Critical Care Medicine-Pulmonary Disorders>>>>>Respiratory Diagnostic Modalities and Monitoring
Question 2#

A 72-year-old female (body mass index of 27 kg/m2 ), admitted for exacerbation of chronic obstructive pulmonary disease (COPD), is started on noninvasive ventilation on the floor. She is claustrophobic, and the intern orders lorazepam for mask tolerance. Soon after, the patient is found to be obtunded and a code is called. During laryngoscopy, particulate gastric contents are noted in the posterior pharynx. Her postintubation vitals are:

Despite adjustment of ventilatory parameters and maximal bronchodilator therapy, airway inspiratory pressures remain high.

Which of the following actions would be BEST next step in the management of this patient?

A. Surface ultrasound of the heart and lungs
B. Arterial blood gas
C. Chest x-ray
D. Bronchoscopy

Correct Answer is D


Correct Answer: D

High-quality randomized control trials support the use of noninvasive ventilation as a first-line intervention for patients with acute hypercapnic respiratory failure due to exacerbation of COPD. It is associated with decreased mortality and a lower likelihood of invasive ventilation. However, vigilance is required, particularly as failure necessitates intubation. Furthermore, as this is a “nonsecure” ventilation modality, there is a potential risk for gastric aspiration. 

For this patient, diagnostic studies such as surface ultrasonography, ABG, chest x-ray (answers A, B, and C) are all reasonable management steps that should be taken, as they can be helpful in narrowing the differential diagnosis. The presence of gastric contents in the pharynx on laryngoscopy does not guarantee aspiration but should raise suspicion. Most aspirated gastric content is liquid and quickly disperses, but in the event of particulate aspiration, bronchoscopy (answer D) could be both diagnostic and therapeutic and should be the next step in management.


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  2. Kabadayi S, Bellamy MC. Bronchoscopy in critical care. BJA Educ. 2017;17(2):48-56.
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