Decisions in COPD vs CHF

Congestive heart failure and COPD are two of the most common underlying conditions a patient presents with when calling EMS for respiratory complaints. The true etiology of the patient’s acute respiratory deterioration is important to differentiate, as effective management strategies in these conditions can differ significantly.

The patient in this case is an 89-year-old male who presented to EMS with acute-onset difficulty in breathing. This patient had a history of both COPD and CHF.

Initial physical assessments revealed wheezes bilaterally in the upper fields, with diminished auscultation and faint wheezing to the lower fields. ETCO2 monitoring was established, with patient showing high-normal ETCO2 in the presence of tachypnea as well as an absence of hypertension. COPD it is! Bronchodilators, steroids, and low EPAP bilevel NPPV was established to assist with patient’s ventilation.

Crew then performed point-of-care ultrasonography, resulting in the following images:

B-lines in the upper fields bilaterally, and a pleural effusion to the right lower chest. It’s CHF too!

Crew modified bilevel NPPV settings to a higher PEEP to assist with pulmonary edema. Unfortunately, as a novice to the art of ultrasound, I was unable to capture solid cardiac and IVC view within a reasonable timeframe, as we had arrived at hospital.

Interestingly, no B-lines were appreciated to the left lower lung field, despite this being the dependent aspect of the lung. My hypothesis is that this region of the lung had hyperinflated, air-trapped alveoli coupled with hypoxic pulmonary vasoconstriction. This may have prevented edema from building there. I’m curious to hear alternatives.