Thursday, June 22, 2006

Worsening SOB

This 76 year old man has IPF documented on a 2004 open lung with typical CT findings as well. In 2004 his FVC was 47% predicted with a DLCO of 31% on 6l. It is severe, but he has been stable over a 2 year period. He did have a trial of steroids back then with no effect (no surprise.
He was doing well until a month ago when he developed a "cold" (increased cough with whitish sputum, runny nose/nasal congestion). He continues to have profound DOE. No fevers or chills. 3 separate antibiotic course were without effect. He is SOB even with urination. On exam he can speak in full sentences and is in no acute distress at rest. His sat is 93% on 4l NC. His lungs show no change in his fine bibasilar crackles 1/2 up. JVP about 5-6 cm. No LE swelling. A spiro showed no chnage in mechanics compared to 3 months ago (before the "cold"); FVC 48% pred, but DLCO now is worse at 23% predicted (31% in 2004 the last time it was checked). However, the IVC was only 38% of predicted.
On exam his sat is 93% on 4l at rest.
His CXR is unchanged from a year ago and is shown here.

What are your thoughts as to the cause of his new dyspnea? What else would you do?
I just saw him today so there is no "magic" answer that I am witholding; just looking for other opinions (you know, like a roundtable discussion).

3 comments - CLICK HERE to read & add your own!:

DrJon said...

I just finished my radiology crash course (about to start third year) and what strikes me about the image is this, are the diaphragms at a really high level?

Just curious.

Baleeiro said...

If the mechanics are kind of the same but DLCO is down and the patient is worse I would look for complicating conditions. Check an ECHO, get some sputum Cxs for atypical agents and look for pulmonary vascular Dz.

Baleeiro said...

DrJon raises an interesting point on the CxR. I assume the diaphragms are high because of his severe restriction and small lung volumes. However if they look higher you might wanna check a SNIFF test as well (pretty low-tech test).