April 2018 Critical Care Case of the Month

Clement U. Singarajah, MD

Phoenix VA Medical Center

Phoenix, AZ USA

History of Present Illness

A 70-year-old man was admitted for shortness of breath (SOB) secondary to a “COPD exacerbation/ILD”. A pulmonary consult was placed for possible interstitial lung disease (ILD). A thoracic CT scan for pulmonary embolism showed no embolism and no obvious ILD. He was treated for a COPD exacerbation with the usual therapy of antibiotics, steroids, nebulized bronchodilators and oxygen. He started to improve.

A few days later as he was preparing for discharge, the patient suddenly decompensated becoming more SOB (once more proving that this a dangerous time for patients in hospital). There were reports that this began after he choked and perhaps aspirated on some food and drink. His blood pressure remained stable, but he became tachycardic to 130 beats/min, hypoxic on 100% non-rebreathing mask with saturations of 92%. Obvious clinical acute respiratory failure was present. The patient was started on non-invasive ventilation but continued to deteriorate.  He was deemed too unstable to obtain a CT scan. EKG showed sinus tachycardia. The patient was transferred to the ICU for respiratory failure. A chest x-ray was obtained (Figure 1).

Figure 1. Panel A: Admission chest x-ray which was interpreted as not different from the patient’s previous chest x-ray. Panel B: Portable chest x-ray taken shortly after initiation of non-invasive ventilation just after arrival in the intensive care unit.

The portable chest x-ray taken in the ICU shows a new right-sided consolidation and which of the following? (Click on the correct answer to proceed to the second of six pages)

1. Left pleural effusion and a loculated pneumothorax with tension physiology
2. Left pneumothorax with tension physiology
3. Left pneumothorax without tension physiology
4. Left sided tension hydropneumothorax
5. None of the above

Cite as: Singarajah CU. April 2018 critical care case of the month. Southwest J Pulm Crit Care. 2018;16(4):183-91. doi: https://doi.org/10.13175/swjpcc042-18 PDF

May 2017 Critical Care Case of the Month

Sapna Bhatia, MD

David Ling, DO

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

History of Present Illness

A 54-year-old Hispanic male who was incarcerated 3 days prior to hospital admission was brought into the emergency room from prison for alcohol related withdrawal seizures.

Physical Examination

Upon arrival to the ER, the patient was noted to be hypoxic with copious thick secretions in his mouth. He was intubated for airway protection, started on propofol and fentanyl drips as well as intravenous thiamine and folic acid.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Portable anterior-posterior (AP) radiograph of the chest.

Which of the following are true regarding management of this patient?

1. Phenytoin should be administered for prevention of seizures
2. Prophylactic antibiotics for aspiration pneumonia should be administered
3. Thiamine and folic acid should be administered
4. 1 and 3
5. All of the above

Cite as: Bhatia S, Ling D, Boivin M. May 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(5):192-8. doi: https://doi.org/10.13175/swjpcc051-17 PDF

Ultrasound for Critical Care Physicians: Take a Deep Breath

David Ling, DO

Michel Boivin, MD

Division of Pulmonary, Critical care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM

A 40 year old man with a past medical history of intravenous drug abuse presented to the emergency department with difficulty walking and lower extremity weakness. He did admit to recent heroin use. He became somnolent in the ED and was given naloxone. However, he did not improve his level of consciousness sufficiently and was intubated for hypercarbia. The patient was transferred to the MICU and was evaluated for respiratory failure. He later that day passed a spontaneous breathing trial after he awoke and was extubated. However, he was soon thereafter was re-intubated for poor respiratory efforts and a weak cough. 

With an unexplained etiology for the respiratory failure, CT of the head, MRI of the brain and lab evaluation were pursued but were negative.  At that point, a bedside ultrasound of the right hemi-diaphragm in the zone of apposition was obtained and is shown below:

Figure 1. Ultrasound of the right hemi-diaphragm at low depth, at the zone of apposition. The diaphragm is visualized above the liver as three parallel echogenic stripes.

Figure 2. M-mode image of the right hemi-diaphragm. The m-mode image is on the left, and the corresponding 2D image is on the right.

What does the video and M-mode of the diaphragm demonstrated above predict for the potential result of the patient’s extubation? (Click on the correct answer for the answer and explanation)

1. Success
2. Failure
3. Has no predictive value

Reference as: Ling D, Boivin M. Ultrasound for critical care physicians: take a deep breath. Southwest J Pulm Crit Care. 2015;11(1):38-41. doi: http://dx.doi.org/10.13175/swjpcc091-15 PDF