Point-of-Care Ultrasound in the Inpatient Setting: A Tale of Four Patients

Renee K. Dversdal, MD; KevinM. Piro, MD; Charles M. LoPresti, MD; Noelle M. Northcutt, MD; Daniel J. Schnobrich, MD

Disclosures

South Med J. 2018;111(7):382-388. 

In This Article

Case 4

A 60-year-old woman without regular medical care was admitted to the medicine teaching service for preorbital cellulitis without other complaints. She denied medical conditions other than a 60-pack per year smoking history, although she had been intermittently hypertensive in the hospital. She initially received intravenous fluids because she met the sepsis criteria and was receiving intravenous vancomycin treatment. Two days after presentation, her morning examination was notable for improved periorbital edema and erythema and decreased breath sounds. Laboratory tests and imaging included normal chemistries, blood cultures, improving leukocytosis, and an initial orbital CT scan without abscess or deep infection. She later developed acute dyspnea in the setting of blood pressure of 192/98. At that time she was afebrile, with a heart rate of 102, a respiratory rate of 22, and a pulse oximetry of 92% on 2 L oxygen by nasal cannula. On repeat examination she had stably decreased breath sounds with scattered wheezes and no crackles. Cardiac examination demonstrated regular tachycardia, no murmur or S3 gallop, no significant jugular venous distension, and no peripheral edema. The electrocardiogram was significant only for sinus tachycardia. There was no response to empiric nebulizer treatments for presumptive chronic obstructive pulmonary disease exacerbation. Pulmonary POCUS, along with focused cardiac views, was then performed, with a unit-based cart US.

Literature Review and Discussion

POCUS has many uses in the dyspneic patient. In a systematic review of studies of emergency medicine patients presenting with undifferentiated acute dyspnea and clinical suspicion of acute cardiogenic pulmonary edema, diffuse interstitial syndrome, as demonstrated by B-line pattern, had a sensitivity of 94.1% and a specificity of 92.5% for acute cardiogenic pulmonary edema.[42] Increasing numbers of B-lines correlate with increasing extravascular lung water,[43–45] and dynamic monitoring of B-lines shows improvement with volume management via diuresis or dialysis.[46–48] Studies have suggested that B-lines present upon discharge from acute heart failure hospitalization correlate with an increased risk of readmission and mortality.[46,49] In addition to interstitial syndromes, US is more sensitive than plain chest radiography for the detection of pleural effusion, pneumonia, and pneumothorax.[50–52]

US Findings and Case Resolution

On pulmonary US the patient was noted to have a diffuse B-line pattern of all inspected lung zones bilaterally (Figure 6). She also was found to have grossly normal left ventricular systolic function. Her IVC collapsed >50% at the hepatic vein, arguing against elevated right heart pressures.[53] The patient's lung US findings of diffuse B-lines were interpreted as likely cardiogenic pulmonary edema in the context of clinical information such as the patient's age, previous fluid resuscitation, and hypertension. It should be noted that noncardiogenic pulmonary edema, fibrosis, pneumonia, or contusion can likewise cause focal or diffuse B-line patterns on US.[54,55] The clinician obtaining the clinical history and physical examination also interpreted the findings and was ideally suited to clinically integrate and act on these findings. The patient improved rapidly with diuresis and blood pressure normalization with nitroglycerin paste. A chest x-ray was ordered but canceled, given the patient's improvement before it was performed. Repeat pulmonary US on teaching rounds the next morning was notable for a normal A-line pattern throughout. A formal echocardiogram obtained the next day was notable only for mild left ventricular hypertrophy and diastolic dysfunction.

Figure 6.

Normal A-line pattern (yellow arrows) on left, pathologic B-line pattern on right. Pleural line as noted. Corresponding ultrasound clips can be viewed at http://links.lww.com/SMJ/A111.

This case highlights the utility of POCUS in acute dyspnea, which can be the result of evolving etiologies during a hospitalization. This patient had no history or physical examination findings suggestive of acute decompensated heart failure; however, she did have US findings of and responded to treatment for "flash" pulmonary edema caused by a hypertensive emergency. Her medical team was able to rapidly guide treatment at the bedside and prevent further decompensation. The patient was later discharged with a new primary care physician and oral antibiotics.

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