bronchospasm

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So...the summary.

When you hear hoof beats.....I guess it usually means horses.

In my case I heard wheezing....consistent with bronchospasm.

If it wasn't for the red herring cxr...I would have continued with bronchodilator therapy...and perhaps not cancelled the case.

The presence of ONE SINGLE abnormal study made me ASSUME a particular diagnosis....when in retrospect all the clues pointed towards bronchospasm and reactive airway disease....

NMB helped
epi helped
deepening the anesthetic helped
hemodynamic stability (+/- for mass)

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So...the summary.

When you hear hoof beats.....I guess it usually means horses.

In my case I heard wheezing....consistent with bronchospasm.

If it wasn't for the red herring cxr...I would have continued with bronchodilator therapy...and perhaps not cancelled the case.

The presence of ONE SINGLE abnormal study made me ASSUME a particular diagnosis....when in retrospect all the clues pointed towards bronchospasm and reactive airway disease....

NMB helped
epi helped
deepening the anesthetic helped
hemodynamic stability (+/- for mass)

Point well taken. On the steps, the correct answer is usually-

a. refer to surgery for biopsy
b. proceed to spine surgery for spondylolisthesis
c. report med hx as positive for lung CA
d. request prior CXR
 
Why would the alleged bronchospasm and the alleged non diagnosed asthma cause massive atelectasis of the left lung?
Why isn't the right lung affected?
Something does not make sense about this whole story!
And the CT does not seem to belong to the same patient.
 
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So...the summary.

When you hear hoof beats.....I guess it usually means horses.

In my case I heard wheezing....consistent with bronchospasm.

If it wasn't for the red herring cxr...I would have continued with bronchodilator therapy...and perhaps not cancelled the case.

The presence of ONE SINGLE abnormal study made me ASSUME a particular diagnosis....when in retrospect all the clues pointed towards bronchospasm and reactive airway disease....

NMB helped
epi helped
deepening the anesthetic helped
hemodynamic stability (+/- for mass)


Assuming that the patient was an easy airway, did you give any thought to extubating the patient (prior to obtaining that CXR)? The reason I ask is that I have a colleague who maintains that he has had a couple cases of bronchospasm which were only fixed by removing the offending stimulus from the trachea. Thus on his treatment algorithm for bronchospasm the last step is to pull the tube. I am not sure that I would have the guts to pull the tube in someone whose SpO2 and Paw both in the 60s.
 
Assuming that the patient was an easy airway, did you give any thought to extubating the patient (prior to obtaining that CXR)? The reason I ask is that I have a colleague who maintains that he has had a couple cases of bronchospasm which were only fixed by removing the offending stimulus from the trachea. Thus on his treatment algorithm for bronchospasm the last step is to pull the tube. I am not sure that I would have the guts to pull the tube in someone whose SpO2 and Paw both in the 60s.

I did think about it......I've discussed in the past during M&M's when I was teaching residents.....

I never got to the point where I had no other options....patient did respond to epi....

and finally, I also am not sure that my balls are big enough.
 
Sorry - I'm missing something here - where was this mentioned?

as for as I know...I never mentioned anything about massive atelectasis...the cxr certainly does NOT show massive atelectasis....there is clearly little to no volume loss.....however, .the cxr does show atelectasis in an unusual location.
 
Look at the CXR, the left lung is obviously compromised while the right lung appears well aerated.
The ETT seems to be in good position so something happened to the left lung.
Here is what I think happened:
They intubated the right main stem so the patient got hypoxic but they did not recognize the selective intubation and they kept vigorously trying to correct the initial hypoxia by hyperventilating the right lung, this produced more hypoxia because of increased shunt and stacking in the ventilated lung, then by the time they realized what happened the patient was almost dead so they pulled the tube back, and this is when they did the CXR and that's why the left lung appears the way it does because it was not fully expanded yet.
By the time the patient got to the PACU and the CT was done the left lung had already expanded.


Sorry - I'm missing something here - where was this mentioned?
 
This is why I love these "clinical threads" so much.

You have someone with limited clinical information challenging the diagnosis of the clinician who was actually there, and wildly speculating about what did and did not happen despite the fact that they never saw the patient, participated in their care, or got the full flavor of what happened even ex post facto.

And, they will move the goalposts, invent new information, and/or change the scenario on-the-fly in an attempt to "win at all costs."

Yeah, pay attention neophytes. You are learning an important lesson with these "clinical threads": these are precisely the type of expert a55holes who will receive a large fee to testify against you in court.

:thumbdown:

-copro
 
as for as I know...I never mentioned anything about massive atelectasis...the cxr certainly does NOT show massive atelectasis....there is clearly little to no volume loss.....however, .the cxr does show atelectasis in an unusual location.

Thanks Mil - good to know I'm not losing my mind!
 
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