During the CHEST 2021 session Critical Care Cases: Act Quickly, a panel of residents and pulmonary and critical care fellows presented very different cases that similarly illustrate how the right tests and the right consults at the right time are keys to making the right diagnoses and treatment decisions.
Patrick Ho, DO, Pulmonary and Critical Care Fellow at Lankenau Medical Center in Pennsylvania, opened the session with the case of a 60-year-old man with a prior history of unprovoked pulmonary embolism (PE) who was not receiving coagulation therapy and presented with syncope and exertional dyspnea that progressed over the previous 2 weeks.
Initial chest x-rays were unremarkable, Dr. Ho said; however, CT angiography revealed extensive acute bilateral PE and subsequent transthoracic echocardiography (TTE) showed serpiginous mobile echo-density in the right atrium consistent with a clot in transit.
“He was diagnosed with having intermediate high-risk PE but with the addition of a clot in transit, the patient’s actual risk level was much higher, requiring a degree of urgency in establishing a treatment plan,” Dr. Ho said. “Finding a clot in transit is rare, with an estimated prevalence of approximately 4%, but it is a medical emergency because it is associated with an extremely high risk of mortality.”
The recommended treatment for this situation, he said, is unclear.
“Known options include anticoagulation alone, thrombolysis, surgery, and now, with more data emerging, catheter-directed therapies,” Dr. Ho said. “Our multidisciplinary PE response team was activated and, after a thorough discussion, the decision was made to take the patient emergently to the cath lab to perform catheter-directed mechanical thrombectomy.”
Prior to transport, ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation, and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery were placed on standby. With adjunctive TTE guidance, the right atrial clot was extracted in its entirety with no hemodynamic deterioration.
“Both pulmonary arterial pressures and cardiac indices improved after clot extraction. The patient was then transferred to the ICU where he remained stable and was discharged after 3 days of rivaroxaban therapy,” Dr. Ho said. “The evidence for catheter-directed therapies for treatment of PE is growing and, as demonstrated in this case, evidence for their use in PE with clot in transit is growing as well.”
Christina Jee Ah Rhee, MD, Pulmonary and Critical Care Fellow at New York-Presbyterian Queens in New York, followed with a case presentation involving a 64-year-old man with rheumatoid arthritis, RA-associated interstitial lung disease, and known involvement of cricoarytenoid joints with bilateral vocal cord hypomobility, who presented with sudden onset shortness of breath, dyspnea, and in severe respiratory distress.
“In the ED, he was notably dyspneic, hypoxemic to 70% on room air, and there was loud audible stridor,” Dr. Rhee said. “Arterial blood gas test results revealed acute respiratory acidosis and acute hypoxemic respiratory failure.”
Initial management in the emergency department, she said, consisted of IV corticosteroids, nebulized racemic epinephrine, and multiple rounds of nebulized albuterol. The patient was also placed on noninvasive positive-pressure ventilation.
“The patient did not tolerate the positive-pressure ventilation very well, and his acidosis did not improve significantly,” Dr. Rhee said. “Soon enough, the decision was made to intubate.”
Videolaryngoscopy revealed vocal cords paralyzed in the closed position. Awake fiberoptic bronchoscopic intubation with minimal sedation was planned with the surgical team prepared at bedside for emergent cricothyrotomy if necessary.
“Cricoarytenoid arthritis is often present in patients with RA, with incidences as high as 70%; however, despite its high prevalence, it appears that the acute onset stridor and respiratory failure that was present in this patient is relatively rare,” Dr. Rhee said. “There are multiple airway implications in RA patients that should be anticipated, and preparations for a difficult airway should be routinely considered. Fiberoptic intubation offers a number of benefits, such as avoidance of cervical hyperextension, minimally invasive inspection of the airway anatomy, and the need for minimal sedation.”
Next, Tripti Kumar, DO, Resident Physician at Lankenau Medical Center in Pennsylvania, discussed the case of a 34-year-old postpartum woman with recurrent spontaneous coronary artery dissection (SCAD).
“Pregnancy-related SCAD accounts for approximately 10% of all SCAD cases and is associated with higher incidences of ST-elevation myocardial infarction (STEMI), cardiogenic shock, and death,” Dr. Kumar said.
The patient initially presented with chest discomfort 5 days after induction of labor at 35 weeks due to preeclampsia. ECG showed STEMI and coronary angiography showed mid-left anterior descending artery dissection with occlusion. Following percutaneous coronary intervention (PCI) and stent placement, the patient was transferred to the ICU and placed on dual antiplatelet therapy.
The patient was subsequently discharged but re-presented 7 days later with recurrent chest pain. After further testing and repeat PCI and stent deployment, the patient was discharged receiving triple therapeutic anticoagulation with clopidogrel, aspirin, and apixaban.
“Because SCAD is a life-threatening disease, prevention and treatment protocols in pre, peri, and postpartum women must become clearer,” Dr. Kumar said. “And it is imperative to risk stratify female patients presenting with acute coronary syndrome based on pregnancy history and ensure long-term cardiovascular follow-up.”
In the final presentation, Huseyin Berk Degirmenci, MD, Resident Physician at Saint Elizabeth’s Medical Center in Boston, reviewed a case of overlap syndrome presenting as pulmonary-renal syndrome (PRS) with persistent diffuse alveolar hemorrhage (DAH).
“PRS is a condition defined by a combination of DAH and glomerulonephritis, which can be a result of multiple disorders, including rheumatological conditions,” Dr. Degirmenci said. “DAH is recognized by the clinical constellation of hemoptysis, anemia, diffuse radiographic pulmonary infiltrates, and hypoxemic respiratory failure.”
In this case, a 47-year-old woman with lupus presented with fatigue, nausea, and shortness of breath. She was found to be tachypneic with an oxygen saturation of 80%. Complete blood count revealed normocytic anemia and leukocytosis. Basic metabolic panel showed an acute kidney injury and high anion gap metabolic acidosis and urinalysis showed significant proteinuria and hematuria with active urine sediment.
Due to acute hypoxemic respiratory failure, the patient was intubated and admitted to the ICU.
“Given active urine sediment with marked azotemia, along with bilateral alveolar filling and without findings of heart failure, we started thinking about pulmonary-renal syndrome,” Dr. Degirmenci said. “For that reason, we did a flexible bronchoscopy, which confirmed DAH, and autoimmune studies came back positive for high titer ANA, low titer anti-dsDNA, low complement levels, and very high titers of p-ANCA and anti-MPO.”
The patient was initially placed on a regimen of pulse-dose steroids, which improved her respiratory status, and she was able to be successfully extubated; however, her oligo-anuric acute kidney injury progressed and required renal replacement therapy.
“The treatment combination with early pulse steroids followed by cyclophosphamide, which was later switched to rituximab due to pancytopenia, improved her kidney function gradually and resulted in successful liberation from dialysis support,” Dr. Degirmenci said. “Unfortunately, she later suffered from recurrent severe DAH episodes confirmed by bronchoscopy, which caused respiratory failure that necessitated re-intubation and, ultimately, she developed a massive DAH episode that led to cardiac arrest, and she passed away.”
Lupus and ANCA-associated vasculitis, he said, is an uncommon combination within traditional overlap syndromes, and requires a careful examination of medication list and toxicology studies.
“And flexible bronchoscopy is crucial because hemoptysis is absent in about one-third of PRS cases, including this case,” Dr. Degirmenci said. “It’s also very important to do supportive care for respiratory failure and renal failure. Multidisciplinary care is the key, as this patient required daily discussions with the pulmonary, nephrology, and rheumatology teams to provide the best care.”
ACCESS SESSIONS ON DEMAND
Registered CHEST 2021 attendees have continued access to 200+ educational sessions until October 1, 2022. Watch sessions on your own schedule and earn up to 50 CME credits/MOC points.
Don’t forget to claim your credit! The deadline is December 15, 2022, at 11:59 pm CT.