Case Study 11-1: Preoperative Testing in a Patient With Asthma
A.D., 15 years old, was seen in the preadmission testing unit in preparation for her elective spinal surgery. She has a history of mild asthma since age 4, with at least one attack per week. In an acute attack, she will have mild dyspnea, diffuse wheezing, yet an adequate air exchange that responds to bron-chodilators. She was sent to pulmonary health services for a consult with a specialist and pulmonary function studies to clear her for surgery. The anesthesiologist reviewed the pulmonologist's report.
Her prebronchodilator spirometry showed a mild reduction in vital capacity but with a moderate to severe decrease in FEV1 and FEV1/FVC ratio. After bronchodilator administration, there was a mild but insignificant improvement in FEV1. The postbronchodilator FEV1 was 55% of predicted and was considered moderately abnormal. The flow volume loops and spirographic curves were consistent with airflow obstruction.
Case Study 11-2: Giant Cell Sarcoma of the Lung
L.E., a 68-year-old man, was admitted to the pulmonary unit with chest pain on inspiration, dyspnea, and diaphoresis. He had smoked 1V2 packs of cigarettes per day for 52 years and had quit 3 months ago. L.E. was retired from the advertising industry and admitted to occasional alcohol use. He was treated for primary giant cell sarcoma of the left lung 3 years ago with a lobectomy of the left lung followed by radiation and chemotherapy.
Physical examination was unremarkable except for a thoracotomy scar in the left hemithorax, decreased breath sounds, and dullness to percussion of the left base. There was no hemoptysis. Radio-nucleotide bone scan showed increased activity in the left upper posterior hemithorax. Chest and upper abdomen CT scan showed findings compatible with recurrent sarcoma of the left hemithorax. Abnormal mediastinal nodes were evident. Thoracentesis was attempted but did not yield fluid. L.E. was scheduled for a left thoracoscopy, mediastinoscopy, and biopsy.
Case Studies, continued
Case Study 11-3: Terminal Dyspnea
N.A., a 76-year-old woman, was in the ICU in the terminal stage of multisystem organ failure. She had been admitted to the hospital for bacterial pneumonia, which had not resolved with antibiotic therapy. She had a 20-year history of COPD. She was not conscious and was unable to breathe on her own. Her ABGs were abnormal, and she was diagnosed with refractory ARDS. The decision was made to support her breathing with endotracheal intubation and mechanical ventilation. After 1 week and several unsuccessful attempts to wean her from the ventilator, the pulmonologist suggested a permanent tra-cheostomy and family consideration of continuing or withdrawing life support. Her physiologic status met the criteria of remote or no chance for recovery.
N.A.'s family discussed her condition and decided not to pursue aggressive life-sustaining therapies. N.A. was assigned DNR status. After the written orders were read and signed by the family, the endotracheal tube, feeding tube, pulse oximeter, and ECG electrodes were removed and a morphine IV drip was started with prn boluses ordered to promote comfort and relieve pain and other symptoms of dying. The family sat with N.A. for many hours while her breaths became shallow with Cheyne-Stokes respirations. She died surrounded by her family, joined by the hospital chaplain.
CASE STUDY QUESTIONS
Multiple choice: Select the best answer and write the letter of your choice to the left of each number.
a. turbulence b. breathing c. twisted d. air quality e. saturation
_ 2. The root pulmon, as in pulmonary, means:
a. chest b. air c. lung d. breath sound e. blood vessel
a. drooping eyelids b. discoloration of skin c. blue nail beds d. spitting of blood e. acute leukemia
_ 4. Dyspnea could NOT be described as:
a. difficulty breathing b. eupnea c. air hunger d. orthopnea e. Cheyne-Stokes respirations
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_ 5. Pulse oximetry is used to measure:
d. oxygen saturation of blood e. positive end-expiratory pressure
_ 6. An endotracheal tube is placed:
a. under the trachea b. beyond the carina c. within the bronchus d. around the airway e. within the trachea
Write the word in the case histories with each of the following meanings:
8. Profuse sweating _
9. Surgical puncture of the chest _
10. A drug that enlarges the lumen of the bronchi _
11. Endoscopic examination of the chest cavity _
13. Movement of air into and out of the lungs _
14. A lung infection _
15. Whistling breath sounds due to narrowing of the breathing passageways
16. Endoscopic examination of the space between the lungs Abbreviations. Define the following abbreviations:
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If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.