This is a story of near drowning.
Recently a 71 year old female who had not been seen in clinic for several months returned. She returned in significant respiratory distress. Her initial pulse ox was in the 70s on Room Air. She was taken immediately to our resus area.
When I arrived at bedside to evaluate her, she was intermittently yelling: "my heart... I'm going to die!" Not typically a favorable prognostic indicator.
Indeed her heart was abnormal- specifically, she had significant systolic dysfunction (and likely some component of diastolic dysfunction given the size of her left atrium). Echo loop below.
Lung ultrasound revealed diffuse B-lines (i.e. interstitial fluid) and LARGE bilateral pleural effusions.
She was placed on a cardiac monitor. IV access established. And supplemental oxygen initiated. She required high flow rates of oxygen via nasal cannula to maintain near normal oxygen saturation.
We ditched the nasal cannula and transitioned to non-invasive positive pressure ventilation (CPAP). Her oxygenation stabilized with CPAP, but she still wasn't fixed.
She was agreeable to therapeutic thoracentesis.
Under ultrasound guidance, thoracentesis was performed and ~800mL of pleural fluid was drained from the right side of her thorax.
Shortly thereafter NIPPV was discontinued. And we were able to titrate off of supplemental oxygenation within the next hour or so.
Vital signs stabilized and she was discharged to home in improved condition no longer requiring supplemental oxygen.
She was seen in follow-up a couple of days later and another 600mL of pleural fluid was drained from the left side of her thorax. Diuresis continues to be challenging due to chronic renal insufficiency and limited response to systemic diuretics.
Nevertheless, it was satisfying to prove our patient wrong. While she (and the rest of us) will give up the ghost one day. She had her day wrong. On that particular day, she just needed to avoid drowning in her pleural effusions and pulmonary edema... and breathe.
Top photo by Jeremy Bishop on Unsplash
Bottom photo by Max van den Oetelaar on Unsplash