During the previous nightshift, the patient was intubated because of dyspnea, still hemodynamically stable. Pulmonary oedema is reported as a cause of respiratory failure.
You are searching for an aetiology, thus performing ultrasonography of the heart and lungs:
PSAX at the level of the mitral valve.
Concentric left ventricular hypertrophy, akinesis of the inferior part of the interventricular septum.
A4C, Mitral inflow, PW sample volume above the leaflets of the mitral valve in the left ventricle
Single-peak filling due to atrial fibrillation. Normal deceleration time of the E-wave, a relatively low maximum velocity of the E-wave.
A5C, CW line across the aortic valve.
No increase in velocity across the aortic valve detected.
Mitral regurgitation with only a small PISA. Vena contracta was not measured in this case. Only small jet running into the left atrium. The image itself is not sufficient for the assessment of the severity of this mitral regurgitation. We need to acquire spatial characteristics of the jet (scan of mitral regurgitation in A4C/A5C/A3C/A2C projections).
A4C, CW line across the tricuspid valve.
Image of tricuspid regurgitation. Maximal velocity of 50 mmHg corresponds to moderate pulmonary hypertension.
Intercostal transverse scanning plane of the right pleural cavity, probe indicator (V) is heading ventrally.
Pleural effusion, plankton sign in dorsal parts of effusion. Two anechoic cavities visualised in the liver – the larger one is inferior vena cava, and the smaller one is the hepatic vein, both in the transverse section. Diaphragm with edge artefact shows irregular shape with an incision (sudden shift of the position of the diaphragm as if there were two of them. However, it is just jumping across incision in the diaphragm heading caudally due to breathing cycle).
Intercostal coronal scanning plane of the right pleural cavity.
Pleural effusion, plankton sign in dorsal parts of effusion. Lower margin of the lung is irregular with sub-B-lines and pleural irregularities (visible during expiration). Suspected infiltration of parenchyma possibly accompanied with exudate.
- Concentric left ventricular hypertrophy with RWMA of the inferior part of septum – possible early ischemia; however, correlation with cardiac enzymes and clinical symptoms are needed.
- Diastolic dysfunction – we may assess its severity by the simultaneous use of TDI, as well as by estimation of left ventricular filling pressure.
- Mitral insufficiency – assessment of its severity cannot be based on a single image.
- Pulmonary hypertension – gradient across the tricuspid valve is approximately 50 mm Hg. By adding right atrial pressure (central venous pressure) to the gradient across the tricuspid valve, we may estimate systolic pressure in the pulmonary artery to be approximately 60 mm Hg. Elevated right atrial pressure is also supported by dilation of inferior vena cava and hepatic veins. Knowledge of thickness of the right ventricle wall would be valuable in this case. However, based on the dilation of hepatic veins, we may rather think of a chronic cause of hypertension. Thus, based on echocardiography, we cannot diagnose pulmonary embolism.
- Fluidothorax on the right side, probably not pure transudate.
- Suspected infiltration of the right lung base.
- Assess cardiac enzymes and ultrasonographic check of all segments of the left ventricle to exclude acute coronary syndrome.
- Puncture of the pleural effusion (with drainage if needed) followed by its biochemical (including pH) and microbiological testing. The puncture itself may result in a decrease of pulmonary hypertension by the mitigation of hypoxic pulmonary vasoconstriction.
- LUS check after the puncture if needed bronchoscopy of right lower lung lobe (if lab results indicate inflammation).
- Completing echocardiography scan with TDI, left atrium diameters, quantification of mitral regurgitation and assessment of chronicity of pulmonary hypertension based on possible right ventricular hypertrophy. Estimation of left ventricular filling pressures, if these are elevated, then the negative fluid balance should be achieved.