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Self-Assessment Questions

Pulmonary Disease

Recognizing Sleep-Disordered Breathing in Hospitalized Patients: Review Questions

Amit Taneja, MD, and Rose A. Franco, MD


Dr. Taneja is a fellow, and Dr. Franco is an associate professor and director of the Sleep Medicine Fellowship Program; both are at the Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI.





Figure. Overnight oximetry performed in the patient described in questions 3 and 4. Spo2= oxygen saturation as measured by pulse oximetry.

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case.
A 67-year-old man with type 2 diabetes mellitus, obesity, and hypertension is admitted to the intensive care unit for acute lower gastrointestinal bleeding. He undergoes an urgent prepped colonoscopy after volume resuscitation. He receives midazolam 1 mg and fentanyl 25 µg. His eyelids close, and he does not respond to voice. Within a few minutes, the nurse reports that the patient’s pulse oximetry reading is falling. He is making an effort to breathe, but there are paradoxical movements of the chest and abdomen.

 

1. Which intervention will most likely correct the oxygen desaturation in this patient?
  1. Flumazenil
  2. Intubation
  3. Jaw thrust
  4. Naloxone
Click here to compare your answer.


2. What is the most likely cause of this patient’s response to conscious sedation?

  1. Aspiration pneumonitis
  2. Hemorrhagic shock
  3. Obstructive sleep apnea (OSA)
  4. Sepsis
Click here to compare your answer.


Questions 3 and 4 refer to the following case.
A 56-year-old woman presents to the emergency department complaining of leg swelling and dyspnea. She is placed on diuretics but experiences little relief. The patient has a history of difficult-to-control blood pressure, currently treated with lisinopril, hydrochlorothiazide, and amlodipine. She reports that for the past several years she has been unable to sleep flat and has headaches on a regular basis. Pulmonary function testing shows a modest restriction with a total lung capacity of 70% and diffusion capacity for carbon monoxide (DLCO) of 70%. A recent pharmacologic stress test showed no perfusion defects and a normal left ventricular ejection fraction. Kidney function and spot urine protein screen are normal. The patient is admitted for further cardiac evaluation. On admission, blood pressure is 160/100 mm Hg, heart rate is 102 bpm, and peripheral oxygen saturation is 92% on room air. She is 5 ft 6 in and weighs 305 lb. HEENT examination reveals no jugular venous distention and a normal thyroid, but the tonsils and uvula cannot be seen. Cardiovascular examination reveals a regular rate and rhythm, no murmurs, and S4 present at the left lower sternal border. The chest is clear to auscultation bilaterally with no retractions. Pulses in the extremities are normal, there is 2+ edema in the ankles, and there is no clubbing or cyanosis. Laboratory testing reveals a hemoglobin level of 15 g/dL, serum creatinine of 1.0 mg/dL, blood urea nitrogen of 14 mg/dL, and bicarbonate level of 30 mEq/L. Portable chest radiograph demonstrates clear lung fields. Arterial blood gases on room air include a pH of 7.40, PaCO2 of 50 mm Hg, PaO2 of 62 mm Hg, and an oxygen saturation of 92%. Overnight oximetry is performed (Figure).

 

3. What is the most likely cause for this patient’s symptoms?
  1. Hypothyroidism
  2. Obesity hypoventilation syndrome (OHS)
  3. Polycythemia vera
  4. Pulmonary fibrosis
Click here to compare your answer.


4. Which of the following is the next best step in the management of this patient?

  1. Bilevel positive airway pressure (BiPAP) at 10/5 cm H2O
  2. Cardiac catheterization
  3. Oxygen and intravenous furosemide
  4. Polysomnography
Click here to compare your answer.


5. A 62-year-old man with a history of hypertension, type 2 diabetes, coronary artery disease, and chronic obstructive pulmonary disease (COPD) is admitted to a hospital after a low-speed motor vehicle accident in which he hit a light post due to loss of consciousness. He was alert and oriented at the scene of the accident but could not recall anything after he got into his car to drive. Initial evaluation including cardiac enzymes, telemetry, and serial electrocardiograms (ECGs) is unremarkable. Examination findings include a body mass index (BMI) of 28 kg/m2, hemoglobin level of 17.2 g/dL, bicarbonate level of 50 mEq/L, resting peripheral oxygen saturation of 88% on room air, droopy eyelids, clear but distant lung sounds, and trace edema. Thyroid-stimulating hormone is 4 µIU/mL. Blood gases on room air show a pH of 7.36, PCO2 of 54 mm Hg, and PO2 of 58 mm Hg. Computed tomography of the chest shows hyperinflated lungs, centrilobular emphysema, and prominent pulmonary arteries without evidence of pulmonary embolism. Telemetry shows no arrhythmias. Chemical stress testing shows no ischemia. Echocardiogram shows normal left ventricular function and evidence of pulmonary arterial hypertension with peak pressures of 48 mm Hg. Pulmonary function tests are significant for forced vital capacity (FVC) of 73% predicted, forced expiratory volume in 1 second (FEV1) of 54% predicted, and FEV1/FVC ratio of 60% and a diffusion capacity of 55%, confirming moderately severe COPD. Further history indicates excessive daytime somnolence, unrefreshing sleep, snoring, and witnessed choking episodes while sleeping. Which of the following is the most likely cause of this patient’s loss of consciousness while driving?

  1. COPD exacerbation with hypercapnia
  2. OHS
  3. Pulmonary overlap syndrome
  4. Seizure disorder
Click here to compare your answer.
 

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