The patient is a 56 year old man who was brought in via EMS for severe respiratory distress. He is sitting straight up in bed, tripoding, diaphoretic with dinner plate eyes. The patient is able to convey that he thinks he might die. He was given one albuterol/atrovent nebulizer per EMS without relief. The patient is unable to provide any further history due to his severe respiratory distress. On exam he has accessory muscle use and has a prolonged expiratory phase to his breathing. Auscultation reveals coarse wheezing bilaterally. BP 220/152 P 130 R 35 T 98.2 O2 80% RA.
This bedside echocardiogram demonstrates a severely depressed left ventricular ejection fraction. The IVC is 2-2.5 cm with < 50% collapse suggesting a high CVP. Further, the lung scan demonstrates bilateral diffuse B-Lines consistent with pulmonary edema. Putting this picture together, this patient has flash pulmonary edema from decompensated heart failure (CHF).
In the patient with severe respiratory distress and impending respiratory failure, it is imperative to institute the correct treatment plan immediately.
Wheezing is a physical exam finding classically associated with bronchospasm and obstructive lung disease. However, several studies of dyspneic patients have shown that the positive predictive value of this finding for COPD in emergency department patients is marginal, with a +LR of only 2-3.1-4
Bilateral crackles/rales are a physical exam sign classically associated with interstitial fluid from either CHF or ARDS. However, this finding has been found to be nonspecific as well. One study looked at asymptomatic elderly patients found that 1/3 of those age >75 had bilateral crackles at baseline.5
The term “cardiac asthma” describes patients who have decompensated heart failure, but present with primarily wheezing instead of crackles. It has been found to be present in up to 1/3 of CHF exacerbations in patients age > 65.6
B-Lines, when present on ultrasound in 3 or more lung fields bilaterally, have a positive likelihood ratio of > 20 for decompensated heart failure according to several studies.7,8 It has been found to be much more accurate than either chest X-ray or physical exam.9 However, one recent study demonstrated a mediocre +LR of 5.8 when B-Lines were present in 8 or more lung fields.10
Bedside thoracic, cardiac and IVC ultrasound should be utilized to augment history and physical in the patient with undifferentiated dyspnea, as it can provide fast reliable diagnostic information that will allow for the initiation of time critical therapies.
Instead of continuing treatment for bronchospasm with nebs and steriods, this patient was immediately started on BiPap and given IV nitroglycerin and ACEI to decreased his severely elevated afterload. Within 10 minutes, his respiratory rate had decreased and he was feeling much more comfortable. He did not require endotracheal intubation and was diuresed without complication.
Mattos WL, Signori LG, Borges FK, Bergamin JA, Machado V. Accuracy of clinical examination findings in the diagnosis of COPD. J Bras Pneumol. 2009;35:(5)404-8. [pubmed]
Broekhuizen BD, Sachs AP, Verheij TJ, et al. Accuracy of symptoms, signs, and C-reactive protein for early chronic obstructive pulmonary disease. Br J Gen Pract. 2012;62:(602)e632-8. [pubmed]
Oshaug K, Halvorsen PA, Melbye H. Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease? Int J Chron Obstruct Pulmon Dis. 2013;8:369-77. [pubmed]
Straus SE, McAlister FA, Sackett DL, Deeks JJ. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. CARE-COAD1 Group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease. JAMA. 2000;283:(14)1853-7. [pubmed]
Kataoka H, Matsuno O. Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients. Ann Fam Med. 2008;6(3):239-45. [PMC]
Jorge S, Becquemin MH, Delerme S, et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcome. BMC Cardiovasc Disord. 2007;7:16. [PMC]
Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15:(2)R114. [pubmed]
Liteplo AS, Marill KA, Villen T, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med. 2009;16(3):201-10. [pubmed]
Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100:(1)9-15. [pubmed]
Chiem AT, Chan CH, Ander DS, Kobylivker AN, Manson WC. Comparison of Expert and Novice Sonographers’ Performance in Focused Lung Ultrasonography in Dyspnea (FLUID) to Diagnose Patients With Acute Heart Failure Syndrome. Acad Emerg Med. 2015;22:(5)564-73. [pubmed]