A 36 year old female is brought into your ED department with acute shortness of breath. She is unable to provide any history due to her tachypnoea. She is sitting upright in bed grasping the bed sides. She has a respiratory rate of 30 breaths per minute, has a GCS of 15, is afebrile and has a BP of 90/60mmHg. She is using accessory muscles. On auscultation, she has widespread expiratory wheeze spread throughout both lung fields.
1) What are the differential diagnoses for her presentation?
The rest of the viva focussed on the assessment and management of bronchial asthma
- Vocal cord paralysis
- Laryngeal stenosis
- Goiter with thoracic inlet obstruction
- Anxiety with hyperventilation
Intrathoracic central airway causes
- Tracheal stenosis
- Mediastinal tumours
- Hyperdynamic airway collapse due to tracheomalacia
- Mucus plugs
- Thoracic aortic aneurysm
- Foreign body inhalation
Intrathoracic lower airway causes
- Bronchitis or bronchiolitis
- Pulmonary oedema - "cardiac asthma"
- Airway distortion due to mechanical causes, eg. bronchial mass, bronchiectasis, pneumothorax
- Exposure to inhaled irritant or corrosive agent, and this includes the aspiration of gastric contents
Pulmonary function test data:
The presence of respiratory acidosis suggests that the patient is tiring
The absence of raised lactate suggests that nebulised salbutamol is ineffective
(air entry is too poor).
Theoretical benefits in asthma:
Lim et al, (2012) ended up scraping together five studies - which only had n=206 in total. Of the 90-or so patients in two RCTs analysed by Lim et al, only two required intubation. There were no deaths in either group. How can you demonstrate a mortality benefit if nobody is dying?..
Alternatively, the candidate interpret see this question as "when would you intubate the asthmatic?" That will be the next question:
These are the consensus indications for intubation quoted by Brenner et al (2009).
The candidates need to mention something about dynamic hyperinflation here.
(this is based on the college answer to Question 1 from the first paper of 2015)
The options for mucolytic choice are
Evidence in support of this practice is lacking:
Selected patients may still benefit, but:
At this late stage in the viva, anything goes - if they had made it this far in 10 minutes they can go on about ECMO as much a they like.
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.