A 56-Year-Old Female With Acute Shortness of Breath

Figure 1: A 56-Year-Old Female With Acute Shortness of Breath
The patient is a 56-year-old female whose prior medical history was notable only for hypertension. She had noted mild paroxysmal nocturnal dyspnea and exertional dyspnea but otherwise was in good health. On the night of admission she went to the bathroom and returned stating “I can’t breathe”. Her husband noted she was severely short of breath and diaphoretic. Emergency medical services was contacted, and shortly after arrival in the emergency department she required intubation.

After intubation, 100% inspired oxygen and increasing levels of positive expiratory pressure to 10 mmHg resulted in oxygen saturations of only 85-90%. Physical exam was notable for a blood pressure of 85/60 mmHg, a heart rate of 110 bpm, temperature 97.6 F, diffuse wheezing, distant heart sounds without obvious murmur, and intact pulses.

The initial chest x-ray (Figure 1) demonstrated the endotrachial tube to be in good position. The initial electrocardiogram demonstrated sinus tachycardia, without ischemic ST-T wave changes.

Lab Values
Creatinine Normal
WBC 25,000 x 106 with left shift
Hgb 11.3 g/dL (normal 13.3-17.3 g/dL)
TnI (initial) <0.6 (normal <1.0 ng/ml)
CK-MB (Initial) 1.9 ng/ml (normal < 8 ng/ml)
BNP (initial) 350 pg/ml (normal < 80 pg/ml)
BNP (2 hours) 228 pg/ml (normal < 80 pg/ml)
TnI (9 hours) 1.8 ng/ml (normal <1.0 ng/ml)
CK-MB (9 hours) 2.3 ng/ml (normal < 8 ng/ml)

There was almost complete opacification of both lungs. The radiologist interpretation was severe bilateral airspace disease, most consistent with acute respiratory distress syndrome or diffuse pneumonia.

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