4 16 14 vascular disease and respiratory failure small group cases %5bcompatibility mode%5d

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Vascular Disease And Respiratory Failure Case

TutorialsCases and Notes Compiled by

James Allen MD

Case #1

• History: 20 yr old Caucasian woman with acute dyspnea, pleuritic chest pain, and hemoptysis

• PMH: recently started birth control pills• SH: OSU student; non-smoker• FH: father had “phlebitis” after hip surgery• Exam: HR = 122, RR = 24, BP = 92/60,

lungs clear to auscultation

Case #1: ABG

pH 7.50

PCO2 25

PO2 55

HCO3 21

SaO2 90%

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Case #1: PFTs

FVC 3.27 liters 100%

FEV1 2.75 liters 100%

FEV1/FVC 92%

TLC 4.98 liters 100%

DLCO 12.3 ml/min/mm 52%

Case #1: Chest X-ray

Case #1: Discussion

• What is the differential diagnosis?

• How would you confirm the diagnosis?

• What are the likely contributing causes of this disease?

• How would you treat her?

• What would you advise her to do regarding future contraception?

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Pulmonary Embolus: Chest CT

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Pulmonary Embolus: Ventilation/Perfusion (V/Q) scan

Ventilation Perfusion

Pulmonary Embolus: Pulmonary Angiogram

Pulmonary Embolus: Pathology

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Pulmonary Infarction: Pathology

Pulmonary Embolus: Pathology

Pulmonary Embolus

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Older Pulmonary Embolus

Very Old Pulmonary Embolus

Case #2: History

• 30 year old woman with progressive dyspnea over the past 9 months; she is now unable to carry out household chores and unable to walk 1 flight of stairs

• Past medical history: normal

• Social history: married with 2 children

• Family history: no cardiopulmonary disease

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Case #2: Physical Exam

• Vital signs:– 225 pounds– HR 78– BP 130/79– RR 18

• Lungs clear to auscultation• 1/VI systolic murmur, loud pulmonic component

of the second heart sound, elevated jugular venous pressure

• Mild pedal edema

Case #2: Chest x-ray


29 cm

18 cm

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Case #2: PFTs

• FVC 2.95 L (79%)

• FEV1 2.37 L (75%)

• FEV1/FVC 80%

• TLC 4.97 L (90%)

• Diffusing capacity 16.5 (66%)

• 6 minute walk: SaO2 98% at rest and 91% while walking

Discussion Questions

• What does her physical examination suggest?

• How do you interpret the chest x-ray?

• How do you interpret the PFTs?

• What is the significance of the 6 minute walk results?

• What additional studies would you order?

Case #2: Cardiac Echo

• Normal left ventricle

• Dilated, hypokinetic right ventricle

• Dilated pulmonary arteries

• No evidence of intracardiac shunt

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Case #2: Right Heart Catheterization

• Before iNO:– PA = 101/43

– Mean PA = 65

– PCWP = 7

– CO = 4.7

– CI = 2.3

• After iNO:– PA = 88/42

– Mean PA = 56

– PCWP = 7

– CO = 4.9

– CI = 2.6

Discussion Questions:

• What is the diagnosis?

• What is the prognosis?


Case #3: History

• 45 year old caucasian man with shortness of breath worsening over the past 3 years.

• Past medical history: scleroderma

• Social history: disabled engineer; married with 2 children; non-smoker

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• Vital signs:– HR 104– RR 18– BP 132/72

• Lungs clear to auscultation• Heart = tachycardic but regular; loud P2;

elevated jugular venous pressure; II/VI systolic murmur at right sternal border



• What are the pulmonary complications of scleroderma?

• Which one is most likely in this case?• What additional tests could you do to

confirm your clinical suspicion?• What physical examination findings support

this diagnosis?• What would a cardiac echo show?

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Case #3: Right Heart Cath

• Pulmonary artery pressure = 97/41 (mean = 50)

• Pulmonary capillary wedge pressure = 8

• Cardiac output = 3.6

• Cardiac index = 1.8

Case #3: Pathology

Case #3: Pathology

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• How would you treat him?

• Why is a pulmonary capillary wedge pressure important to measure when evaluating pulmonary hypertension?

Case #4

• 51 year old man with new onset seizures and status epilepticus

• Persistent seizures despite Dilantin, phenobarbital, and Propofol

• Intubated and started on pentobarbital drip for pentobarbital coma

• He developed pneumonia after 1 week that improved with antibiotics

Case #4 (continued)

• After 2 weeks, he continues to have seizures when the pentobarbital is held. He remains comatose on a ventilator.

• On rounds, you note that he has developed hypoxemia resulting in an increase in his inhaled oxygen concentration from 30% to 100%

• On exam, he has new swelling of the right leg

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Case #4 (continued)

• What is the most likely diagnosis?

• What test could you do to prove this diagnosis?

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Image courtesy of GE Healthcare; used with permission



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Case #4 (continued)

• What is this patient’s risk factor(s) for this condition?

• What could have been done to prevent it?

• What other tests could have been used in the diagnosis of this condition?

Case #5

• History: 44 yr old African American woman admitted with diverticulitis. 6 days after admission, she is febrile and dyspneic

• PMH: non-insulin dependent diabetes; prior MI• SH: non-smoker• FH: diabetes• Exam (day 6): temp 102, RR = 32, HR = 136, BP

= 74/52; severe respiratory distress; lungs clear to auscultation

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Case #5: ABGs (on 100% supplemental oxygen face mask)

pH 7.24

PCO2 25

PO2 52

HCO3 12 (anion gap = 22)

SaO2 85%

Case #5: Chest X-rays

Admission Hospital Day #6

Case #5: Chest CT

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Case #5: Additional Tests

• Cardiac echo: LV ejection fraction = 42%

• Pulmonary artery catheter (Swan-Ganz): pulmonary capillary wedge pressure = 10 mm Hg

• Blood cultures: E. coli

Case #5: Discussion

• What are the possible causes of her pulmonary infiltrates and hypoxemia?

• How do you know if this is acute respiratory distress syndrome (ARDS) vs. heart failure?

• How should she be managed immediately?

ARDS pathology

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Case #6: History

• 19 year old man with increasing confusion and morning headaches

• Past medical history: Duchenne’s muscular dystrophy; no surgery, no current medications

• Social history: disabled after high school

• Family history: first degree relatives healthy

Case #6: History

• Review of systems: wheelchair bound; some difficulty swallowing; requires assistance with activities of daily living


• Vital signs:– Afebrile– RR = 16– HR = 102– BP = 100/68

• Diffuse muscle atrophy• Lungs clear to auscultation but both

diaphragms elevated to percussion

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Case #6: PFTs

• FVC 1.76 L (52%)

• FEV1 1.48 L (56%

• FEV1/FVC 84%

• TLC 3.54 L (60%)

• Diffusing capacity 24 (120%)

Case #6: ABG

• pH 7.30

• PO2 62

• PCO2 68

• HCO3 35

• SaO2 91%

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• Is this hypercarbic or hypoxemic respiratory failure?

• What is the cause of his respiratory failure?

• What is the cause of his confusion?

• How would you treat him?

• What is the prognosis?

Case #7: History

• 60 year old woman with cough and increasing dyspnea for 2 weeks. Her family physician started oral steroids and antibiotics 4 days ago (for presumed exacerbation of COPD) with no benefit yet. For the past 24 hours, she has become much more short of breath

• Past medical history: – Illnesses: emphysema– Surgery: cholecystectomy 10 years ago

Case #7: History

• Medications:– Atrovent (inhaled bronchodilator)

– Serevent (inhaled bronchodilator)

– Prednisone 40 mg/day (oral steroid)

– Doxycycline (oral antibiotic)

• Social history: 60 pack year smoker - still smokes; real estate agent; divorced

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Case #7: History

• Family history: mother died of myocardial infarction; father died of stroke

• Review of systems: cough productive of yellow sputum; unable to climb one flight of stairs


• Vital signs:– Afebrile– RR = 32– HR = 112– BP = 134/80

• Severe respiratory distress; only able to speak 2-3 words per breath

• Lungs - barely audible breath sounds; prolonged expiratory phase of respiration


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Case #7: ABG

• Room Air:– pH 7.18

– PO2 52

– PCO2 74

– HCO3 28

– SaO2 85%

• 60% oxygen:– pH 7.12

– PO2 72

– PCO2 80

– HCO3 29

– SaO2 92%


• Is the main problem acute hypoxemic or hypercarbic respiratory failure?

• What is the cause of her respiratory failure?

• How would you treat her respiratory failure?

Case #7: Follow-up

• After you successfully manage her in the hospital, her acute illness has resolved and she follows up in your office 2 months later

• Although her dyspnea has improved, she can only walk one flight of steps and is unable to return to work as a realtor because of limiting dyspnea when showing houses

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Case #7: Outpatient ABG

• Room Air:– pH 7.38– PO2 52– PCO2 42– HCO3 25– SaO2 87%

• SaO2 while walking in the clinic hallway = 78%


• Is her chronic respiratory failure hypercarbic or hypoxemic?


4 16 14 vascular disease and respiratory failure small group cases %5bcompatibility mode%5d

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