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FSM Critical Care Clerkship: PBL 1- CASE 1

A 34-year old woman with asthma came to the ED for increasing shortness of breath of 3 days
duration. She was unable to sleep the night before and was using albuterol 2 puffs every 10
minutes for several hours prior to ED arrival.

She had been treated 3 times in an ED over the past 6 months for similar symptoms (never
intubated). She never smoked cigarettes and is unemployed. She is a patient of Dr. Lams in
General Medicine Clinic. Meds: albuterol, dicyclomine.

In the ED: HR 118/min; BP 134/90; T 36.9; RR 32/min. She was able to speak in short sentences,
sitting upright, diaphoretic and using accessory muscles of respiration. She had decreased air
entry bilaterally with expiratory phase prolongation and faint expiratory wheezes. The cardiac
exam demonstrated a fast and regular rate without gallop or murmur. The abdomen was soft and
non-tender and there was no c/c/e.

Routine screening for pregnancy: + urine HCG

137 105 21 glucose 94
3.2 22 1.0
ABG (room air): PaO2 63 mmHg, PaCO2 46 mmHg, pH 7.30

She received 2 LPM supplemental oxygen by nasal cannula to maintain oxygen saturations >
94%, albuterol 6 puffs by MDI and spacer every 15 minutes X 3, magnesium sulfate 2 grams
over 20 minutes by vein and solumedrol 60 mg IV. Peak expiratory flow rate was 120 LPM on
arrival and 110 LPM after one hour of treatment. The patient was transferred to the MICU for
further treatment and close observation.

In the ICU you find a diaphoretic woman with monosyllabic speech sitting upright. Air
movement is poor and there are no wheezes. The cardiac rhythm is fast and regular. During your
examination the patient becomes increasingly somnolent. You call an airway emergency and the
anesthesiologist intubates the patient orally with a 7.5 ETT. The respiratory therapist ventilates
the patient with an AMBU-bag, while calling for a ventilator, and tells you that the patient is
extremely difficult to bag. You note diminished breath sounds bilaterally, distended neck veins,
a drop in BP to 85/65 and an increase in HR to 140/min.

PBL 1- CASE 2
A 46 year-old, 70 kg, 70 inches tall man was found agitated and incoherent in a hotel room. He
was brought to the ED by paramedics where his temperature was 102.1, HR 140/m, RR 28/m and
BP 90/60. Pupils were dilated and the skin was erythematous and dry. The patient was intubated
after a short-lived generalized seizure. Vomitus was noted in the oropharnx during intubation.
One liter of normal saline was infused rapidly through a large bore IV and a noncontrast head CT
was normal. His ECG is below:
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ABG: pH of 7.31, PaCO2 of 31 mmHg, PaO2 250 mmHg on assist control-volume ventilation,
RR 12 (patient is breathing 3 times over the ventilator for a total rate of 15), tidal volume 600 ml,
PEEP 5 cmH2O, constant inspiratory flow rate of 60 LPM and FiO2 1.0. Serum electrolytes were
sodium 142 meq/L, bicarbonate 15 meq/L and chloride 106 meq/L. CXR immediately after
intubation: lower zone patchy alveolar infilatrates bilaterally.

PBL 1- CASE 2 continued-

During initial ventilator assessment, you note a peak pressure (on the above settings) of 35
cmH2O. During a 0.5 second inspiratory pause (i.e, inspiratory hold maneuver), airway opening
pressure falls to 25 cmH2O (this is called the plateau pressure) and then, after the pause, airway
opening pressure falls further to the set level of 5 cmH2O PEEP. No auto-PEEP is detected
during an expiratory hold maneuver.
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Below is the CXR taken the following morning (12 hours after admission):

At this time ABG is pH of 7.37, PaCO2 of 37 mmHg, PaO2 60 mmHg on assist control-volume
ventilation with set RR of 12 (patient is now breathing 8 times over the set rate so the respiratory
rate is 20/m), tidal volume 600 ml, PEEP 5 cmH2O, constant inspiratory flow rate of 60 LPM and
FiO2 0.6. Peak pressure is 45 cmH2O and plateau pressure is 35 cmH2O. CVP via a right IJ
venous catheter is 8 mmHg and an echocardiogram demonstrates normal LV and RV function.

PBL1a
1) Was this patient an appropriate candidate for non invasive mechanical
ventilation?
2) Why did this patient become hypotensive after intubation?

PBL1b
1) What was the initial diagnosis?
2) Why did this patient develop bilateral alveolar infiltrates and how should
this have informed subsequent management?