A 22-year-old woman presents to the hospital with severe dyspnea. She has a history of atopic dermatitis and recently started a topical corticosteroid. She lives with her parents and two younger siblings, one of which recently had an upper respiratory infection. She does not smoke or use any illicit drugs. On examination, her temperature is 37.8°C, blood pressure is 108/72 mmHg, heart rate is 112 beats per minute, respiratory rate is 26 breaths per minute, and oxygen saturation is 88% on room air. Her systolic blood pressure decreases by more than 10 mmHg during inspiration. She is having difficulty speaking in full sentences and is diaphoretic. There are bilateral inspiratory and expiratory wheezes on examination with no dullness to percussion or tactile fremitus over the lung fields. There is no urticaria or angioedema on skin examination.
Which of the following treatments should be given for this patient’s current condition?
Nebulized albuterol for bronchodilation. This patient is suffering an acute asthma exacerbation without a previous asthma diagnosis. She has another component of the atopic triad (eczema), which indicates an increased risk for asthma. She is likely suffering from an asthma exacerbation caused in part by her recent exposure to a viral illness. There were wheezes on examination with no urticaria or angioedema, making an anaphylactic reaction unlikely. Once the reader can guess that the diagnosis is asthma, the next step is knowing how to manage an acute exacerbation.
Management of an acute asthma exacerbation involves oxygen administration as well as intermittent or continuous nebulized albuterol, which is the first-line treatment. If the patient fails to respond to albuterol, then ipratropium and magnesium are additional options to promote bronchodilation. Oral corticosteroids should also be given to reduce airway inflammation during and after the exacerbation. Response to therapy can be monitored by following the SaO2 as well as either the FEV1 or the peak expiratory flow (PEF). Arterial blood gases may also be useful; be concerned about the finding of a normal PaCO2, which is often indicative of respiratory fatigue leading to the requirement of intubation (hypoxemia should cause hyperventilation and hypocapnia). There are important differences between the management of asthma and COPD exacerbations, which is summarized in below.
Differences in the Treatment of Acute Asthma and COPD Exacerbations:
(A) Oxygen should be administered to asthmatics with a target SaO2 >90%. In COPD, the target is 90% to 94% due to the concern for the development of hypercapnia; however, this is not seen in asthma. (B) This patient is unlikely to have pneumonia given that she is afebrile and has no suggestive findings of pneumonia on lung examination. (C) Subcutaneous epinephrine is useful in anaphylaxis, but has no benefit over inhaled β2 agonists in asthma for bronchodilation. (D) Ipratropium is an anticholinergic and is the first-line treatment for COPD exacerbation (although albuterol is often used too); it may be used as an adjunctive therapy in asthma exacerbation, but albuterol is the firstline therapy. Pulsus paradoxus is not specific to cardiac tamponade and can result from airway obstruction, which causes air trapping and hyperinflation of the lungs leading to an increase in intrathoracic pressure and therefore an increase in external pressure around the heart. The rest of the patient’s presentation is not consistent with tamponade.
A 28-year-old man with a history of asthma is hospitalized for an acute exacerbation. After discharge, he follows up in clinic. A further history is obtained, and the patient reports daily symptoms with night-time awakenings occurring more than 1 night each week. The symptoms are especially prominent with exercise. He uses inhaled albuterol as his reliever medication and inhaled fluticasone as his controller medication. Spirometry is performed and shows a mildly reduced FEV1/FVC ratio from his baseline.
Which of the following changes to the patient’s therapeutic regimen would have been appropriate and might have prevented the acute exacerbation?
Adding salmeterol. Based on his symptoms, this patient’s asthma severity can be graded as “moderate.” Appropriate management of asthma is somewhat similar to COPD in that there is a stepwise approach to achieve adequate control of the disease. The goal is to have daily symptoms 2 or less times a week with no nightly symptoms. All patients should be on a reliever medication (rapid acting β2 agonist such as albuterol), but their controller medications can be adjusted based on the severity (Figure below). Because this patient requires a step up in therapy, the most appropriate next step would be to add a long acting β agonist (e.g., salmeterol). These medications are especially good for asthma with a strong exercise component. (A, D) Shortand long-acting anticholinergics are more useful in COPD when compared to asthma. (B) Oral steroids are used for acute exacerbations and for chronic severe asthma, using the lowest dose possible; they are not used for chronic therapy in COPD. The patient might be on a steroid taper after his recent acute exacerbation; however, the question is asking about changes to his chronic regimen. (E) Theophylline is not a first-line treatment but may be used in patients with difficulty to control asthma. Montelukast and other leukotriene antagonists may be useful as adjunctive therapy. A change in therapy is warranted to achieve symptomatic control.
A 21-year-old woman volleyball player complains of chest pain and dyspnea after practice. She finished a vigorous practice and was watching television at home when the symptoms occurred suddenly. She denies any fevers, loss of consciousness, or recent travel. She takes OCPs and her last menstrual period was 2 weeks ago. She does not drink alcohol but admits to smoking cigarettes socially. On examination, she is 183 cm (6′0″) tall and weighs 65.77 kg (145 lb). Her blood pressure is 104/68 mmHg, heart rate is 95 beats per minute, and respiratory rate is 28 breaths per minute. There are no murmurs on cardiac examination, and there is no jugular venous distention. There is hyper-resonance to percussion and decreased breath sounds along the right lung field, with normal vesicular sounds along the left lung field. Her trachea is shifted to the right. The rest of the examination is unremarkable.
Which of the following is the most likely cause of this patient’s presentation?
Rupture of an air bleb at the lung apex. The most common cause of a primary spontaneous pneumothorax is rupture of subpleural blebs (collections of air within the visceral pleura), which commonly occurs while the patient is at rest. These patients will present with symptoms of pleuritic chest pain and shortness of breath, and will have hyper-resonance to percussion with decreased breath sounds in the affected lung due to collapse of that lung. As opposed to a tension pneumothorax, a spontaneous pneumothorax will draw the unaffected lung and the mediastinum toward the affected lung due to collapse and loss of volume of that lung. This will cause the trachea to shift toward the affected lung (whereas in a tension pneumothorax the trachea will shift away from the affected lung). Risk factors for spontaneous pneumothoraces include smoking, a family history of pneumothoraces, and Marfan syndrome. Diagnosis can be confirmed with a chest x-ray. Treatment depends on the size of the pneumothorax. For small asymptomatic pneumothoraces, oxygen administration and observation is sufficient. For larger pneumothoraces or if the patient is symptomatic, needle aspiration is appropriate. If they fail this treatment, then a chest tube should be placed. With recurrent pneumothoraces, thoracoscopy should be performed with chemical pleurodesis as an option to prevent recurrence.
(B) This answer choice refers to a pulmonary embolism, which is in the differential diagnosis based on the history but it does not fit with the physical examination findings (the lung examination is commonly normal with a pulmonary embolism). (C) Thoracic endometriosis is a potential cause of spontaneous pneumothorax, but this patient’s last menstrual period was 2 weeks ago and therefore she is close to ovulation in her cycle and not menstruation. (D) A tension pneumothorax will shift the trachea contralaterally and is associated with hypotension and jugular venous distention.
A 49-year-old man is hospitalized with fever, shortness of breath, and a productive cough containing rust-colored sputum. On examination, he has dullness to percussion over the right lung base. Thoracentesis is performed with removal of 1.5 L of fluid. The results of laboratory tests and pleural fluid studies are shown below.
Pleural fluid studies:
Which of the following is the most appropriate next step in management?
Drainage with a chest tube. The pleural fluid studies meet Light’s criteria for an exudative process, which is likely a parapneumonic effusion (occurring next to a pneumonia) based on the patient’s symptoms. The next step is to figure out whether the parapneumonic effusion is complicated or uncomplicated, since this will help to determine the appropriate management. A complicated parapneumonic effusion is defined as a pH <7.2, glucose <60 mg/dL, or a positive Gram stain or culture. If gross pus is removed from the pleural space, then it is likely infected and called an empyema. Uncomplicated effusions typically resolve with antibiotics alone; however, complicated effusions require drainage. The best option for these patients is to drain the effusion with a chest tube. (A) Observation alone is not appropriate. (C, D) These antibiotic regimens are for inpatient treatment of community-acquired pneumonia and health care associated pneumonia, respectively. Antibiotics should be given, but drainage is also necessary. (E) Chest tube placement (tube thoracostomy) is preferred to more invasive procedures such as VATS. VATS is performed by thoracic surgeons and may be useful if there is a multiloculated empyema that does not drain properly with a chest tube.
A 54-year-old homeless man comes to the Emergency Department complaining of shortness of breath. There is the smell of alcohol on his breath, and obtaining the patient’s history is limited. His vitals show a temperature of 37.2°C, blood pressure of 142/90 mmHg, heart rate of 86 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 94% on room air. For the pulmonary examination, the patient is moved from a supine position to a seated position; however, his dyspnea is exacerbated and he refuses to stay in a seated position. His oxygen saturation also decreases slightly while he is in an upright position. The patient has a distended abdomen with shifting dullness, and there are several spider angiomas over the chest with palmar erythema.
Which of the following is the most likely cause of this patient’s chief complaint?
Hepatopulmonary syndrome. The presence of dyspnea in a patient with manifestations of chronic liver failure (ascites, spider angiomas, palmar erythema) is suggestive of hepatopulmonary syndrome. The unique features of this disease are the presence of platypnea (worsening dyspnea when moving from a supine to an upright position) and orthodeoxia (decreased PaO2 when moving from a supine to upright position). The pathophysiology of this process involves arteriovenous dilatations that are hypothesized to be the result of vasoactive substances (e.g., nitric oxide) not broken down by the failing liver. These dilatations preferentially occur at the lung bases, which creates a V/Q mismatch with hypoxemia and an elevated A–a gradient. When the patient is upright, there is even more perfusion of these dilatations, which worsens the V/Q mismatch and causes further hypoxemia. Diagnosis can be made with a contrast echocardiogram, which can differentiate between intracardiac and intrapulmonary shunts. Treatment involves supplemental oxygen and liver transplantation if the patient is eligible.
The rest of the answer choices would not cause platypnea and orthodeoxia. (B) Congestive heart failure presents with orthopnea, which is increased dyspnea when lying flat. When supine, there is increased preload to the failing heart with an increase in pulmonary vascular pressures. (C) α1-Antitrypsin deficiency is a cause of both lung and liver disease in young patients, though this patient’s liver disease is likely related to alcohol abuse. (D) COPD can cause a congestive hepatopathy as a late finding in the disease process, which would occur from increased venous pressures as a result of cor pulmonale. (E) Polycystic kidney disease is an autosomal dominant disease with the formation of many cysts within the kidneys and potentially the liver as well.
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