A 73 year old female presents with a history of COPD presents with two weeks of shortness of breath and weakness.
Her vital signs are HR 105, BP 96/63, RR 18, T 36ºC, SpO2 92% on 3L (baseline). Physical exam is notable for abdominal pain and wheezes. The remainder of the exam is unremarkable.
While receiving and infusion of a normal saline bolus the patient becomes more short of breath and requires 5L of oxygen.
The physician then performs a cardiac and pulmonary ultrasound to assess for congestive heart failure and differentiate the patient’s hypoxia.
They obtain the following images of the patient’s left and right anterior chest.
They obtain the following cardiac views:
And they measure the following hemodynamics:
They attempt but are unable to see the patient’s IVC because of the patient’s abdominal pain and barrel shaped chest.
Are the images consistent with congestive heart failure? Would you diurese this patient? (Click the button for the answer!)
Bilateral Pneumonia, Hold Diuretics
This patient has more than three B-Lines in two bilateral lung zones, which according to one study has a positive likelihood ratio of 12.38 [1] for congestive heart failure. This patient, however, appeared to have a normal ejection fraction. On the parasternal long axis view the E-Point Septal Separation is zero, which suggests an EF of more than 50 percent [2]. More importantly, the left ventricle as a whole appears to be adequate, and clinically the physician did not think the patient had congestive heart failure.
The physician solved the case by measuring diastolic function and estimating the pulmonary capillary wedge pressure.
By measuring the mitral inflow velocity (E) and tissue doppler velocity of the mitral annulus (e’), they were able to estimate pulmonary capillary wedge pressure with the following formula [3]:
PCWP = E/e’ + 4
PCWP = 34 / 6 + 4 = about 10 mmHg
The hydrostatic pressure required to push capillary fluid into the alveoli and generate B line artifact is about 20-25 mmHg [4]. The PCWP in this patient is nowhere near high enough to generate B-lines.
The patient received a 1L fluid bolus, was started on empiric antibiotics, and a CT scan of the chest showed bilateral infiltrates consistent with pneumonia
- B-lines can be from any fluid in the alveoli
- Focal B-lines are more specific for pneumonia, however bilateral B-lines can be seen in atypical infections such as COVID-19
- Diastology is an essential tool for assessing critical patients in the emergency department. If you can obtain an apical four chamber view, then it’s only a small step to measure diastology. You can do it! Refer to the following video for a tutorial:
https://coreultrasound.com/diastology/
Authors: Rebecca Pilkerton MD, David Crockett MD, Jennifer Cotton MD
Peer Reviewer: Jacob Avila MD and Ben Smith, MD, FACEP
References
- Deeb, Mohammad A., Skye Barbic, Robin Featherstone, Jerrald Dankoff, and David Barbic. 2014. “Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis.” Academic Emergency Medicine 21, no. 8 (August): 843-52. 10.1111/acem.12435.
- McKaigney, Conor, Mori Krantz, Cherie Rocque, Nicole Hurst, Matthew Buchanan, and John Kendall. 2014. “E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction.” American Journal of Emergency Medicine 32, no. 6 (June): 493-7. 10.1016/j.ajem.2014.01.045.
- Nagueh, S F, K. J. Middleton, H. A. Kopelen, W. A. Zoghibi, and M. A. Quiñones. 1997. “Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.” Journal of the American College of Cardiology 30, no. 6 (November): 1527-33. 10.1016/s0735-1097(97)00344-6.
- Kostuk, William, John Barr, Allen Simon, and John Ross, Jr. 1973. “Correlations Between the Chest Film and Hemodynamics in Acute Myocardial Infarction.” Circulation XLVIII (September). 10.1161/01.CIR.48.3.624.
