A 75-Year-Old Man With Dyspnea and Chest Pain

Giovanni Volpicelli, MD


November 30, 2016

Figure 3

The patient in the above case underwent treatment with intravenous diuretics (furosemide 40 mg) and steroids (methylprednisolone 125 mg). Despite adequate diuresis of approximately 60 mL/h, the clinical picture did not improve. His blood pressure dropped further to 90/50 mm Hg, and it was impossible to maintain an ideal SPO2 even with maximum oxygen supplementation via a nonrebreather mask.

The decision was made to stop diuretics and begin treatment with CPAP, and to add an inotropic agent to his treatment regimen. CPAP was initiated via a helmet, with a positive end-expiratory pressure of 7.5 cm H2O and a FiO2 of 0.5, along with the addition of dopamine (5µg/kg/min).

The clinical picture improved progressively once CPAP was initiated, with the pulse oximetry consistently above 95% and normalization of blood pressure (permanently over 110/70 mm Hg), heart rate, and respiratory rate. A blood gas analysis obtained 10 hours later revealed a pH of 7.47, a PCO2 of 25.9 mm Hg, and a PO2 of 73.4 mm Hg. CPAP treatment was discontinued after 36 hours, with a repeat arterial blood gas analysis showing a pH of 7.47, a PCO2 of 33.5 mm Hg, and a PO2 of 75 mm Hg on 4 L of oxygen via a nasal cannula.

A new follow-up chest radiograph was obtained (Figure 3), which showed marked improvement of the pulmonary edema.


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