POINT-OF-CARE ULTRASOUND HELPED DIAGNOSE PERSISTENT RIGHT UPPER LOBE INFILTRATE FROM ECENTRIC JET OF MITRAL INSUFFICIENCY

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Approximately 0.2% of all cardiogenic pulmonary edema is unilateral and almost always associated with severe mitral regurgitation. It is often mistaken as focal lung disease like pneumonia, infarction or aspiration. It may lead to misdiagnosis and delay in management (1). Use of bedside echocardiography in diagnosis and management of critical illness is continuously evolving. Here we present a case of persistent right upper lobe infiltrate secondary to mitral valve insufficiency diagnosed with bedside focused echocardiography. CASE PRESENTATION: A 78-year-old woman with history of Heart failure (preserved ejection fraction), atrial fibrillation, severe chronic obstructive pulmonary disease and left upper lobe lung cancer status-post lobectomy presented with worsening dyspnea and respiratory failure. She was intubated in the emergency room for hypoxic and hypercapnic respiratory failure. She was treated for pneumonia of right upper lobe three weeks prior to this presentation. Her vital signs were BP156/78 mmHg, HR 120 bpm, Temp 99.0 F and saturation 96% of 60% FiO2. Respiratory exam was notable for rhonchi on right lung field and diffuse wheezes bilaterally. Chest x-ray showed persistent right upper lobe infiltrate. CT scan chest confirmed airspace opacity of the right upper lobe. Patient was started on intravenous antibiotics and IV steroids for presumed pneumonia and COPD exacerbation. Her infectious and cardiac work up remained negative. She remained on mechanical ventilation because of rapid shallow breathing. Bedside echocardiography was performed and showed eccentric jet of mitral regurgitation around posterior mitral leaflet occupying less than 40% of left atrial area consistent with mild to moderate mitral insufficiency. This finding was confirmed with transthoracic Echo. Patient had aggressive diuresis and after load reduction. Her rapid shallow breathing index improved and she came off mechanical ventilation and discharged later. DISCUSSION: Goal directed echocardiography helps integrate data and images to answer clinical question. It has been shown that bedside echocardiography performed by trained intensivist gives information promptly otherwise not accessible by physical exam alone(2). American college of chest physician competence in basic and advanced critical care echocardiography requires cognitive skills in recognition of clinical syndrome associated with acute massive valvular regurgitation and to answer whether valvulopathy is clinically relevant respectively(3).Our case is an excellent example demonstrating the advanced use of critical care echocardiography to diagnose a rare clinical presentation of mild to moderate mitral insufficiency causing right upper lobe infiltrate. CONCLUSIONS: Persistent right upper lobe infiltrate should prompt the use of bedside echocardiography looking for eccentric jet of posterior mitral leaflet. Reference #1: Attias, David, et al. "Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.” Circulation 122.11 (2010): 1109-111 Reference #2: Beaulieu, Yanick. "Specific skill set and goals of focused echocardiography for critical care clinicians.” Critical care medicine 35.5 (2007): S144-S149. Reference #3: Mayo, Paul H., et al. "American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.” Chest 135.4 (2009): 1050-1060 DISCLOSURES: No relevant relationships by Mohammedumer Nagori, source=Web Response No relevant relationships by Muhammad Shafi, source=Web Response No relevant relationships by Ziad Shaman, source=Web Response No relevant relationships by Edward Warren, source=Web Response