Ultrasound For Critical Care Physicians: Neutropenic Patient With Fever and Shortness of Breath

Erik Kraai MD

Michel Boivin MD

Division of Pulmonary / Critical Care and Sleep

University of New Mexico

Albuquerque, NM

A 63 year old female with a history of acute myelogenous leukemia presents with shortness of breath, fever and hypotension to the ICU. She is in septic shock on norepinephrine, and has been treated on the oncology unit with vancomycin, cefepime, acyclovir and voriconazole. She has been neutropenic for 1 month. The patient develops a progressive right lower chest opacity. This opacity has progressed in spite of antibiotics and antifungals. The portable AP chest radiograph is presented below (Figure 1). 

Figure 1. Portable AP of chest.

An ultrasound of the right chest was performed for further evaluation of the opacity (figure 2). 

Figure 2. Ultrasound of right hemithorax.

Question: What pathology does the ultrasound reveal in the right hemithorax? (Click on the correct answer to proceed to the next panel)

1. Air filled cavity
2. Chest wall abscess
3. Fractured ribs
4. Pleural effusion and suspected empyema
5. Simple consolidation

Refernece as: Kraai E, Boivin M. Ultrasound for critical care physicians: neutropenic patient with fever snd shortness of breath. Southwest J Pulm Crit Care. 2014;8(6):330-3. doi: http://dx.doi.org/10.13175/swjpcc073-14 PDF

June 2014 Critical Care Case of the Month: Acute Exacerbation in Cystic Fibrosis

Seongseok Yun, MD PhD¹ 

Juhyung Sun, BS²

Laura Howe, MD¹

Roberto Bernardo, MD¹

Sepehr Daheshpour, MD¹

Department of Medicine¹

College of Medicine²

University of Arizona

Tucson, AZ 85724

History of Present Illness

A 28 year-old woman with a history of cystic fibrosis, presented with worsening shortness of breath and cough associated with productive secretions. She was diagnosed with cystic fibrosis when she was 14 months old, and has a history of multiple inpatient admissions for acute pulmonary exacerbation of cystic fibrosis. Her most recent hospitalization was a month prior to this admission, and sputum culture demonstrated methicillin-resistant Staphylococcus aureus, multidrug-resistant Pseudomonas aeruginosa, and Achromobacter xylosoxidans. She was treated with linezolide, meropenum, colistin, and azithromycin with significant symptom improvement, then, discharged home with ciprofloxacin, linezolide and zosyn. However, she developed worsening respiratory distress again and came back to hospital. In the emergency department she required 10 L/min of oxygen to maintain an SpO₂ above 90 %.

PMH

• Cystic fibrosis
• Seizure
• Kidney stone
• Portacath placement
• Gastrostomy tube placement

Medications

• Azithromycin 500 mg 3 times a day
• Dornase alpha 1 mg/ml nebulizer twice a day     
• Fluticasone-salmeterol 500-50 mcg/dose inhaler twice a day
• Lipase-protease-amylase 21,000-37,000-61,000 unit 4 caps a day
• Cholecalciferol  2,000 unit capsule daily
• Ferrous sulfate 325 mg PO twice a day
• Ascorbic acid 250 mg PO twice a day
• Oxycodone-acetaminophen  10-325 mg 4 times a day as needed

Social History

• No smoking
• No alcohol use
• No recreational drug use

Physical Examination

Vital signs: Temperature 37.3 °C, heart rate 114 beats/min, respiratory rate 20-24 breaths/min, blood pressure 99/69mmHg, SpO2 88-90 % on 10 L NC

General: Alert and oriented X 3, acutely distressed, tachypneic and dyspneic

Skin: Diaphoretic. No rash or lesions.

HEENT: Unremarkable.

Respiratory: Diffuse rales in all lung fields, no wheezing, no stridor

CVS: Tachycardic, regular rhythm, no murmur.

Abdomen: Soft, non-tender, no tenderness, no guarding, no hepato-splenomegaly, PEG tube placed

Lymphatics: No cervical or axillary lymphadenopathy

Extremities: No clubbing, no cyanosis, no peripheral edema, normal tone, normal range of movement

Neurological: Normal speech, no focal neurologic deficit, CN exam within normal range

Laboratory

CBC: WBC 11.9X 10³ /μL, Hb 9.8 g/dL, Hct 30.7%, Platelets 356,000 /μL.

Chemistries: Na⁺ 137 meq/L, K⁺ 4.1 meq/L, Cl^- 107 meq/L, CO₂ 22 mmol/L, blood urea nitrogen (BUN) 13 mg/dL, creatinine 0.7 mg/dL, glucose 106 mg/dL, calcium 8.0 mg/dL, albumin 2.6 g/dL, liver function tests within normal limits.

Prothrombin time (PT) 14.0 sec, international normalized ratio (INR)1.1, partial thromboplastin time (PTT) 37.2sec

Pulmonary Function Test

FVC 48 % (1.95 L), FEV₁ 36 % (1.25 L), FEF_25-75 14 % (0.55 L/sec)

Radiography

An old chest x-ray and thoracic CT scan were reviewed (Figure 1).

Figure 1. Previous PA (Panel A), lateral (Panel B) chest x-ray and representative image from the thoracic CT scan (Panel C).

Which of the following are findings of cystic fibrosis on chest x-ray? (Click on the correct answer to move to the next panel)

1. Bronchiectasis
2. Hyperinflation
3. Lobar collapse
4. Prominent pulmonary arteries
5. All of the Above

Reference as: Yun S, Sun J, Howe L, Bernardo R, Daheshpour S. June 2014 critical care case of the month: acute exacerbation in cystic fibrosis. Southwest J Pulm Crit Care. 2014;8(6):305-19. doi: http://dx.doi.org/10.13175/swjpcc047-14 PDF

Ultrasound for Critical Care Physicians: Really, At Her Age?

A 71 year old woman presented with dyspnea since late 2013 and denies a prior history of dyspnea. She had a cardiac pacemaker placed in 2008 for sick sinus syndrome. Her physical exam was unremarkable and her SpO2 was 96% on room air. However,  it decreased to 84% with exercise. Chest x-ray and pulmonary function testing were unremarkable (a DLco was unable to be performed). A transthoracic echocardiogram was performed (Figure 1).

Figure 1. Movie with Doppler flow of transthoracic echocardiogram. 

Which of the following best explains the patient's dyspnea and hypoxia? (Click on the correct answer to proceed to the next panel)

1. Cardiac tamponade
2. Decreased cardiac contractility
3. Intracardiac shunt
4. Mitral insufficiency
5. Ventilation perfusion mismatch from COPD

Reference as: Wesselius LJ. Ultrasound for critical care physicians: really, at her age? Southwest J Pulm Crit Care. 2014;8(5):278-9. doi: http://dx.doi.org/10.13175/swjpcc061-14 PDF

May 2014 Critical Care Case of the Month: Second Wind

Kenneth K. Sakata, MD

Sudheer Penupolu, MD 

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 65 year old woman was admitted for gastrointestinal bleeding as evidence by hematochezia. At the time of admission she denied any respiratory symptoms other than mild dyspnea. However, she rapidly developed respiratory failure, was transferred to the ICU and required emergent intubation.

PMH, FH, SH

She has a history of rheumatoid arthritis with a cervical spine fusion. There is also a history of sarcoidosis and she was receiving prednisone 30 daily up until the time of admission. There is no significant family history. She does not smoke or drink.

Physical Examination

Afebrile. Pulse 78. BP 105/65 mm Hg. Respirations: 28. SpO2 96% while receiving an FiO2 of 60% at the time of transfer to the ICU.

Neck: No jugular venous distention.

Lungs: Scattered rales and rhonchi.

Cardiovascular: Regular rhythm. 

Abdomen: no hepatosplenomegaly.

Radiography

A portable chest x-ray taken after intubation is shown in figure 1.

Figure 1. Portable chest x-ray taken shortly after intubation.

Which of the following best describe the chest x-ray? (Click on the correct answer to move to the next panel)

1. Chronic interstitial disease
2. Diffuse consolidation
3. Endotracheal tube in the right mainstem bronchus
4. Small right pneumothorax
5. All of the above

Reference as: Sakata KK, Penupolu S, Viggiano RW. May 2014 critical care case of the month: second wind. Southwest J Pulm Crit Care. 2014;8(5):258-65. doi: http://dx.doi.org/10.13175/swjpcc033-14 PDF

Ultrasound for Critical Care Physicians: The Big Squeeze

A 57 year-old man without significant past medical history presented with difficulty swallowing and pleuritic chest pain.  He was undergoing evaluation for his dysphagia when he was noted to be tachycardic and hypotensive shortly after admission to the medical-surgical ward.  His initial chest x-ray revealed bilateral pleural effusions and what appeared to be cardiomegaly. A cardiac ultrasound was performed (Figure 1).

Figure 1. Subxiphoid view of patient's heart, inferior vena cava and hepatic vein.

What is the cause of the patient's tachycardia and hypotension?

1. Aortic dissection
2. Cardiac tamponade
3. Cardiomyopathy
4. Mitral insufficiency
5. Pulmonary embolus

Reference as: Siddiqi T, Assar S, Malo J. Ultrasound for critical care physicians: the big squeeze. Southwest J Pulm Crit Care. 2014;8(4):221-2. doi: http://dx.doi.org/10.13175/swjpcc036-14 PDF