A 65-year-old female with 50 pack-year tobacco history presents to the ED after being involved in a motor vehicle accident. Her vitals on arrival were:
She underwent a CT head, chest, abdomen, and pelvis. The CT chest demonstrated a 5 cm spiculated nodule in the right middle lobe. Thoracic surgery was consulted for possible lobectomy. Pulmonary function tests were performed which demonstrated a forced expiratory volume (FEV1) of 1.4 L (53% predicted), forced vital capacity (FVC) of 2.39 L (71% predicted), and a diffusing capacity of the lungs for carbon monoxide (DLCO) of 48% predicted.
What would be the next step in management?
Correct Answer: B
Prior to pneumonectomy or lobectomy, the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS)recommend starting with pulmonary function tests. A reduced FEV1 has been associated with increased respiratory mortality rates post surgery In the BTS guidelines, a preoperative FEV1 >2 L (or 80% predicted) generally suggests the patient would tolerate a pneumonectomy well and for lobectomy, the FEV1 cutoff is 1.5 L. In patients with a FEV1 <30%, the incidence of respiratory morbidity has been as high as 43% but drops to 12% in patients with a FEV1 >60%. DLCO is also recommended for all patients prior to lung resection surgery. Ferguson et al. demonstrated that DLCO <60% was associated with 25% mortality and 40% pulmonary morbidity. If patients do not fall into a low-risk category (FEV1 >80% and DLCO >80%), it is recommended that a postoperative (PPO) pulmonary function test be calculated. A PPO calculation involves using the preoperative FEV1 or DLCO and multiplying by 1—the fraction of total perfusion in the to-be-resected lung. This involves the use of a ventilation/perfusion scan. If the PPO FEV1 and PPO DLCO are >60% predicted, no additional testing is recommended. If the PPO FEV1 and PPO DLCO are <60% and greater than 30%, either a stair testing or shuttle testing is recommended. If the PPO FEV1 and PPO DLCO are <30%, a cardiopulmonary exercise test is recommended. An arterial PO2 has not been shown to predict mortality prior to lung resection surgery. For this patient, given the FEV1 and DLCO do not clearly place the patient into a low-risk category, the next best step would be to calculate a PPO and then determine if stair climbing or a cardiopulmonary exercise test was necessary.
A 75-year-old male with a history of tobacco use (50 pack year), chronic obstructive pulmonary disease (COPD), hypertension (HTN), and recent diagnosis of adenocarcinoma of the lung for which he has not started treatment presents to the ED with a 4-day history of increased dyspnea at rest and with exertion, productive cough, and subjective fevers at home. His initial vitals were notable for:
He was placed initially on a nonrebreather and his saturations increased to 92%. He had a CXR performed which showed a dense consolidation in the right lower lobe. He was started on ceftriaxone and azithromycin for community-acquired pneumonia (CAP) and admitted to the ICU given his high oxygen requirements. Three days into his ICU course, his high flow requirements remained unchanged. He remained tachycardic in the low 100s and continued to have low-grade fevers.
Correct Answer: C
The patient continues to demonstrate tachycardia, hypoxemia, and lowgrade fevers. However, he also displays clinical and subjective findings to suggest improvement in his pneumonia with reduced cough and rhonchi. Given the patient has an underlying diagnosis of non–small-cell lung cancer, he is at increased risk for the development of PE. In comparison to cancer-free controls, patients with lung cancer were six times more likely to develop a PE. He also has a recent diagnosis of malignancy, and the incidence of PE is greatest within the first 6 months of lung cancer diagnosis. The patient has been diagnosed with adenocarcinoma which independently is a risk factor for PE (OR 3.6). Given is lack of improvement and his associated risk factors, a CT-PE would be warranted to rule out a PE as the cause for his continual symptoms. Adding on vancomycin would not be appropriate, given the patient has low methicillin-resistant Staphylococcus aureus (MRSA) risk factors. Steroids would likely not be helpful as clinically the patient does not appear to have a COPD exacerbation and his sputum production is improving and he has no evidence of wheeze on examination. In patients, without significant risk factors for PE, it may be appropriate to wait for clinical improvement, given the patient did have an initial diagnosis of pneumonia, however, missing a PE in this patient could be life threatening.
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