A 65 year old female with past medical history significant for recently diagnosed COPD presenting with shortness of breath. She has been symptomatic for the past month but has been getting progressively worse over the past couple weeks. She is medically compliant with her prescribed inhalers and is not on supplemental oxygen at home. She also reports worsening bilateral lower extremity edema and fatigue over the past two days.
Patient has an initial pulse oximetry of 65% in triage on room air, placed on non-rebreather and improved to 85%. Other vitals are as follows: BP 122/87, HR 101, Temp 97.4, RR 18. Physical exam significant for tachycardia, respiratory distress with poor air movement bilaterally, and bilateral lower extremity pitting edema from the knees down. A focused cardiopulmonary point-of-care ultrasound is shown below. What’s the likely diagnosis and abnormal ultrasound finding?
Answer: COPD with pulmonary hypertension and right heart strain
- Shown by dilated right ventricular outflow tract (RVOT) on PSLA and D-sign on PSSA.
- Normally in PSLA, the RV outflow tract, aortic outflow tract, and L-atrium should be roughly the same size. Additionally, in PSSA the LV is normally bowing into the RV due to the increased pressures comparatively. When there is right heart strain, the RV dilates from the increased pressure and pushes the interventricular septum back to the midline, creating the “D-sign”.
- This is most concerning for pulmonary embolism in the acute setting. This patient had a CTA chest performed which was negative for pulmonary embolism.
- Right heart strain is also congruent in the setting of long-standing, untreated COPD leading to pulmonary hypertension causing her shortness of breath and bilateral lower extremity edema without pulmonary edema.
- When seeing an acutely ill patient like this at bedside, it is important to rule out the most life-threatening pathology with the information you have readily available. While the acute-on-chronic nature of her story may support a diagnosis of COPD causing chronic pulmonary hypertension and right heart strain, a pulmonary embolism must be ruled out in the setting of hypoxia and right heart strain on POCUS as it would require more emergent intervention and can also be concurrently present.
References:
https://www.pocus101.com/the-d-sign-right-heart-strain-from-pressure-vs-volume-overload/
Falster C, Egholm G, Wiig R, Poulsen MK, Møller JE, Posth S, Brabrand M, Laursen CB. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open. 2023 Jan 16;8(2):E59-E67. doi: 10.1055/a-1971-7454. PMID: 36726389; PMCID: PMC9886498.
