As the duty locum Intensivist you have been called to urgently review a patient on the medical ward of a small private hospital. The patient, Jane, is a 62-year-old female who was admitted to the ward yesterday with shortness of breath and leg swelling.
She presents with shortness of breath often, and has recently been started on a bronchodilator.
A local GP registrar was on the ward reviewing another patient and noticed that Jane was working very hard to breathe. The registrar emergently intubated her prior to your arrival.
You arrive on the ward 10 minutes post intubation. The registrar and a ward nurse are hand-ventilating Jane, who is hypoxic – O2 saturations 85% - and hypotensive – BP 75/50 mmHg.
The registrar and nurse are with the patient and you have been called to assist.
(After an initial period of slightly embarrassed simulation, this turned into a discussion of mechanical ventilation strategies for asthma. The gas was never part of this viva; it has been introduced so that the solitary viva coordinator is able to do a session on their own. Also, Jane was initially 32 yars old. The age was modified to turn this into a COPD discussion)
ABCDE approach may be attempted here. An appropriate series of steps:
A) Make sure the ETT is in correct position by auscultating the chest
B) Ensure the manual resuscitator bag is connected to wall oxygen and the reservor is inflating well
C) Assess the cardiovascular system quickly by physical examination, looking for signs of heart failure
D) Review the recently administered medications.
Some collateral history would be useful from bystanders, and background history from the notes.
The main issues are with the ventilator:
Also: because of the evidence of bronchospasm, one might want to start her on corticosteroids.
Parameters such as the BODE index can be used:
|Points on the BODE index|
|FEV1 (% of predicted)||>65%||50-64%||36-49%||<35%|
|Distance walked in 6 minutes||<350||250-350||150-249||<149|
|MMRC dyspnoea scale||0-1||2||3||4|
|Body mass index (BMI)||>21||<21|
- Among the most severe group, there is a 50% mortality at 36 months.
Another is the MMRC breathlessness scale, a subjective report of how breathless the patient feels; 0 is "doin fine" and 4 is "can't leave the house".
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.