The Patient with Respiratory Failure

Why does this patient have respiratory failure?

The problem could be at any level:

  • Central (hyper or hypoventilation)
  • Cranial nerve (aspiration, or poor cough)
  • Neuromuscular junction (weakness, poor cough)
  • Pleural disease (pneumothorax, plaques)
  • Airway disease (bronchospasm or bronchiectasis)
  • Parenchymal disease (pneumonia, emphysema, fibrosis, ARDS)
  • Chest wall abnormality (eg. kyphosis/scoliosis, or flail chest)
  • Abdominal abnormality (eg. distension, post-operative pain)
  • Cardiac failure (decreased tolerance of respiratory effort, or increased lung parenchymal fluid resulting in decreased compliance)

Previous hot cases with this sort of theme to them can be found below.

A Structured Approach to the Respiratory Failure Hot Case

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands. Failure to do this identifies the candidate as an unhygienic oaf.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine your (insert system here).”
    This routine behaviour gives you a moment to compose yourself, and prepare to launch into your smoothly polished well-practiced examination technique.

One should point out before going any further that the patient being examined may be prone. This is an entirely different kettle of fish, and calls for a different approach.

The Monitors

  • SpO2 is important.
  • The EtCO2 waveform can also yield interesting information.
  • The respiratory change in arterial pulse amplitude may be a sign of dynamic hyperinflation

The routine is also relevant.

  • Rhythm
  • Rate
  • Morphology: QRS width,
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • Ancillary waveforms eg. the PA catheter waveform

The Ventilator

  • This is probably the most important part of the end-of-bedogram.
  • Careful scrutiny of the settings is expected.
  • Specific features one should focus on:
    • How are we oxygenating this patient?
    • How are we ventilating this patient?
    • What is the effect of the settings (i.e. is everything still crap in spite of our efforts?)
    • One may ask to perform an inspiratory hold. If this is not permitted, one should ask about the following parameters:
      • FIO2
      • PEEP
      • Peak pressure
      • Plateau pressure
      • Tidal volume and minute volume

One should also ask to look at the pressure-volume loops.

Urine catheter

  • Unusual colour
  • Anuria

Drains (surgical, intercostal, etc)

Special attention should be paid to the behaviour of the ICCs.

If there is a constant vigorous air leak, one should prepare for a vigorous discussion of bronchopleural fistula.

The content of these drains could be informative, especially if one notices blood or chyle.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

  • Which modality is being used?
  • What is the dose of dialysis?
  • What is the rate of fluid removal?
  • How is the circuit anticoagulated?
  • How long has this filter lasted?

IABP / ECMO

The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:

  • VA or VV?
  • Flow rate
  • Fresh gas flow
  • Any recent problems with the circuit

The presence of extracorporeal circuits may act as a marker of severity. One must have failed conventional ventilation to move on to ECMO.

If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.

Infusions

  • Specifically, one needs to keep mindful of brochodilator infusions.
  • The patient may be paralysed.
  • There may be antibiotics hanging.
  • A bottle of IV immunoglobulin may be left for the candidate to find, a clue to a vasculitic cause of respiratory failure.

EVD

Intracranial pressure monitoring may point to the central nervous system as a cause of the respiratory failure. Has the patient lost their medulla? Or have they had severe neurogenic pulmonary oedema following an SAH?

Weird machinery

The respiratory failure patient may have a plethora of additional devices around them. These may include the following:

  • Heliox
  • NAVA
  • Prostacycline nebuliser
  • INOmax or another nitric oxid gas blender

The presence of such toys is a splendid gift, as it all but delivers the case into the hands of the candidate.


The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°.

This may not be possible. However, one should still ask for it.

The patient should be exposed from the waist up.

The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)
  • Assymetry of chest wall movement (eg. a pneumonectomy)
  • Chest wounds or old scars

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.Now, time to look at them more closely.

First, one should spent a second assessing whther they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page.

In brief, the nail signs one could look for are as follows:

A candidate examining the respiratory failure patient needs to dwell on the clubbed digits. The examiners must appreciate the fact that clubbing has been found, and that the candidate is very excited about it.

Then, one should note the presence of any sort of characteristic deformities, eg:

  • Assymetrical wasting of the small muscles
  • Joint changes of rheumatoid arthritis
  • Hypertrophic pulmonary osteoarthropathy

Next comes the pulse.

  • Compare the radial pulses.
  • Observe the arterial line trace again.

Arms

Tone of the upper limbs

Perform a gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows. This is not the primary focus of the respiratory failure examination, but one should keep in mind that the respiratory failure may be due to some sort of myopathy or neuromuscular disorder, which may reflect in a decreased tone.

Asterixis

In the consciosu patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed. This may be useful if hypercapnea is suspected.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

A sophisticated and detailed cranial nerve examination is desirable; however, the limitations of the respiratory failure hot case force one to truncate this part of the examination.

Thus, after looking for Horner's syndrome in the eyes, one should focus on the lower cranial nerves (those involved with speech and swallowing):

Horner's sign

This sign, associated with stroke and with an apical lung tumour, is composed of the following features:

  • Ptosis
  • Miosis (narrowed pupils)
  • Anhydrosis
  • Enophthalmos
  • Bloodshot conjunctiva

It is a classical med-school sign. If it is present, and you miss it, your examiners will be very disappointed.

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

Cough reflex

While on the subject of CN X, one may test the cough reflex by suctioning the trachea.

This tests CN X.

This is also a convenient time to ask about the volume and character of the secretions.

Tongue movements

The conscious patient is asked to protrude their tongue, and move it from side to side.

This tests CN XII.

Uvula deviation

The uvula deviates away from the lesion.

This tests CN X and IX.

The airway is worth spending some time on.

Specific clues will be grossly obvious: eg. the dual lumen tube with one lumen clamped, or the endobronchial blocker, or the flanged tracheostomy tube.

It would also be worthwhile to note whether the cuff pilot balloon is well inflated. A tracheostomy patient with the cuff deflated may be able to speak, and is likely ready for decannulation.

Important questions to ask at this stage would be the character and quantity of secretions, and how long the patient has been intubated.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

Percussion:

One might wish to percuss the chest.

Changes in percussion resonance may be worth commenting on.

Not everybody does this in their day-to-day practice, and in hot case practice scenarios consultants who are not college examiners tend to either scoff at this practice, or attribute to it an undue emphasis. Theoretically, percussion is a part of the physical examination and should not be forgotten, but it is a low-yield investigation and one may wish to omit it if one were asked to focus on another system.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible.

The money is in the bases.

This, if done thoroughly in a patient on a mandatory mode, may be somewhat laborious (there may only be 12 breaths per minute, and one needs a breath for every change in stethoscope bell position).

Palpation and auscultation of the praecordium

The cardiac examination is a part of the respiratory assessment.

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen.
  • The specific things one is looking for is distension and abdominal wounds; these findings may suggest that the diaphragmatic excusion is impaired.

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal exmaination. The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? What is the PiCCO for?

Examination of the genitals and rectum

  • One should take note of any rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymmetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition; it may be reflective of a systemic weakness, which may contribute to respiratory failure.
  • Pitting oedema should be palpated.
  • Test the tone of the leg muscles.
  • Look for calf tenderness.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the lower limbs

Now is the time to properly start the neurological examination of this patient.

In the context of the respiratory failure hot case, one is looking for the following features:

  • Asymmetry of power, suggestive of stroke
  • Generalised decrease, suggestive of global weakness
  • Proximal power loss, suggestive of myopathy

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.

Power in the upper limbs

The patient has spent most of this time flat and supine. Time to sit them back up again.

Power of the upper muscle groups may be tested in the following sequence:

  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output
  • Urine output

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

Specialised respiratory investigations

One may wish to ask for the following information:

  • Spirometry
  • Peak expiratory flow
  • Maximum inspiratory and expiratory pressure (MIPs and MEPs)

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods
  • Urinalysis
  • Culture results
  • Case-specific bloods, eg. CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR

You sometimes want to see the following:

  • CSF analysis
  • CT or MRI results

 

Case presentation and discussion: when you have a good idea of what is going on

"Mr Bloggs' respiratory failure is multifactorial."

"Contributing factors include [insert a list of respiration-impairing aetiologies]."

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of this respiratory failure in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

"My approach to ventilation in this setting would consist of the following strategies:[describe how you would change the ventilator settings]"

Case presentation and discussion: when you don't have a clue

”This is a complex case and I’m not certain of the diagnosis."

"I note the following organ dysfunctions which may be contributing to the respiratory failure: [list contributing organ problems]."

"I have identified clinical findings which support this hypothesis: namely, [insert list of findings]." "Thus, the possible aetiologies responsible for this respiratory failure could include [list of differentials]"

"In order to discriminate between these differentials, I would like to perform the following investigations: [list of investigations]"

"Furthermore, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"

"In the absence of a clear diagnosis, my ventlation strategy would consist of the following techniques: [demonstrate to the examiners that you would be able to ventilate this patient safely in the absence of a clear diagnosis]"

Number of previous hot cases in this topic: 31

2015, Paper 2

Unspecified hospital in Adelaide

75-year-old male, day 2 ICU, admitted with respiratory failure. Findings on examination included the presence of droplet precautions, poor peripheral perfusion, the presence of a pacemaker/ICD and coarse crackles throughout all lung fields.

Candidates were directed to provide a differential diagnosis for his respiratory failure based on the findings on examination.

Discussion points included interpretation of imaging and echo findings and further assessment of his cardiac function.

Unspecified hospital in Adelaide

68-year-old male day 3 ICU admitted with respiratory failure and septic shock secondary to pneumonia complicated by acute kidney injury. Background included type 2 diabetes and alcohol dependence. Findings on examination included mechanical ventilatory support with relatively high ventilatory requirements, bilateral chest signs and vasopressor dependent shock.

Candidates were told he had presented with dyspnoea increasing over several days and were directed to provide a differential diagnosis for his initial presentation and make a management plan.

Unspecified hospital in Adelaide

64-year-old male, day 6 ICU, having presented to a regional hospital six days earlier with infected left foot ulcer and Hb 67 g/l. He was transfused one unit of packed red cells and rapidly developed respiratory failure. He was transferred later that day for respiratory support and was intubated on arrival at the second hospital. Background included diabetes, peripheral vascular disease and coronary artery grafts. The patient had been extubated the previous day, requiring BIPAP overnight.

The candidates were directed to assess his current respiratory status and postulate causes of his initial respiratory failure.

Unspecified hospital in Adelaide

60-year-old male, day 31 ICU, admitted to hospital, one month earlier with severe respiratory failure secondary to legionella pneumonia, mechanically ventilated since with increasing O2 requirements over the previous 36 hours. Clinical findings included fever, tachycardia with atrial flutter, peripheral oedema, palpable liver edge and hyper-reflexia.

Candidates were directed to examine him for potential causes of his ongoing ventilatory requirement and for the deterioration in the past 36 hours.

Discussion points also included the management of elevated creatinine, and the significance of a positive blood culture for candida.

2015, Paper 1

Unspecified hospital in Melbourne

38 - year - old female farmer day 8 ICU, admitted with severe sepsis and respiratory failure secondary to community - acquired pneumonia, and now with new - onset fever. Clinical signs included right - sided bronchial breathing, high minute ventilation, and a hyperdynamic circulation with a systolic murmur. Candidates were asked to examine her and provide a summary of the clinical findings, differential diagnosis and manage ment plan.

2014, paper 2

Unspecified hospital in Sydney

  • 65-year-old male, day 1 in the ICU, with acute hypoxic respiratory failure. His clinical findings included obesity, intubated ventilated, paralysed and sedated, low cardiac index on PiCCO, inotropic and vasopressor support, high FiO2 and PEEP. His bedside echo demonstrated globally reduced left ventricular function, his chest X-ray showed an endobronchial intubation with bilateral infiltrates.
  • Candidates were asked to assess the patient with regards to his initial management plan.

Unspecified hospital in Sydney

  • 45-year-old man, day 13 ICU. Admitted with SCC tongue, necrotising pneumonia, neutropenic sepsis and multi organ failure. Clinical findings included bilateral wheeze, crepitations at the right lung base, and portacath in situ.
  • Candidates were informed the patient had a background of intravenous drug use and hepatitis C, and had been admitted with respiratory failure. They were asked to examine and provide a differential diagnosis.
2014, Paper 1

Royal Brisbane and Women’s Hospital

  • 53-year-old female, day 7 ICU, with pneumococcal pneumonia and bacteraemia, admitted following a Medical Emergency Team call for respiratory distress. Her ICU stay had been complicated by acute kidney injury and biventricular failure. She had not required invasive ventilatory support. Clinical findings included fever, widespread septic vasculitic rash, left sided bronchial breath sounds and signs of right heart failure. Candidates were directed to examine her to determine her cardio-respiratory status and the cause of her respiratory failure.

Prince Charles Hospital

  • 7-year-old female, day 3 ICU, with scleroderma, pulmonary fibrosis and pulmonary hypertension, presenting with haemoptysis and respiratory failure. Clinical findings included signs of scleroderma with CREST, blood-stained respiratory secretions, bronchial breathing at left base with diffuse crackles, aortic regurgitation and hepatomegaly.
  • Candidates were directed to identify the key clinical findings and to provide a management plan.
2013, paper 2

Nepean Hospital

  • 72-year-old man, day 2 in ICU, following presentation with ARDS on the background of a recent admission with H. influenza pneumonia. Clinical findings included high ventilatory requirements, bilateral crackles and wheezes and signs of left upper lobe consolidation on auscultation. Candidates were asked to examine him and give a differential diagnosis. Additional points for discussion included interpretation of CXR, ventilatory management, choice of antibiotic and diagnostic criteria for ARDS
2013, Paper 1

Royal Adelaide Hospital

  • 31-year-old woman, day 6 in ICU, with urosepsis and respiratory failure on a background of SLE. Candidates were asked to assess her focussing on possible causes and management of her respiratory failure.

Queen Elizabeth Hospital

  • 64-year-old woman, day 1 post VAT / decortication of empyema with chest drain in situ, intubated and ventilated with moderate oxygen and PEEP requirements. Candidates were asked to assess her respiratory status.
2012, Paper 2

Royal Melbourne Hospital

  • 42-year-old man with bilateral community-acquired pneumonia. Clinical signs included subcutaneous emphysema of his upper trunk. Candidates were told that he had been ventilated for one week in ICU for severe hypoxaemic respiratory failure and were asked to assess his prognosis overall. Discussion points included the management plan, causes of the subcutaneous emphysema, deranged liver function and thrombocytopaenia.
2012, Paper 1

Royal Brisbane Hospital

  • 29-year-old female day 23 ICU and 10 weeks post bone marrow transplantation for ALL complicated by engraftment syndrome and GVHD. Admitted to ICU following MET call for respiratory distress, managed with HFOV. Candidates were asked to identify causes for her deterioration and discuss the plan for the next 24-48 hours, her overall prognosis and rescue therapies for ARDS.
2011, Paper 2

Royal Prince Alfred Hospital

  • 70-year-old IVDU admitted with respiratory failure. On examination severely deconditioned and wasted, awake and responsive, ventilated with low FiO2, CXR showing 3/4 quadrant involvement with interstitial infiltrate. Candidates were directed to assess the patient with a view to identify current problems and how to progress patient management

Prince of Wales Hospital

  • 69-year-old male admitted the previous day with community-acquired pneumonia and septic shock requiring non-invasive ventilation and low dose vasopressors. Candidates were directed to review the patient's respiratory status and formulate a plan for ongoing management
2011, Paper 1

Westmead Hospital

  • 29-year-old lady with severe hypoxaemic respiratory failure secondary to aspiration following an elective laparascopic cholecystectomy.
2010, Paper 2

Royal Adelaide Hospital

  • A 30 year old man admitted following an MVA. On presentation, awake but hemodynamically unstable requiring an urgent trauma laparotomy. Post op complicated by new onset respiratory failure requiring reintubation and found to have H1N1. Candidates asked to discuss management of respiratory failure secondary to H1N1 and nutritional management. .

Royal Adelaide Hospital

  • A 40 year old lady with SLE and bilateral renal transplants admitted with high grade fever, productive cough and respiratory failure. Issues for discussion included differential diagnosis of pneumonia in immunocompromised patients, H1N1,CMV and role of NIV in pneumonia in immunocompromised patients.

Queen Elizabeth Hospital

  • A 71 year old male with previous h/o gastric cancer and liver metastases was admitted with a parapneumonic effusion and empyema requiring a thoracotomy. Post operative course complicated by hemoptysis. Ongoing problems included cachexia, pleural effusions, recent thoracotomy, management of hemoptysis and intercostal drains

Queen Elizabeth Hospital

  • A 38 year old man with severe respiratory failure secondary to H1N1 and complicated by ARDS.
2010, Paper 1

Austin Hospital

  • 58 year old male intubated following a late leak from a lobectomy stump. Septic with marked acididosis. Lung not re-expanded on CXR, significant effusion. Still intubated. Candidates asked to formulate a management plan.

Austin Hospital

  • 61 year old lady with multiple surgical interventions following bariatric surgery years earlier. Currently admitted with pneumonia for which she was ventilated. There were multiple potential causes for respiratory failure. Candidates were told she had been in the surgical ward for one month and had been admitted to ICU last night. Candidates were asked to do a general assessment with a focus on her respiratory status

Austin Hospital

  • 80 year old lady with cardio-pulmonary compromise (obstructed expiratory flow and stigmata of steroid use, heart failure) who experienced respiratory failure following hip replacement under epidural. Significant post operative troponin rise. Candidates were asked to explain why they think this might have happened. X ray showed significant hiatus hernia (but otherwise clear lung fields) and flow trace on the ventilator showed marked obstruction, ECG showed LBBB.
2009, Paper 2

Royal Prince Alfred Hospital

  • A 73 year old man with chronic bronchiectasis and a left lower lobectomy, admitted to ICU post lung biopsy for diagnosis of BOOP. Findings: clubbing, tracheal deviation to left, stony dullness, poor chest compliance. Issues for discussion: Septic shock, difficult to ventilate, poor nutrition, discussion of PFT

Royal North Shore Hospital

  • A 40 year old man with TBI 3 months ago was sent to rehab unit where his tracheostomy was decannulated and developed severe respiratory distress resulting in a readmission. Candidates asked to examine his neurology and other a systemic examination and formulate a plan.

Prince of Wales Hospital

  • 81 year old male with OSA and CCF presents with respiratory failure. Issues for discussion: Management of heart failure, BIPAP, OSA, interpretation of CXR and ABG.

Prince of Wales Hospital

  • 67 year old male ptresents with increasing shortness of breath and difficulty in swallowing. Issues for discussion: Respiratory assessment, discussion of findings of CREST syndrome, CXR (patchy pneumonitis), antibiotic and weaning management.
2008, Paper 2

Unspecified hospital

  • 52 yeard old male, admitted with pneumonia, bilateral infiltrates, worsening respiratory function, empyema, decortication and slow respiratory wean.

Unspecified hospital

  • 64 year old lady with ruptured oesophagus after vomiting. Currently sedated and ventilated. No candidate noted a left thoracotomy wound
2007, Paper 2

Unspecified hospital

  • 19 yr old man with severe acute respiratory failure following a MVA with long bone fractures. His bedside therapies included IPPV, NO, ECMO
    Discussion: on causes of respiratory failure, management of refractory hypoxemia. NO and ECMO were considered to be specialized therapies and only were referred to fleetingly in the discussion.