dimps
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A 53-year-old man is admitted to the hospital because of rapid onset of shortness of breath. He reports that a little less than 2 weeks ago he noticed that he was short of breath and since that time it has progressed to the point where at rest, he is barely able to breath, and he is unable to walk without "nearly passing out." He denies chest pain, pressure, any altered mental status, cough, or fever. His past medical history is remarkable only for hypertension treated with atenolol. The patient denies any recent travel, occupational exposures, or sick contacts. On arrival to the emergency department, the patient is mildly cyanotic and breathing at 24-28/min. He is conversant and appropriate, but visibly short of breath. There are no obvious signs of accessory muscle engagement. His room air oxygen saturation is 82%. The most appropriate management of this patient at this time is to
A. administer heliox
B. administer high flow oxygen via non-rebreathing mask
C. administer 3 liters/min oxygen via nasal prongs
D. administer 3 liters/min oxygen via simple face mask
E. perform endotracheal intubation
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hi how r u
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| pedsdoc2004
Forum Newbie
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D
Administer O2 and see what happens to the sats?
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| meg
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I agree
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| usmleasr
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E?..
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| meg
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he is conversant wihtout using accessory muscles, so I doubt if we have to intubate....
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| dimps
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The correct answer is B. This patient has severe hypoxia of unknown etiology. The nature of his illness and rapid course suggests a disease such as interstitial pulmonary fibrosis. Most rapid cases such as this are idiopathic (Hammond-Rich syndrome). Regardless of the cause, immediate management is the same, provide adequate oxygen to determine if the hypoxia can be corrected. High flow oxygen delivered via NRB mask offers about 82-86% inspired oxygen concentration. If the shunt fraction is less than 50%, inspired oxygen of this amount will be able to correct the hypoxia. The patient can then continue on oxygen until he can no longer protect his airway, his work of breathing becomes too great, or he begins to desaturate.
Heliox (choice A) is a mixture of helium and oxygen that is used in patients with severe bronchoconstriction. The combination gas is more laminar with its' flow and allows better delivery of oxygen to the distal airways. It has no role in the correction of hypoxia since it is a low oxygen
concentration mixture.
Oxygen via nasal prongs (choice C) is inadequate for this patient. 3 L/min offered in this manner is essentially 26-28% inspired oxygen concentration. With this marginal escalation over ambient tensions, the patient will improve minimally, or more likely, not at all.
In order to use a simple face mask for oxygen delivery (choice D) the flows need to be greater than 6 L/min in order to effectively evacuate the expired carbon dioxide from the mask and prevent rebreathing.
There is no indication to place an endotracheal tube at this time (choice E). Although the patient is exerting tremendous effort to breathe, he is not in distress, has no accessory muscle use, and is not discoordinate. The first attempt at management should be to determine if oxygen, delivered via external devices, can augment his oxygenation. If this is successful, his respiratory rate will decline and his work of breathing will decrease substantially
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hi how r u
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| meg
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thanks dimps, it is very challenging and interesting to do these questions from you.
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