Daily Archives: January 9, 2020

A case of cardiogenic pulmonary edema

Nephrology was consulted for acute kidney injury and hypervolemia in a chronically ill nursing home resident. You decide to perform lung POCUS to assess extravascular lung water.

Multiple B-lines per rib interspace are noted bilaterally consistent with pulmonary edema. Chest X-ray shown for comparison.

But would you stop there? No. Focused cardiac ultrasound (FoCUS) may give an idea if the pulmonary edema is caused by pump failure or a result of other structural abnormalities of the heart. Here are the apical 4 chamber and 2 chamber views.

The left ventricle seems dilated and there is a mobile echodensity (yellow arrow, merged clip) on the anterior mitral valve leaflet. LV systolic function appears fine, may be hyperdynamic actually. Color Doppler images revealed severe mitral regurgitation along with a separate regurgitant jet across the leaflet coaptation line suggestive of leaflet perforation (yellow arrow, still image).

So the cause for pulmonary edema is severe mitral regurgitation secondary to valve destruction caused by endocarditis. Cardiothoracic surgery was consulted but unfortunately, the patient was too sick to be a surgical candidate.

Learning point: Multi-system POCUS often provides management-changing information.

What are the key elements of establishing a POCUS program?

Below image is the summary of the key elements involved in establishing a POCUS program. First of all, the faculty need to be comfortable with the common POCUS applications, which comes only by repeated scanning. Performing educational scans and comparing with formal images/report is a good way to start.

While there is a lot of enthusiasm about hand-held devices because of the lower cost and enhanced portability, their image quality is not sufficient for advanced applications or comprehensive studies. It is very easy to miss findings such as a small stone, cyst or even a renal mass. On the other hand, if the main purpose of the program is to just introduce the trainees to basic applications such as evaluating extravascular lung water, these are good. Also, find the comparison of various hand held devices below courtesy of ACEP now.