darkhorse
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A 53-year-old woman who is a heavy smoker presents to the emergency department complaining of increasing shortness of breath for the past 3 days. She denies any history of asthma or coronary artery disease. Her temperature is 37.3 C (99.2 F), blood pressure is 150/90 mm Hg, heart rate is 110/min, and respiratory rate is 34/min. On examination, she is awake, alert, and oriented. Diffuse bilateral wheezes are heard on lung auscultation. Pulse oximetry measures 90% oxygen saturation on room air. An arterial blood gas is drawn and the results showpH 7.3
pO2 60
pco2 65
A chest radiograph demonstrates bilateral, hyperinflated lungs with a flattened diaphragm. Sputum Gram stain shows a few polymorphonuclear cells, moderate number of epithelial cells, and a moderate number of Gram-positive cocci. She receives supplemental oxygen, albuterol nebulizer treatments, and steroids. Her symptoms improve and pulse oximetry now reads 93% saturation. The most appropriate next step is to
A. add antibiotics to the treatment regimen
B. do diffusion capacity testing by carbon monoxide
C. intubate and begin mechanical ventilation
D. obtain lung spirometry measurements
E. start non-invasive positive pressure ventilation
Edited by darkhorse on 11/06/07 - 07:45 AM
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| dr.wad
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D
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| AAAAA
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A
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| AAAAA
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because this is an acute event, and the pt desaturate, you must give antibiotics to stabilize the pt
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| Doc750
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so where's the abg results?
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| darkhorse
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pH 7.3
pO2 60
pco2 65
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| Kamsi
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A .Thereis infection .... sputum findings in d pt with emphysema
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| jvo_md
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i think its D...
Answer darkhorse
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| darkhorse
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Explanation: The correct answer is A. The patient is a smoker who presented with progressive shortness of breath. Physical examination found diffuse wheezing and chest X-ray noted emphysema. In addition, she had an elevated pCO2 with acute respiratory acidosis and moderate hypoxia. These findings are consistent with an exacerbation of chronic obstructive lung disease. Such flares are treated with β2-agonists, anticholinergics, and steroids. In addition, antibiotics have also been shown to improve clinical outcome, and so they are part of the treatment regimen for chronic obstructive lung disease flares. Diffusion capacity (choice B) for this patient will likely be low given her emphysema and is an important measurement for diagnosis, but it is not required in the acute management of this condition.The patient has a normal mental status and is able to protect her airway. Her symptoms and oxygenation also improve with treatment. Thus, there is no current indication for intubation (choice C). Intubation is required if the patient has severe CO2 retention and/or hypoxia refractory to medical therapy. Intubation is also indicated if her condition is refractory to non-invasive ventilation, if she has severe acid-base disturbances, or if there is any change in her mental status that would compromise the airway. Lung spirometry (choice D) will aid in the diagnosis of her disease but is not useful in management of her clinical course.Non-invasive positive pressure ventilation (choice E) is indicated in patients with severe chronic obstructive pulmonary disease that is refractory to medical therapy. It is also useful in patients with increasing respiratory fatigue. A patient must be able to initiate breathing and tolerate the breathing mask. This patient has a normal mental status and her symptoms improve with treatment. Thus, she currently does not require any assistance in ventilation.
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| jvo_md
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thanks darkhorse
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