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Not a Good ‘Short-Cut’ to Take!

Authors
Kunal Jakharia, MD, Pulmonary and Critical Care Fellow, University of North Carolina, Chapel Hill
Christine L. Vigeland, MD Clinical Instructor, University of North Carolina, Chapel Hill


Case

55-year-old man with history of obesity, alcohol use disorder, untreated hepatitis C, with no prior history of lung disease, presented to the emergency room with shortness of breath. He was noted to be awake and alert with 1+ bilateral lower extremity edema. Oxygen hemoglobin saturation (O2 sat) was 85% on room air. An arterial blood gas on CPAP 12cm H20, FiO2 50% showed a PaO2 of 90 mmHg. Respiratory viral panel with COVID-19 PCR was negative, with a normal appearing chest X-ray. His platelet count and albumin were 125 x 103 /ul and 2.8 gm/dl respectively. He was admitted to the ICU for hypoxemia requiring high flow nasal cannula (HFNC) and intermittent CPAP. He was noted to have a decrease in his O2 sat while sitting upright, requiring up to 100% HFNC. As part of workup of his hypoxemia, he had a transthoracic echocardiogram performed that was a technically difficult study but showed a normal left ventricular ejection fraction, trace tricuspid regurgitation, and was unable to estimate right ventricular systolic pressure (RVSP). A perfusion scan was performed, which is shown below.

FIGURE A – Anterior
FIGURE A – Anterior
FIGURE B - Posterior
FIGURE B - Posterior
FIGURE C
FIGURE C

Question

What is the most likely cause of his hypoxemia?

A. High probability pulmonary embolism (PE)
B. Hepatopulmonary syndrome (HPS).
C. Lobar pneumonia
D.Porto pulmonary hypertension (PPH)

Answer