Dyspnea in a Man Who Was Stuck in a Bathroom for 24 Hours

Joshua J. Solano, MD

Disclosures

November 04, 2020

The Bedside Lung Ultrasonography in Emergency (BLUE) protocol is useful for patients with undifferentiated disorders.[3] It involves multiple assessments of the lungs for lung sliding, A lines, B lines, consolidations, and effusions, as well as deep venous thrombosis. The lung sliding seen in Figure 10 signifies that the visceral and parietal pleura of the lung are moving against each other, and no air is observed in the potential space; thus, a pneumothorax is ruled out at that site. A lines are a form of reverberation artifact that appear as horizontal lines parallel to the pleural lines; this finding signifies that the lung is aerated without fluid or consolidation (Figure 11). B lines are a form of artifact that spread from the pleural line and propagate to the end of the frame at least 12 cm down on the sonogram and represent the presence of fluid in alveoli (see Figure 6). Consolidations and effusions appear as areas of anechoic fluid collection.

Figure 10.

Figure 11.

Figure 6.

In this patient, several important history points, physical examination findings, and data help narrow the differential diagnosis and allow for the implementation of treatment. He is notably hypoxic, requires oxygen, and denies any history of pertinent pulmonary disorders. These findings tend to exclude the causes of chronic dyspnea. The lack of a smoking history reduces the likelihood of COPD. The absence of a fever, cough, defined infiltrate on the chest radiograph, leukocytosis, and lactic acidosis makes viral or bacterial pneumonia less likely.

The patient has a history of atrial fibrillation and is taking warfarin. His INR is in the therapeutic range, which makes pulmonary embolism much less likely. If he had a history of noncompliance and subtherapeutic INRs, pulmonary embolism would be more of a consideration. In addition, the patient's abnormal chest radiograph, significant bilateral pitting edema, and lung crackles reduce the likelihood of pulmonary embolism. The absence of stridor, wheezing, and urticaria tends to exclude angioedema, asthma exacerbation, and anaphylaxis. The lack of reported upper airway or lower facial or neck trauma makes a foreign body (from an aspirated tooth, for instance), tracheal injury, or obstruction from aspirated blood much less likely. The presence of jugular venous distension points to such causes as pericardial effusion (less likely owing to the degree of hypoxia), tension pneumothorax (unlikely because of bilateral breath sounds and ruled out on the chest radiograph), and congestive heart failure.

This patient has a history of congestive heart failure with pitting edema on examination, crackles in the lung fields, a chest radiograph with pulmonary edema, a point-of-care lung sonogram with B lines, and a point-of-care echocardiogram with a reduced ejection fraction.[4,5]

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