A 72-year-old woman is found to be severely short of breath at her skilled nursing facility. The patient was recently hospitalized for vertebral osteomyelitis and discharged 2 weeks ago to complete a 6-week course of piperacillin-tazobactam via a peripherally inserted central venous catheter. Her dyspnea began only with exertion but is now also present at rest. Medical history includes coronary artery disease with ischemic cardiomyopathy, chronic obstructive pulmonary disease, and chronic kidney disease. She has had 2 hospitalizations for heart failure over the last year; noninvasive positive-pressure ventilation was required. Paramedics observe the patient to be obtunded with agonal respirations and rales throughout the bilateral lung fields. Oxygen saturation is 72% on room air. She is intubated and transferred to the emergency department. On arrival, the patient is minimally responsive to stimuli. Temperature is 36.7 C (98 F) , blood pressure is 115/65 mm Hg, and pulse is 110/min and regular. The patient's oxygen saturation is 88% on 100% inspired oxygen. BMI is 19 kg/m². The trachea is midline. On physical examination, rales are heard on the right side and markedly decreased breath sounds on the left side of the chest. S3 is heard. There is 2+ bilateral peripheral edema. A chest x-ray reveals the following:
Which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old woman is found to be severely short of breath at her skilled nursing facility. The patient was recently hospitalized for vertebral osteomyelitis and discharged 2 weeks ago to complete a 6-week course of piperacillin-tazobactam via a peripherally inserted central venous catheter. Her dyspnea began only with exertion but is now also present at rest. Medical history includes coronary artery disease with ischemic cardiomyopathy, chronic obstructive pulmonary disease, and chronic kidney disease. She has had 2 hospitalizations for heart failure over the last year; noninvasive positive-pressure ventilation was required. Paramedics observe the patient to be obtunded with agonal respirations and rales throughout the bilateral lung fields. Oxygen saturation is 72% on room air. She is intubated and transferred to the emergency department. On arrival, the patient is minimally responsive to stimuli. Temperature is 36.7 C (98 F) , blood pressure is 115/65 mm Hg, and pulse is 110/min and regular. The patient's oxygen saturation is 88% on 100% inspired oxygen. BMI is 19 kg/m². The trachea is midline. On physical examination, rales are heard on the right side and markedly decreased breath sounds on the left side of the chest. S3 is heard. There is 2+ bilateral peripheral edema. A chest x-ray reveals the following:

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient is in acute hypoxic respiratory failure likely due to an exacerbation of chronic heart failure. Because of rapid decompensation, she required endotracheal intubation in the field but has persistent hypoxemia following initiation of 100% supplemental oxygen. Complications can occur during any intubation procedure but are more common with field intubations due to the relatively uncontrolled environment outside of a medical facility. Therefore, it is important to confirm correct endotracheal tube (ETT) placement by checking for ETT depth, chest excursion, and bilateral breath sounds and by obtaining a chest x-ray. This patient's chest x-ray demonstrates right mainstem bronchial intubation (RMBI), a complication that results from excessive depth of ETT placement. Patients typically have respiratory distress due to hypoventilation, and breath sounds are diminished or absent on the left side. Retracting the ETT a few centimeters and rechecking placement typically leads to marked improvement in hypoxemia. In general, appropriate insertion depth for an ETT is 21 cm (8.3 in) for women and 23 cm (9 in) for men. (Choice A) Chest tube placement would be indicated if this patient had a left-sided hemothorax or pneumothorax. However, the chest x-ray shows large-volume atelectasis due to left lung collapse, so chest tube placement is not indicated. (Choice B) Although a chest CT scan may help further identify the underlying lung pathology and would demonstrate the positioning of the ETT, it is not appropriate for checking ETT placement due to the time required and unnecessary radiation exposure. (Choice C) Needle decompression at the midclavicular line of the second intercostal space is appropriate emergency treatment for a tension pneumothorax, a complication that can occur if RMBI is not corrected in a timely manner. Although patients with pneumothorax typically have absent breath sounds on the affected side, this patient's chest x-ray, which shows lung markings extending to the lung periphery, rules out significant pneumothorax. (Choice E) Dobutamine infusion is indicated for inotropic support in patients with cardiogenic shock. This patient's presentation is consistent with an acute exacerbation of heart failure (dyspnea, pulmonary edema on chest x-ray, lower extremity edema), and she may need inotropic support at some point; however, the RMBI should be addressed first. Educational objective: When endotracheal intubation has been used to secure the airway, it is important to confirm correct placement by checking endotracheal tube depth, chest excursion, and bilateral breath sounds and by obtaining a chest x-ray. References: The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. (http://www.ncbi.nlm.nih.gov/pubmed/17312220) Impact of ATLS training on preventable and potentially preventable deaths. (http://www.ncbi.nlm.nih.gov/pubmed/24770906)

A 72-Year-Old Woman Is Found to Be Severely Short of Breath