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Ultrasound Corner |

A 47-Year-Old Man With Dyspnea and HypotensionA 47-Year-Old Man With Dyspnea and Hypotension FREE TO VIEW

Pralay K. Sarkar, MD, DM; Seth J. Koenig, MD, FCCP; Paul H. Mayo, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care and Sleep Medicine (Dr Sarkar), Department of Medicine, University of Florida, Gainesville, FL, and Division of Pulmonary, Critical Care and Sleep Medicine (Drs Koenig and Mayo), Hofstra North Shore-LIJ, Long Island Jewish Medical Center, New Hyde Park, NY.

Correspondence to: Pralay K. Sarkar, MD, DM, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610-0225; e-mail: pralay.sarkar@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(4):e1-e3. doi:10.1378/chest.13-0335
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Published online

A 47-year-old man was brought to the ED with acute delirium and severe dyspnea. He was unwell for the past several days with a low-grade fever, dry cough, exertional dyspnea, and fatigue. His medical history included hypertension, diabetes mellitus, and end-stage renal disease requiring hemodialysis through a fistula in his left arm.

On presentation, the patient had a BP of 80/40 mm Hg, a regular heart rate at 120/min, a temperature of 38°C, and a respiratory rate of 32/min. His oxygen saturation was 84% on an Fio2 of 1.0. The physical examination revealed an obtunded male with bilateral vesicular breath sounds without crackles or rhonchi. Cardiac auscultation revealed normal first and second heart sounds and a grade 1/6 systolic murmur over the apical area. Skin examination showed several palpable purpuric spots on the lower extremities and a gangrenous fourth toe tip on the left foot. Chest radiograph showed bilateral alveolar opacities. CT scan of the brain was normal. Pertinent laboratory values were hemoglobin,7.5 g/dL; WBC, 3,600/μL; creatinine, 5.4 mg/dL; and an arterial blood gas of pH 7.30, Paco2 of 25 mm Hg, Pao2 of 48 mm Hg, and bicarbonate of 12 mEq/L. Lactate level was 8 mEq/L. The patient was placed on mechanical ventilation, and volume resuscitation was started for a presumptive diagnosis of pneumonia with septic shock. The patient was admitted to the medical ICU where the critical care team immediately performed bedside ultrasonography to assess the cause of his hypotension and hypoxemic respiratory failure (Videos 1-6).

Video 1: Case Video

Based on the interpretation of the six videos and the patient’s clinical history and physical examination, what would be the most logical next step?

  • 1. Continue volume administration because patient is preload sensitive;

  • 2. Administer an inotropic agent for depressed left ventricular contractility;

  • 3. Perform thrombolysis for obstructive shock secondary to presumptive pulmonary embolism; or

  • 4. Begin vasopressors and obtain urgent cardiothoracic surgery consultation.

Begin vasopressors and obtain urgent cardiothoracic surgery consultation. The patient had developed mitral valve endocarditis and pulmonary edema as a result of mitral valve regurgitation.

This patient’s acute respiratory failure mandated ultrasonography examination of the thorax (see Discussion Video).

Video 2: Discussion Video

It showed bilateral profuse B lines over the anterior lungs with bilateral anechoic pleural effusions (Videos 1, 2). Bilateral lung sliding was preserved. The diffuse bilateral anterior B-line pattern with preserved lung sliding has been shown to have high sensitivity and specificity for the diagnosis of cardiogenic pulmonary edema.1 The presence of features of pulmonary edema and shock state warranted immediate goal-directed echocardiography, which was performed next (Videos 3-5). The parasternal long-axis view (Videos 3 and 4) showed preserved left ventricular function, a minimal pericardial effusion during systole, and an echogenic mass attached to the upstream (ie, atrial) side of the anterior leaflet of the mitral valve. The mass had a pattern of motion in tandem with the valve movement, with a high-frequency oscillation pattern. These features were consistent with vegetation. The valve leaflets were morphologically intact with good coaptation (Video 4). The presence of a large vegetation and development of pulmonary edema indicated a high likelihood of severe valvular regurgitation. Color flow Doppler echocardiography can be used to assess the presence and quantitative severity of valvular regurgitation, but it is not an essential part of basic goal-directed critical care echocardiography. The presence of a valve vegetation combined with a clinical examination consistent with embolic phenomenon, as seen with the gangrenous toe and palpable purpuric skin lesions, made infective endocarditis likely.2 Video 5 is a short-axis view showing normal left ventricular function and the mobile vegetation that was visible during diastole. In the long-axis view, the inferior vena cava (Video 6) measured 2.45 cm in diameter without respiratory variation while the patient breathed passively on the ventilator, indicating with high sensitivity and specificity that this patient was not volume responsive and that vasopressors should be administered to support his BP.

Combined with the history and physical examination, the critical care team used ultrasonography as the primary imaging modality to establish a diagnosis that was different from the one initially ascribed to the patient. Rather than pneumonia with septic shock, the patient had bacterial endocarditis with acute mitral valve regurgitation, shock, and respiratory failure from cardiogenic pulmonary edema. Prompt identification of this process leads to specific interventions that include urgent cardiothoracic consultation, stabilization of hemodynamic function with an aortic balloon pump, and valve replacement surgery.

This case demonstrates the importance of critical care ultrasonography for all patients presenting with cardiopulmonary failure. One reason to use ultrasonography as a routine part of the initial evaluation is to identify a life-threatening process that requires prompt therapeutic intervention, such as pericardial tamponade; acute cor pulmonale with thrombus in transit; tension pneumothorax (ruled out by bilateral lung sliding); profound hypovolemia; or, as in the present patient, severe valve failure. Although uncommon, it is important to identify such cases immediately because they are amenable to specific lifesaving interventions. Another reason to perform ultrasonography routinely for initial evaluation of hemodynamic failure is to categorize the shock state, to rule out an alternative diagnosis for shock, and to develop a logical management strategy. It also helps in identifying coexisting conditions that may complicate management and may be used to follow the progress of the disease and response to therapy with sequential examinations. In the present patient, the finding of normal left ventricular function, the absence of acute cor pulmonale pattern, and the determination that the patient was not preload sensitive were important aspects of the examination. In encouraging the use of ultrasonography, the emphasis often is on what abnormalities are found. Of equal importance are the abnormalities that are not present, and early use of ultrasonography ensures that therapy for those presumptive abnormalities is not started inappropriately. In the present patient, volume resuscitation was started in the ED because of the presumption that he had septic shock. The cardiac ultrasonography showed that this treatment was not appropriate, and the critical care team discontinued it immediately.

A goal-directed echocardiography examination is a key element in the initial evaluation of the patient in shock.3 It includes the two-dimensional examination of the parasternal long-axis view, parasternal short-axis view at the papillary muscle level, apical four-chamber view, subcostal long-axis view, and inferior vena cava longitudinal view. The examination of the heart should be accompanied by lung and pleural ultrasonography because the results are complementary to the cardiac examination.

Critical care ultrasonography is a well-defined imaging modality.4 Training is widely available, and competence is within the capability of any interested intensivist. The bedside examination may be performed in a few minutes, and the results are immediately available to the frontline team who is in the best position to integrate the findings into the overall care plan. The present case is an example of its utility.

  • 1. In combination with standard history, physical examination, and laboratory tests, bedside ultrasonography is a key element in the evaluation of the patient with cardiopulmonary failure. Thoracic ultrasonography allows the intensivist to rapidly diagnose pneumothorax, pleural effusion, alveolar consolidation, and pulmonary edema with a high degree of accuracy.

  • 2. Goal-directed echocardiography helps to characterize the etiology of shock, allowing appropriate therapeutic management of the hypotension while avoiding inappropriate volume administration when a patient is not preload sensitive.

  • 3. Gross valvular failure may be detected with goal-directed echocardiography, allowing the intensivist to quickly obtain appropriate consultation from other services.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: To analyze this case with the videos, see the online version of this article.

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. [CrossRef] [PubMed]
 
Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35(suppl 5):S235-S249. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 

Figures

Tables

Video 1: Case Video

Video 2: Discussion Video

References

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. [CrossRef] [PubMed]
 
Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med. 2007;35(suppl 5):S235-S249. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 
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