Pre-hospital Shortness of Breath

Raghav Sahni, DO, Morgan Ritz, MD, and Maxwell Cooper, MD

Shortness of breath, or dyspnea, is a common complaint that can present to an emergency department (ED) caused by an exacerbation of either Congestive Heart Failure (CHF) or Chronic Obstructive Pulmonary Disease (COPD). At our campus over the past 1-year, more than 200 calls were made for shortness of breath with patients having a history of CHF or COPD. In the last year, from February 2019-2020, ten pre-hospital cases were treated for shortness of breath, usually with nebulizer treatments, but were then found to have a CHF exacerbation after ED work-up and were subsequently started on the appropriate treatment of nitrates, diuretics, or non-invasive positive pressure ventilation. A large portion of our population has a history of both CHF and COPD, which can make the pre-hospital treatment of dyspnea more complicated. For example, six different prehospital cases of shortness of breath were diagnosed with both CHF and COPD exacerbations upon ED work up.

Several studies have demonstrated the increased sensitivity and specificity of point-of-care ultrasound (POCUS) in appropriately diagnosing CHF versus COPD. Pulmonary edema in a CHF exacerbation can be identified on ultrasound by B-lines, a comet-tail reverberation artifact. A two-patient case series in 2010 expanded upon this knowledge and illustrated how pre-hospital POCUS when used by EMS for the chief complaint of shortness of breath could appropriately diagnose and assist in the correct management of the undifferentiated dyspneic patient.

Case

A 57-year-old female with a past medical history of CHF and COPD on 2L home oxygen, diabetes mellitus type 2, hypertension, and hyperlipidemia called emergency medical services (EMS) complaining of shortness of breath. Patient described symptoms developing over the past two days with increased lower extremity swelling. Patient noted that she is supposed to be on several medications including furosemide but has not taken it in several days. Patient said she has tried an albuterol inhaler with minimal relief of her symptoms. The patient admitted to being intubated one time in the past for similar symptoms.

On arrival by EMS, the patient was saturating 99% on 2L nasal cannula, blood pressure of 155/90, and respiratory rate of 28. She was sitting upright and leaning forward with increased work of breathing. On auscultation, the patient had diffuse wheezing in all lung fields and bibasilar rales. The patient had symmetric +2 edema in her lower extremities.

Portable ultrasound exam was performed by a PGY-2 emergency medicine resident in the ambulance during transport. The exam showed more than three B-lines per high-powered field in bilateral anterior and lateral lung fields suggesting pulmonary edema. The exam showed lung markings with lung slide in all fields. Portable ultrasound and physical exam findings suggested a multifactorial cause of the patient’s dyspnea, which included suspicion for both CHF and COPD exacerbations with less clinical concern for pneumothorax.

Due to the moderate to severe respiratory distress, the patient was placed on non-invasive positive pressure ventilation (NIPPV). Due to diffuse wheezing, the patient was given ipratropium/albuterol en route. O

n arrival to the ED, the patient had improved work of breath with respiratory rate improving to 20 breaths per minute and oxygen saturation of 100% and was transitioned from NIPPV to 2L nasal cannula. The physical exam in the ED was noted as scattered wheezing, diminished breath sounds, and pitting lower extremity edema. Her brain natriuretic peptide (BNP) was 504, correlating with a CHF exacerbation. Her chest x-ray was consistent with pulmonary vascular congestion without pneumothorax. A COVID-19 test was negative.

The patient was treated in the ED for COPD exacerbation with albuterol nebulizers and methylprednisolone and for CHF exacerbation with furosemide. Following treatment, the patient had resolved wheezing and improved work of breathing. She was admitted to the hospital under monitored care for further management of CHF and COPD exacerbations.

Pre-hospital pulmonary ultrasound exam, which showed B-lines, alerted the emergency department care team on arrival that that patient’s symptoms included a component of fluid overload. A bedside ultrasound exam in the ED confirmed B-lines bilaterally in the lungs along with a plethoric IVC and decreased cardiac ejection fraction estimated at 30% using E-point septal separation (EPSS).

CHF and COPD are two common comorbidities that present as shortness of breath. Point-of-care ultrasound is often used in the ED to evaluate for pulmonary edema. Pre-hospital ultrasound exams are theorized to further expedite diagnosis of the etiology of shortness of breath. In this patient’s case that was noncompliant on medications, an ultrasound exam expedited her diagnosis as multifactorial including CHF and COPD exacerbations. In addition, NIPPV and albuterol/ipratropium were appropriately started and improved the patient’s symptoms dramatically enough to be transitioned off CPAP and onto nasal cannula upon arrival. In other cases, portable ultrasound exams can allow for more accurate medication therapy decisions during transport such as deciding between albuterol/ipratropium, steroids, or nitroglycerin. Further pre-hospital data can provide a more accurate idea of how this practice can become standard of care for EMS providers in the near future.