Academy Board Prep
PCCM
Question 1
• A 48-year-old man is evaluated for a 1-year history of cough. He has not
had dyspnea, abdominal pain, heartburn, or change in appetite or weight.
He has a 30-pack-year history of smoking. He does not have seasonal
allergies. His medical history is significant for hypertension that is treated
with losartan.
• On physical examination, vital signs are normal. Pulmonary examination
discloses normal breath sounds that are equal bilaterally with no wheezing.
No nasal polyps are noted. Abdominal examination is unremarkable. There
is no cyanosis, clubbing, or edema. Pulmonary function tests disclose an
FEV1 of 75% of predicted and an FEV1/FVC ratio of 63%. Following
administration of a bronchodilator, there is no significant change in the
FEV1/FVC ratio, and the FEV1 is 83% of predicted. Chest radiograph shows
no masses and normal lung markings.
Which of the following is the most likely cause
of this patient’s cough?
A)
B)
C)
D)
Asthma
COPD
GERD
Losartan
Correct Answer: B
• The most likely cause of this patient's cough is COPD. His postbronchodilator FEV1/FVC
ratio less than 70% confirms airflow limitation and a diagnosis of obstructive lung
disease; his relatively preserved FEV1 suggests that his COPD is mild. COPD should be
considered in any patient older than 40 years who has dyspnea, chronic cough or sputum
production, and/or a history of risk factors (such as exposure to tobacco smoke, dust,
chemicals, outdoor air pollution, or biomass smoke). Spirometry is the gold standard for
diagnosing COPD and monitoring its progress; it should be done to confirm the diagnosis
and to exclude other diseases.
• The American College of Physicians and Global Initiative for Chronic Obstructive Lung
Disease (GOLD) guidelines require an FEV1/FVC ratio of less than 70% of predicted to
establish the diagnosis of COPD. The GOLD guidelines use the degree of airflow
obstruction as measured by the FEV1 to further describe the level of disease. Level 1
(mild) COPD is characterized by an FEV1 of 80% of predicted or greater; level 2
(moderate) COPD is characterized by an FEV1 of 50% to 79% of predicted; level 3 (severe)
COPD is characterized by an FEV1 of 30% to 49% of predicted; and level 4 (very severe)
COPD is characterized by an FEV1 less than 30% of predicted.
GOLD Criteria
Classification of Severity of Airflow Limitation in COPD (Based on Postbronchodilator FEV1)
In patients with FEV1/FVC <70%:
GOLD 1
Mild
FEV1 ≥80% of predicted
GOLD 2
Moderate
50% ≤ FEV1 < 80% of predicted
GOLD 3
Severe
30% ≤ FEV1 < 50% of predicted
GOLD 4
Very severe
FEV1 <30% of predicted
GOLD = Global Initiative for Chronic Obstructive Lung Disease.
• Although asthma may present with cough, it is unlikely in this patient
owing to the lack of atopy and history of respiratory symptoms as a
child or any other clinical findings consistent with bronchospasm.
• Gastroesophageal reflux disease may cause cough; however, COPD is
the more likely cause of cough in this patient who does not have
heartburn symptoms, has a history of smoking, and demonstrates
airflow obstruction on pulmonary function testing.
• ACE inhibitors may be associated with cough, but angiotensin
receptor blockers (such as losartan) have a significantly lower rate of
cough as a side effect and would not be a likely cause of this patient's
cough given his other clinical parameters.
• Key Point: Spirometry is essential for the diagnosis of COPD and
assessing its degree of severity; a postbronchodilator FEV1/FVC ratio
less than 70% confirms airflow limitation.
Question 2
• A 66-year-old man is evaluated in the intensive care unit for possible
extubation. He was admitted for a severe COPD exacerbation 3 days ago.
His carbon dioxide remained markedly elevated despite a trial of
noninvasive ventilation, and he was therefore intubated and placed on
invasive mechanical ventilation. He has improved with treatment of his
COPD. His medications are methylprednisolone, albuterol, ipratropium,
propofol, and levofloxacin.
• On physical examination, he is awake and responsive. Temperature is 37.0
°C (98.6 °F), blood pressure is 138/82 mm Hg, pulse rate is 96/min, and
respiration rate is 20/min. Pulmonary examination reveals decreased
breath sounds bilaterally with no wheezing. Accessory muscle use is noted.
A small amount of thin secretions is noted with endotracheal suctioning.
Question 2
• Arterial blood gas levels have returned to baseline with pH 7.36, PCO2
of 55, and a PO2 of 70 on a FiO2 of 0.35. He tolerates a weaning trial
well and a decision is made to extubate.
Which of the following interventions will
decrease this patient’s risk for reintubation?
A)
B)
C)
D)
Incentive spirometry every 2 hours
Inhaled helium oxygen mixture
Nebulized N-acetylcysteine
Noninvasive positive pressure ventilation
Correct Answer: D
• Educational Objective: Manage weaning from invasive ventilation with
noninvasive positive pressure ventilation.
• The most appropriate intervention at the time of extubation is noninvasive
positive pressure ventilation (NPPV). Application of NPPV shortly after
extubation for a 24-hour period reduced the need for reintubation in
previous trials of intubated patients with chronic lung disease and
hypercapnia after a successful weaning trial. This population also appears
to benefit from NPPV even if it is not applied until after the patient has
developed respiratory failure following extubation. However, studies
enrolling unselected patients with postextubation respiratory failure
indicate that the use of NPPV may actually increase mortality.
• The use of incentive spirometry reduces the risk of postoperative
pulmonary complications but does not have a role in the routine
management of nonsurgical patients following extubation.
• The reduced gas density of helium-oxygen mixtures (heliox) reduces
resistance to airflow, and thereby the work of breathing, in patients
with obstructive lung disease. However, there is insufficient evidence
to support the routine use of heliox in the management of COPD
exacerbations.
• N-acetylcysteine is a mucolytic agent that has been used to thin
secretions in patients with excess mucus production. However, Nacetylcysteine is less likely to benefit this patient because he had
minimal secretions prior to extubation. Furthermore, nebulized Nacetylcysteine may trigger bronchospasm.
• Key Point: Application of noninvasive positive pressure ventilation
shortly after extubation for a 24-hour period reduced the need for
reintubation in trials of intubated patients with chronic lung disease
and hypercapnia after a successful weaning trial.
Question 3
• A 78-year-old man is evaluated during a routine physical examination. One year
ago, he was treated in the intensive care unit (ICU) for severe sepsis and
respiratory failure due to community-acquired pneumonia. He was intubated for
9 days during the ICU stay and required treatment with corticosteroids,
ceftriaxone, levofloxacin, lorazepam, vecuronium, and norepinephrine. A family
member reports concern that the patient has not regained his ability to function
independently since the illness. He is forgetful, has occasional difficulty finding
words, gets lost easily in familiar places, and cannot seem to make decisions. The
patient has successfully completed a physical therapy rehabilitation program and
has regained his former muscle strength. There is no history of chronic illness
such as coronary artery disease, diabetes mellitus, or hypertension, and he takes
no medications.
• On physical examination, vital signs are normal. He is alert but slow to answer
questions. The cardiopulmonary examination is normal. The Mini–Mental State
Examination score is 25/30. There are no focal neurologic deficits.
Which of the following factors associated with this
patient’s critical illness is the most likely cause of
his critical findings?
A)
B)
C)
D)
Chronic disseminated intravascular coagulation
Critical illness polyneuropathy
Post-ICU neuropsychiatric impairment
Prolonged neuromuscular blockade
Correct Answer: C
• Educational Objective: Diagnose neuropsychiatric impairment as a common
complication after critical illness.
• The most likely long-term complication of critical illness is persistent neuropsychiatric
impairment, which can affect up to 75% of critically ill patients, especially those with the
diagnosis of either severe sepsis or acute respiratory distress syndrome. The syndrome
appears clinically as acquired dementia. The factors in the intensive care unit (ICU) that
are associated with the development of the syndrome include age, duration of
mechanical ventilation, and glycemic control (hyperglycemia or hypoglycemia). There is
some evidence that the degree of impairment correlates with hypoxemia in these
patients.
• A patient with chronic disseminated intravascular coagulation would most likely have
problems related to low platelets and possibly thrombosis. Acquired dementia can be a
result of microvascular thrombosis, but this is an unlikely explanation in the absence of
other findings. Failure to provide appropriate prophylaxis in the ICU usually results in
more acute complications, such as infection, peptic ulcer disease, or deep venous
thrombosis.
• Critical illness polyneuropathy is one type of ICU-acquired weakness,
along with critical illness myopathy. ICU-acquired weakness is
common with recognized risk factors, including corticosteroid use and
neuromuscular blocking agents, but it does not affect cognition. By
the time this patient's family member raised concerns, the patient
had regained his former muscle strength. Therefore, ICU-acquired
weakness is not the explanation for this patient's psychiatric disability.
• Prolonged neuromuscular blockade is an uncommon condition
associated with prolonged use of paralytic agents typically in patients
with concomitant liver disease, but it does not cause cognitive
impairment.
• Key Point: Persistent neuropsychiatric impairment can affect up to
75% of critically ill patients, and it is associated with the patient's age,
duration of mechanical ventilation, and glycemic control
(hyperglycemia or hypoglycemia).
Question 4
• A 67-year-old man is evaluated for a 3-month history of pauses in
breathing during sleep that have been witnessed by his wife. He has
minimal snoring but occasional paroxysmal nocturnal dyspnea. His normal
sleep schedule is 10:30 PM to 6:30 AM. He does not have insomnia or
daytime sleepiness. He was recently diagnosed with heart failure. His
current medications are aspirin, lisinopril, atorvastatin, and metoprolol.
• On physical examination, temperature is 36.6 °C (97.9 °F), blood pressure is
128/78 mm Hg, pulse rate is 88/min, and respiration rate is 16/min; BMI is
24. Cardiac examination discloses an S3 but no murmurs. Pulmonary
examination shows a widely patent oropharyngeal airway and a few
bibasilar crackles. There is trace bilateral lower extremity edema.
Polysomnography discloses classic Cheyne-Stokes breathing. Oxygen
saturation throughout the study is greater than 88%.
Which of the following is the most
appropriate next step in treatment?
A)
B)
C)
D)
E)
Adaptive Servoventilation
CPAP
Diuresis
Nocturnal Oxygen
Oral Appliance
Correct Answer: C
• Educational Objective: Treat central sleep apnea in a patient with heart failure.
• The most appropriate treatment is diuresis. This patient has Cheyne-Stokes breathing/central
sleep apnea (CSA) related to underlying heart failure. Breathing pauses may be observed by a bed
partner; however, in contrast with obstructive sleep apnea, snoring is not as common, and
patients are not as likely to be sleepy or overweight or have a crowded oropharynx on
examination. Cheyne-Stokes breathing/CSA is believed to occur as a consequence of heart failure,
a condition that predisposes to hyperventilation. CSA severity tends to correlate with the degree
of cardiac dysfunction, such that improvements in cardiac function will have a concordant effect
on CSA. Therefore, the usual first step in the management of CSA in the setting of heart failure is
medical optimization of cardiac function. This patient has evidence of inadequately treated heart
failure, with crackles, an S3, and lower extremity edema on examination. Diuresis to improve fluid
balance and manage heart failure would be the most appropriate next step before initiating
additional therapies for his sleep-disordered breathing.
• In cases where CSA persists after medical optimization, a form of positive airway pressure therapy
called adaptive servoventilation (ASV) often effectively controls CSA, although clinical outcomes
data are scant. The computer algorithm governing ASV promotes ventilatory stability with timed
delivery of pressure support that is synchronized to the patient's breathing effort.
• Continuous positive airway pressure (CPAP) may be effective,
particularly if there is a mixed element of obstructive sleep apnea,
but CPAP can also exacerbate or worsen CSA.
• This patient had normal oxygen levels during polysomnography, so
supplemental oxygen is not needed at this time. However, the use of
supplemental oxygen could be considered in the setting of low
oxyhemoglobin saturations due to impaired gas exchange from
cardiac disease.
• Oral appliances may be a useful adjunct in the treatment of
obstructive sleep apnea. However, the use of a device in this patient
without evidence of obstruction and a diagnosis of CSA would not be
appropriate.
• Key Point: The most appropriate first-line treatment for central sleep
apnea in a patient with heart failure is medical therapy to improve
cardiac function.
Question 5
• A 70-year-old woman is evaluated during a routine examination. She has
severe COPD with recurrent exacerbations and decreasing exercise
capacity. She does not have cough or fever, but she has dyspnea with
activities of daily living. She stopped smoking 1 year ago and is adherent to
her medication regimen. Her inhaler technique is good. Her medications
are fluticasone/salmeterol, tiotropium, and an albuterol inhaler as needed.
• On physical examination, pulse rate is 80/min and respiration rate is
22/min; BMI is 22. Pulmonary examination reveals diminished breath
sounds that are equal bilaterally. No wheezing or crackles are noted. FEV1 is
45% of predicted. Oxygen saturation is 92% at rest and 90% after exertion
breathing ambient air. Chest radiograph shows no infiltrate or mass.
Which of the following is the most
appropriate management?
A)
B)
C)
D)
Morphine
Oxygen therapy
Prednisone
Pulmonary rehabilitation
Correct Answer: D
• Educational Objective: Manage severe COPD with pulmonary rehabilitation.
• Pulmonary rehabilitation is the most appropriate management for this patient. Current
guidelines recommend pulmonary rehabilitation for symptomatic patients with an FEV1
less than 50% of predicted. Pulmonary rehabilitation may be considered for symptomatic
or exercise-limited patients with an FEV1 greater than or equal to 50% of predicted, but
this is a weaker recommendation based upon moderate-quality evidence. Exercise
training improves skeletal muscle function and reduces dynamic hyperinflation. Benefits
of pulmonary rehabilitation include improvement in exercise capacity, reduction in the
perceived intensity of breathlessness, improvement in health-related quality of life, and
reduction in anxiety and depression associated with COPD. It is not recommended for
patients who cannot walk or who have unstable angina or recent myocardial infarction.
• Morphine can be used in palliation for patients with severe dyspnea, especially at rest.
However, this patient's dyspnea is not severe, so morphine is not appropriate at this
time.
• This patient's oxygenation is adequate, and supplemental oxygen is not
required. Oxygen therapy is indicated for patients who have hypoxemia,
arterial PO2 of 55 mm Hg (7.3 kPa) or lower, or oxygen saturation of 88% or
lower.
• This patient has no indication for a short-term course of a systemic
corticosteroid because she does not have evidence of an acute
exacerbation. An exacerbation of COPD is defined as an acute event
characterized by a change in baseline dyspnea, cough, and/or sputum
production beyond normal daily variation. The main symptoms include
increased dyspnea often accompanied by wheezing and chest tightness,
increased cough and sputum production, change in the color and/or
tenacity of sputum, and fever. Various nonspecific signs and symptoms
such as fatigue, insomnia, depression, and confusion may accompany these
findings.
• Key Point: Current guidelines recommend pulmonary rehabilitation for
patients with symptomatic COPD who have an FEV1 less than 50% of
predicted.
Pharmacologic therapies
Therapy for Stable, Symptomatic COPD Based on Level of Airflow Obstructiona
Level of Airflow Obstruction
Recommended Therapyb
FEV1 60%-80% of predicted
Consider inhaled bronchodilator therapy
(anticholinergic or β2-agonist) (weak
recommendation, low-quality evidence)
FEV1 <60% of predicted
Daily monotherapy with an inhaled bronchodilator
(long-acting anticholinergic or long-acting β2agonist), with the choice of therapy based on patient
preference, cost, and side-effect profile (strong
recommendation, moderate-quality evidence)
Consider combination inhaled therapy (long-acting
anticholinergic, long-acting β2-agonist, or
corticosteroid) (weak recommendation, moderatequality evidence)
FEV1 <50% of predicted
Consider adding pulmonary rehabilitation (weak
recommendation, moderate-quality evidence)
aIn
patients with an FEV1/FVC ratio <70%.
use of short-term bronchodilators for breakthrough symptoms or exacerbation is appropriate
at any level of pulmonary function in COPD.
bOccasional
Question 6
• A 52-year-old woman is evaluated for a 1-month history of cough associated with
yellow phlegm production. She has a 35-pack-year history of cigarette smoking
but stopped smoking at the time of cough onset. She received albuterol, but the
cough did not improve. A follow-up chest radiograph showed hyperinflation and a
2-cm nodular opacity in the left lower lobe. There are no old images available for
comparison. A mammogram and Pap smear earlier this year were normal. She
has not had colorectal cancer screening.
• On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is
132/77 mm Hg, pulse rate is 76/min, and respiration rate is 18/min; BMI is 23.
Pulmonary examination reveals diminished breath sounds bilaterally. No
lymphadenopathy is noted.
• Laboratory studies, including a complete blood count and metabolic profile, are
normal. CT images (lung and mediastinal windows) of the 2.3-cm nodule in the
left lower lobe are shown
CT scan of lung and mediastinal windows
Which of the following is the most likely
diagnosis?
A)
B)
C)
D)
Carcinoid tumor
Granuloma
Metastatic Cancer
Non-small cell lung cancer
Correct Answer: B
• Educational Objective: Evaluate a 2-cm calcified lung nodule in a former smoker.
• The nodule in the CT images is densely, centrally calcified and smoothly bordered,
consistent with a granuloma. The likelihood that a nodule is malignant depends
on such factors as its size and surface characteristics and the patient's age,
smoking history, and history of previous malignancy. Nodules with smooth
borders are usually benign; nodules with spiculated borders have a high
likelihood of being malignant. “Popcorn” (amorphous calcification in rings and
arcs), lamellar (concentric rings), central, and diffuse patterns of calcification are
associated with benign disease. Although this patient is at risk for lung cancer
owing to her smoking history, this benign nodule needs no further evaluation.
Not all patterns of calcification are associated with benign disease. A nodule that
has eccentric or off-center calcification may be either benign or malignant, and
further evaluation or follow-up is advised.
Followup recommendations
Recommendations for Pulmonary Nodule Evaluation Based on Risk
Nodule Size (mm)
Low-Riska Follow-up
High-Riskb Follow-up
<4
None
12 months; if unchanged, stop
4-6
12 months; if unchanged, stop
6-12 months; if unchanged, 18-24
months
6-8
6-12 months; if unchanged, 18-24
months
3-6 months; if unchanged, 9-12 and
24 months
>8
Consider contrast CT study, PET
scan, or biopsy; if followed, 3, 9,
and 24 months
Same as low risk
aLow
risk: Never-smoker and no other risk factors.
bHigh risk: Current or former smoker or other risk factors.
• Bronchial carcinoid tumors are low-grade malignant neoplasms that consist
of neuroendocrine cells and account for 1% to 2% of all tumors of the lung.
Patients may present with hemoptysis, have evidence of bronchial
obstruction, or be asymptomatic. Carcinoid tumors are often located
within a central airway, have a smooth border, and are not calcified.
• A history of malignancy is another indicator of possible cancer. The lung is a
common site of metastasis from various tumors; the most common are
tumors of the breast, head and neck, colon, thyroid gland, and kidney. This
patient does not have a history of cancer, and metastases are usually
multiple and smoothly bordered but not calcified.
• Calcium within a non–small cell carcinoma is unusual and, when present, is
eccentric (off-center).
• Key Point: Calcification in certain patterns (popcorn, central, diffuse,
lamellar) indicates that a pulmonary nodule is probably benign and
requires no further investigation.
Question 7
• A 55-year-old man is evaluated in the emergency department after being
found unconscious on the ground outside of his home by family members.
He was difficult to arouse and was confused. He was breathing
spontaneously, but his breaths were rapid and shallow.
• On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is
135/91 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. He is
arousable only with noxious stimuli. Other than tachycardia, the
cardiopulmonary examination is normal. The abdomen is soft, and there
are no focal findings on neurologic examination.
• Toxicology screen is negative for ethanol, opioids, benzodiazepines, and
common recreational drugs. Chest radiograph shows no lung infiltrates or
masses. There is very little urine in the bladder, but urine obtained by
catheterization contains many erythrocytes and envelope-shaped crystals.
Question 7
Laboratory studies:
Blood urea nitrogen
14 mg/dL (5 mmol/L)
Creatinine
1.9 mg/dL (168 µmol/L)
Electrolytes:
Sodium
138 meq/L (138 mmol/L)
Potassium
4.1 meq/L (4.1 mmol/L)
Chloride
90 meq/L (90 mmol/L)
Bicarbonate
12 meq/L (12 mmol/L)
Glucose
90 mg/dL (5.0 mmol/L)
Lactic acid
2.8 mg/dL (0.3 mmol/L)
Serum osmolality
390 mosm/kg (390 mmol/kg)
Blood gases:
pH
7.24
Arterial PCO2
28 mm Hg (3.7 kPa)
Arterial PO2
102 mm Hg (13.6 kPa)
Which of the following is the most
appropriate treatment?
A)
B)
C)
D)
E)
Hemodialysis
Intravenous ethanol
Intravenous fomepizole
Intravenous fomepizole and hemodialysis
Supportive care
Correct Answer: D
• Educational Objective: Manage toxic alcohol (ethylene glycol) ingestion.
• The most appropriate treatment is intravenous fomepizole and hemodialysis. This
patient has acute toxicity from ingestion of ethylene glycol. Ethylene glycol is a
component of antifreeze and solvents. Metabolism of ethylene glycol by alcohol
dehydrogenase generates various acids, including glycolic, oxalic, and formic acids.
Ethylene glycol poisoning initially causes neurologic manifestations similar to ethanol
intoxication, and seizures and coma can rapidly develop. If this condition is not treated,
noncardiogenic pulmonary edema and cardiovascular collapse may occur. Approximately
24 to 48 hours after ethylene glycol ingestion, patients may develop flank pain and
kidney failure that are often accompanied by calcium oxalate crystals in the urine.
Fomepizole is an inhibitor of alcohol dehydrogenase and should be given to decrease
metabolism of ethylene glycol, which is itself not toxic. Hemodialysis should be started in
this patient because there is evidence of end-organ damage to the kidney (elevated
serum creatinine, oliguria, and hematuria), an osmolal gap (104 mosm/kg [104
mmol/kg]), and significant anion gap metabolic acidosis (anion gap, 36 meq/L [36
mmol/L]), even though the acidosis may be masked by concomitant respiratory alkalosis
and metabolic alkalosis from vomiting.
Osmolal Gap
• Calulcated Osmol
• (2 𝑥 𝑁𝑎) +
𝐵𝑈𝑁
(
)
3
+
𝐺𝑙𝑢𝑐
(
)
18
= Calculated Gap
• Gap
• 𝑀𝑒𝑎𝑠𝑢𝑟𝑒 𝑂𝑠𝑚𝑜𝑙𝑎𝑙𝑖𝑡𝑦 – 𝐶𝑎𝑙𝑐𝑢𝑙𝑎𝑡𝑒𝑑
• Normal Gap <10
• Hemodialysis plays a crucial role in ethylene glycol poisoning,
particularly in patients with impending acute kidney failure.
Hemodialysis alone would remove toxic metabolites, but without any
competitive inhibition, ethylene glycol would continue to be
converted into additional toxin.
• Intravenous fomepizole or intravenous ethanol alone, without
hemodialysis, would be insufficient to rapidly remove the toxic acid
metabolites.
• Supportive care alone will not be sufficient to prevent acute kidney
failure, prevent cardiovascular complications, or correct the acid-base
disorder.
• Key Point: The most appropriate treatment for ethylene glycol toxicity
is intravenous fomepizole and hemodialysis.
Clinical Manifestations of Ethylene Glycol, Methanol, and Isopropyl Alcohol Ingestion
Alcohol
Common
Name
Toxic
Metabolite
Methanol
Wood
alcohol
Formic acid
Ethylene
glycol
Antifreeze
Glycolic,
glyoxylic,
and oxalic
acids
Isopropyl
alcohol
Rubbing
alcohol
-
CNS = central nervous system.
Nontoxic
Metabolite
-
-
Acetone
Anion Gap
Yes
Yes
No
Osmolar
Gap
Toxicity
Antidote
Yes
Retina
Fomepizol,
ethanol,
dialysis
Yes
Renal
tubules
Fomepizol,
ethanol,
dialysis
Yes
CNS
depression
Fomepizol,
ethanol,
dialysis
Question 8
• A 67-year-old woman is evaluated for the abrupt onset of right-sided pleuritic chest pain
and moderate dyspnea. She recently had symptoms typical of an upper respiratory
infection (rhinorrhea, headache, sore throat, and nonproductive cough), and her chest
pain and dyspnea seemed to be triggered by an episode of vigorous coughing. She has
not had fever, chills, purulent sputum, or risk factors for thromboembolic disease. She
smokes, and her medical history is significant for COPD without additional complications.
Her medications are daily salmeterol and as-needed albuterol.
• On physical examination, she appears uncomfortable but is not in respiratory distress.
She is speaking in full sentences. Temperature is 37.0 °C (98.6 °F), blood pressure is
129/58 mm Hg, pulse rate is 78/min and regular, and respiration rate is 22/min. Oxygen
saturation is 98% on 2 L of oxygen via nasal cannula. Pulmonary examination is significant
for a prolonged expiratory phase but no wheeze; breath sounds are symmetric bilaterally.
The trachea is midline. There is no accessory muscle use. Cardiac examination is normal
with no murmurs. No edema is noted.
• Electrocardiogram shows normal sinus rhythm without ischemic changes.
Question 8
In addition to hospital admission, which of the
following is the most appropriate next step in
management?
A)
B)
C)
D)
Evaluation for pleurodesis
Needle aspiration
Serial chest radiography
Tube thoracostomy
Correct Answer: C
• Educational Objective: Manage secondary spontaneous pneumothorax.
• The most appropriate next step in management is serial chest radiography.
This patient presents with a small, spontaneous pneumothorax in the
setting of known COPD. The pneumothorax is therefore classified as a
secondary spontaneous pneumothorax. In this case, there is less than 2 cm
between the chest wall and lung, and it is reasonable to observe the
pneumothorax with serial chest radiography rather than intervene at this
time. Given the decreased respiratory reserve and higher likelihood of
progression and mortality in this patient group when compared with
patients without known underlying structural lung disease (primary
spontaneous pneumothorax), observation should be performed in the
inpatient setting.
• If a persistent air leak is noted after 3 to 5 days, it is reasonable to consider
definitive treatment of the pneumothorax. Definitive management to
prevent recurrence typically consists of chemical pleurodesis via
thoracostomy (which is shown to reduce recurrence to 25%) or
thoracoscopic repair with pleurodesis (which reduces recurrence to
approximately 5%).
• Needle aspiration is an option for treating secondary pneumothoraces, but
it has been shown to be significantly less effective than tube thoracostomy
in patients requiring therapeutic intervention.
• If at any time the pneumothorax increases to greater than 2 cm, a smallbore chest tube should be placed, because the patient is experiencing
dyspnea.
• Key Point: For secondary spontaneous pneumothoraces, outpatient
management is discouraged; even small (<2 cm) pneumothoraces are more
safely observed in the inpatient setting.
Pneumothorax Key Points
• Initial management for a large, hemodynamically significant pneumothorax is
the same regardless of whether it is primary or secondary and consists of
high-flow supplemental oxygen, emergent needle thoracostomy, and chest
tube placement.
• For primary spontaneous pneumothoraces, small pneumothoraces with
minimal symptoms may be managed with observation alone.
• For secondary spontaneous pneumothoraces, inpatient management is
indicated; even small (<2 cm) pneumothoraces are more safely observed in
the inpatient setting.