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Alveolar elastic tissue destruction
7%
3/41
Aortic intimal tear
5%
2/41
Lung collapse
15%
6/41
Lung hyperinflation
41%
17/41
Pericardial fluid accumulation
32%
13/41
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This patient is presenting with dyspnea and bilateral poor air movement with hypoxia and hypercarbia and a positive pulsus paradoxus (note his blood pressure drop with inspiration). Given his age and risk factors, asthma is the most likely diagnosis. Asthma occurs secondary to hyperreactive airways that constrict when perturbed by stimuli such as cold weather or antigens. Patients can present with dyspnea and wheezing; however, in severe asthma exacerbations patients may present only with poor air movement bilaterally without wheezing. Pulses paradoxus is also possible in asthma and presents with a drop in blood pressure > 10 mmHg during inspiration. Pulsus paradoxus occurs in asthma because the hyperinflated lungs compress the heart after inspiration which makes the intrathoracic pressure more negative leading to increased right heart flow and decreased left ventricular cardiac output. Acute asthma exacerbations should be treated with albuterol, ipratropium, and steroids. Magnesium can also be added and reduces the need for hospital admission. Krishnan et al. studied whether pulse oximetry could be used to detect pulsus paradoxus in patients who present with asthma exacerbations. They found that patients with pulsus paradoxus required more interventions such as adjunct medications. They recommend using pulse oximetry as a potential point of care method of assessing asthma severity. Incorrect Answers: Answer 1: Alveolar elastic tissue destruction is the pathophysiology of COPD, which occurs in older patients with a significant smoking history. Patients often present with dyspnea, wheezing, hypoxia, hypercarbia, and a barrel chest. This patient is too young and lacks a history supportive of COPD as the etiology of his symptoms. COPD can be treated with supplemental oxygen as well as bronchodilatory drugs such as albuterol and ipratropium. Steroids should also be given. Answer 2: Aortic intimal tear describes an aortic dissection, which presents with tearing chest pain that radiates to the back with asymmetric pulses on physical exam, a widened mediastinum on chest radiograph, and an intimal flap on a CTA of the chest. Aortic dissection should be treated with rate control agents, blood pressure control agents, and surgery in type A dissections. Answer 3: Lung collapse describes a tension pneumothorax which presents with chest pain, dyspnea, hypoxia, hypotension, tachycardia, and absent unilateral breath sounds. Tension pneumothorax is an emergency that should be treated with needle decompression and chest tube placement. A chest radiograph can confirm resolution of the pneumothorax and chest tube placement. Answer 5: Pericardial fluid accumulation describes cardiac tamponade which presents with hypotension, tachycardia, muffled heart sounds, and a pericardial effusion on ultrasound. A pericardiocentesis can be used in order to remove fluid in this condition and stabilize the patient prior to definitive management (pericardial drain or window). Bullet Summary: Asthma is caused by bronchoconstriction and presents with decreased air movement and pulsus paradoxus in severe exacerbations.
3.8
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