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Chapter 8: Hypoxemic Respiratory Failure

A 72-year-old woman with history of Parkinson disease and diabetes presents to the emergency department (ED) complaining of nausea, vomiting, and abdominal pain. A CT scan revealed a small bowel obstruction secondary to a twist in the mesentery. She subsequently was intubated for exploratory laparotomy and lysis of adhesions. She continued to fail daily spontaneous breathing trials for the last 3 days. The chest radiograph below is the morning post breathing trial failure (Fig. 8-2).



Figure 8-2. Chest radiograph after third day of failing spontaneous breathing trial.

What is the next step?

A. Chest physiotherapy

B. Acetylcysteine with bronchodilators

C. Bronchoscopy

D. Albuterol

A. Chest physiotherapy

Initial treatment for atelectasis include nonpharmacologic methods such as chest physiotherapy, postural drainage, incentive spirometry, humidification of oxygen supplementation, and early ambulation. There is debate on whether pharmacologic treatment such as albuterol and acetylcysteine (choice D and B) truly improve atelectasis. Nebulized acetylcysteine can cause bronchoconstriction, and often, it is given with a bronchodilator. It has been suggested that acetylcysteine is truly beneficial with intrabronchial administration during bronchoscopy. Bronchoscopy (choice C) maybe considered if the patient has persistent atelectasis after 24 hours of conservative treatment and/or to rule out intrabronchial etiology such as a neoplasm.

A 30-year-old man decided to go hiking. After 48 hours, he has reached an altitude of 4000 feet. He decides to continue further when he suddenly complains of headache and shortness of breath. Then he starts to have fever and chills, and begins coughing up pinkish, frothy secretions. He starts to climb down where he encountered other hikers who managed to help him. What is the primary treatment?

A. Descent and oxygen supplementation

B. Nifedipine

C. Sildenafil

D. Dexamethasone

A. Descent and oxygen supplementation

High-altitude pulmonary edema is the result of a maladaptive response to reduced oxygen tension. There is poor ventilator response, increased sympathetic tone, heterogeneous vasoconstriction, inadequate production of nitric oxide, and overproduction of endothelin resulting in uneven disruption of the blood–gas barrier and the accumulation of plasma and red blood cells in the alveolar spaces. Risk factors include the following: male sex, cold weather, respiratory infection, altitude above 2500 m, pulmonary hypertension, PFO, atrial septal defect (ASD), and VSD.

High-altitude pulmonary edema rarely happens when the patient has been on a certain altitude for more than 7 days. Clinically, it presents ...

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