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 FEV FEV 1 1 of 75% of predicted and an FEV /FVC ratio, and the FEV 1 1 /FVC ratio of 63%. Following administration of a bronchodilator, there is no significant change in the 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) Asthma B) COPD C) GERD D) Losartan

Correct Answer: B

• • The most likely cause of this patient's cough is COPD. His postbronchodilator FEV 1 /FVC ratio less than 70% confirms airflow limitation and a diagnosis of obstructive lung disease; his relatively preserved FEV 1 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 FEV 1 /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 FEV COPD is characterized by an FEV COPD is characterized by an FEV 1 1 1 to further describe the level of disease. (mild) COPD is characterized by an FEV 1 (moderate) COPD is characterized by an FEV 1 less than 30% of predicted.

Level 1 of 80% of predicted or greater; level 2 of 50% to 79% of predicted; level 3 (severe) of 30% to 49% of predicted; and level 4 (very severe)

GOLD Criteria

Classification of Severity of Airflow Limitation in COPD (Based on Postbronchodilator FEV1) In patients with FEV1/FVC <70%: GOLD 1 GOLD 2 GOLD 3 GOLD 4 Mild Moderate Severe Very severe FEV 1 ≥80% of predicted 50% ≤ FEV 1 < 80% of predicted 30% ≤ FEV 1 < 50% of predicted FEV 1 <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 FEV 1 /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) Incentive spirometry every 2 hours B) Inhaled helium oxygen mixture C) Nebulized N-acetylcysteine D) 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, N acetylcysteine is less likely to benefit this patient because he had minimal secretions prior to extubation. Furthermore, nebulized N acetylcysteine 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) Chronic disseminated intravascular coagulation B) Critical illness polyneuropathy C) Post-ICU neuropsychiatric impairment D) 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 appears clinically as acquired dementia are associated with the development of the syndrome include , especially those with the diagnosis of either severe sepsis or acute respiratory distress syndrome. The syndrome . The factors in the intensive care unit (ICU) that age, duration of mechanical ventilation, and glycemic control some evidence that the degree of impairment correlates with patients.

(hyperglycemia or hypoglycemia). There is hypoxemia in these 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 impairment.

, but it does not cause cognitive 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) Adaptive Servoventilation B) CPAP C) Diuresis D) Nocturnal Oxygen E) 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) examination.

related to underlying heart failure a condition that predisposes to hyperventilation. . 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 Cheyne-Stokes breathing/CSA is believed to occur as a consequence of heart failure, 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 S 3 , 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 without evidence of obstruction and a diagnosis of CSA would not be appropriate.

device in this patient 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. FEV 1 45% of predicted. Oxygen saturation is 92% at rest and 90% after exertion breathing ambient air. Chest radiograph shows no infiltrate or mass.

is

Which of the following is the most appropriate management?

A) Morphine B) Oxygen therapy C) Prednisone D) 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 FEV 1 less than 50% of predicted.

Pulmonary rehabilitation may be considered for symptomatic or exercise-limited patients with an FEV 1 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 FEV 1 less than 50% of predicted.

Pharmacologic therapies

Therapy for Stable, Symptomatic COPD Based on Level of Airflow Obstruction a Level of Airflow Obstruction Recommended Therapy b FEV FEV 1 1 60%-80% of predicted <60% of predicted Consider inhaled bronchodilator therapy (anticholinergic or β 2 -agonist) (weak recommendation, low-quality evidence) Daily monotherapy with an inhaled bronchodilator ( long-acting anticholinergic or long-acting β 2 agonist ), 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 β quality evidence) 2 -agonist, or corticosteroid) (weak recommendation, moderate FEV 1 <50% of predicted Consider adding pulmonary rehabilitation (weak recommendation, moderate-quality evidence) a In patients with an FEV 1 /FVC ratio <70%.

b Occasional use of short-term bronchodilators for breakthrough symptoms or exacerbation is appropriate at any level of pulmonary function in COPD.

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) Carcinoid tumor B) Granuloma C) Metastatic Cancer D) 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-Risk a Follow-up <4 None 4-6 12 months; if unchanged, stop 6-8 6-12 months; if unchanged, 18-24 months >8 Consider contrast CT study, PET scan, or biopsy; if followed, 3, 9, and 24 months a Low risk: Never-smoker and no other risk factors.

b High risk: Current or former smoker or other risk factors.

High-Risk b Follow-up 12 months; if unchanged, stop 6-12 months; if unchanged, 18-24 months 3-6 months; if unchanged, 9-12 and 24 months Same as low risk

• • • • 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.

Laboratory studies: Blood urea nitrogen Creatinine Electrolytes: Sodium Potassium Chloride Bicarbonate Glucose Lactic acid Serum osmolality Blood gases: pH Arterial PCO 2 Arterial PO 2

Question 7

14 mg/dL (5 mmol/L) 1.9 mg/dL (168 µmol/L) 138 meq/L (138 mmol/L) 4.1 meq/L (4.1 mmol/L) 90 meq/L (90 mmol/L) 12 meq/L (12 mmol/L) 90 mg/dL (5.0 mmol/L) 2.8 mg/dL (0.3 mmol/L) 390 mosm/kg (390 mmol/kg) 7.24

28 mm Hg (3.7 kPa) 102 mm Hg (13.6 kPa)

Which of the following is the most appropriate treatment?

A) Hemodialysis B) Intravenous ethanol C) Intravenous fomepizole D) Intravenous fomepizole and hemodialysis E) 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 24 to 48 hours after ethylene glycol ingestion . 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 , patients may develop flank pain and kidney failure that are often accompanied by this patient because there and metabolic alkalosis from vomiting.

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 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

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 Methanol Wood alcohol Toxic Metabolite Formic acid Ethylene glycol Antifreeze Glycolic, glyoxylic, and oxalic acids Isopropyl alcohol Rubbing alcohol CNS = central nervous system.

Nontoxic Metabolite Anion Gap Yes Yes Acetone No Osmolar Gap Yes Yes Yes Toxicity Retina Antidote Fomepizol, ethanol, dialysis Renal tubules Fomepizol, ethanol, dialysis 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) Evaluation for pleurodesis B) Needle aspiration C) Serial chest radiography D) 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 small bore 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.