January 2024 Critical Care Case of the Month: I See Tacoma

Lewis J. Wesselius MD

Mayo Clinic Arizona, Scottsdale, AZ USA

History of Present Illness

An 80-year-old man was admitted to the hospital for exacerbation of COPD. He has a history of emphysema and has been on Breo Ellipta and Spiriva Respimat. He became increasingly short of breath although he had no productive cough.

Past Medical History, Social History and Family History

He has a past medical history of right upper lobe resection for an adenocarcinoma of the lung and a history of coronary artery bypass grafting and aortic valve replacement done about 5 years ago.

He smoked ½ pack/day of cigarettes but quit 5 years ago.

Medications

He takes warfarin for a history of atrial fibrillation and prosthetic aortic valve replacement.

Physical Examination

Other than dyspnea with tachypnea and decreased air movement on auscultation, as well as the expected right thoracic scar, his physical examination is unremarkable.

Laboratory

His arterial blood gases showed a PaO2 of 58, a PaCO2 of 32, and a pH of 7.50 on 2L/min by nasal cannula. Complete blood count, electrolytes were normal. Prothrombin time was therapeutic.

Radiography

Chest x-ray taken in the emergency department is shown in Figure 1.

Figure 1. Initial PA of chest.

What should be done at this time? (click on the correct answer to be directed to the second of five pages)

1. Admit to the hospital
2. Begin on a theophylline drip
3. Treat with inhaled bronchodilators, oral antibiotics and corticosteroids
4. 1 and 3
5. All of the above

Wesselius LJ. January 2024 Critical Care Case of the Month: I See Tacoma. Southwest J Pulm Crit Care Sleep. 2024;28(1):1-4. doi: https://doi.org/10.13175/swjpccs051-23 PDF