present similarly to COPD with a chronic cough, daily sputum production, wheezing, and dyspnea. It is also a common cause of hemoptysis. This patient’s CT confirms the diagnosis of bronchiectasis and shows enlarged airways predominantly in the lower lobes, which is likely the result of recurrent aspiration pneumonias (risk factors in this patient are old age and dementia). Other causes of bronchiectasis include cystic fibrosis, obstructions (COPD, lung tumor, mucus plugging), allergic bronchopulmonary aspergillosis, and immunosuppression. (A) A history of smoking may lead the reader to suspect COPD; however, the CT scan does not fit this diagnosis. In COPD, there is typically bronchial wall thickening from chronic bronchitis and alveolar septal destruction with enlargement of airspaces from emphysema. (B) Recurrent pseudomonal infections are a complication of bronchiectasis, and are unlikely to be the cause of bronchiectasis in this patient. Culture of her sputum would likely show mixed flora containing anaerobes since her pneumonia is caused by aspiration events. (D) Goodpasture syndrome is an autoimmune disease that affects the lungs and the kidneys and may present with hemoptysis and nephritic syndrome, which are not seen in this patient.
An older man with a history of COPD presents for follow-up after being hospitalized with an acute exacerbation. He asks you what treatments are available to decrease his risk of death.
Which of the following therapies has been shown to reduce longterm mortality in this condition?
Home oxygen therapy. The two most important interventions for reducing mortality in COPD are smoking cessation and home oxygen therapy, provided that the patient meets certain criteria. Patients with an SaO2 ≤88% or PaO2 ≤55 mmHg during rest, exercise, or sleep will benefit from chronic home oxygen therapy with a significant reduction in mortality. The cutoffs are slightly higher in a patient that has polycythemia or cor pulmonale. There are other interventions that show some mortality benefit, but the two interventions mentioned above are the most likely interventions to be tested on the shelf examination. (A) Mucolytics such as guaifenesin may partially reduce symptoms from excess airway secretions; however, there is debate over their usefulness and they do not reduce mortality. (B) Oral prednisone is used in acute exacerbations to reduce airway inflammation, but chronic treatment with systemic steroids has many side effects and can increase mortality. (D) Inhaled ipratropium is useful both in chronic treatment and in acute exacerbations. It decreases symptoms and improves lung function but does not decrease overall mortality.