Cardiogenic pulmonary edema (ultrasound)

Case contributed by Dr David Carroll

Presentation

Progressive dyspnea on exertion.

Patient Data

Age: 55 years
Gender: Male
Ultrasound

Lungs: sliding present bilaterally, visceral-parietal pleural interface regular, symmetric and innumerable B-lines anteriorly.

Parasternal long axis: septum/posteroinferior wall severely hypokinetic, wall thickening markedly reduced, E-point septal separation >2cm (normal <7mm), no apparent pericardial fluid.

Subcostal vena cava: junction with right atrium visualized in long axis, IVC plethoric with minimal respirophasic variability, hepatic veins distended.

Case Discussion

Point‐of‐care echocardiography is often integrated into the emergency evaluation of undifferentiated presentations suspected to have a cardiopulmonary etiology5

Designed to assess the presence or absence of common hemodynamic patterns encountered in the critically ill, a limited examination of the lungs often serves as a surrogate for left atrial pressure if signs of elevated filling pressures are present. Assessment of the IVC serves as a rough correlate of RAP.2

Presenting with progressive dyspnea on exertion, the patient in question was examined with the following questions:

  • what is the global (qualitative) left ventricular function?
  • is there any obvious pathology e.g. effusion, septal bowing, dissection flap?
  • what are the chamber dimensions and wall thickness?

In this context (clinical suspicion for CHF), the findings of depressed wall movement and thickening, chamber dilation, extravascular lung water, and a dilated IVC are consistent with the presence of poor forward flow, cardiac remodelling, elevated pulmonary venous and capillary pressures, and volume overload,6 defining features of the heart failure syndrome (with prominent systolic dysfunction). Myocardial stiffness and relaxation are more laborious to approximate; with a preserved ejection fraction but findings consistent with heart failure, point of care echocardiography protocols often use increased wall thickness as supporting evidence of "diastolic'' dysfunction.6

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Case information

rID: 62735
Published: 29th Aug 2018
Last edited: 5th Sep 2018
System: Chest, Cardiac
Inclusion in quiz mode: Included
Institution: St. George's University

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