An 86-year-old man arrived by ambulance at the emergency department (ED) at 7:15 P.M. with shortness of breath, wheezing, and sweating. The history obtained of his present illness was brief due to the patient's extreme dyspnea. He had missed his dialysis appointment the previous day, and he complained of worsening shortness of breath that morning. En route he received nebulized albuterol and was on 100% O2 by nonrebreather mask. The patient had suffered a myocardial infarction approximately 7 years previously. He had also undergone two cardiac catheterizations documenting extensive coronary artery disease (CAD), resulting in angioplasty with subsequent stent placement. In addition, he had a history of congestive heart failure (CHF) and hypertension that precipitated end-stage renal failure requiring hemodialysis. He also had chronic obstructive pulmonary disease (COPD) and was on home O2 at 2 l/min. His medications were as follows: enalapril 40 mg/day, clonidine 0.1 mg t.i.d., isosorbide dinatrate 25 mg/day, atenolol 25 mg/day, salmeterol 2 puffs b.i.d., fluticasone 2 puffs b.i.d., albuterol p.r.n., lansoprazole 15 mg/day, calcium acetate 665 mg t.i.d., and Nephrocaps 1/day.
ExaminationVital signs were temperature 37.6°C, heart rate 110 beats/ min, respiratory rate 34 breaths/min, blood pressure 200/86 mmHg, SO2 91% on 100% FIO2.The patient was a well-developed, well-nourished Caucasian male in severe respiratory distress. He was seated in a tripod position, diaphoretic, anxious, and using accessory muscles. Additional observations included the following:• Neck: neck veins distended • Heart: S 1 S 2 , tachycardic rate, grade II systolic murmur of greatest intensity at the left lower sternal border • Lungs: Rapid shallow breathing, scattered wheezing, audible diffuse rales bilaterally • Abdomen: nontender • Extremities: warm, 2+ pitting edema • Neurologic exam: nonfocal. Physiologically, this patient's presentation is consistent with a warm and wet profile (Fig. 1). More than 80% of patients presenting to the ED with acutely decompensated heart failure (ADHF) have clinical congestion (i.e., are classified as being wet) and, if right heart catheterization were performed, would show elevated pulmonary capillary wedge pressure (PCWP). 1 These patients may have adequate (wetwarm) or reduced (wet-cold) perfusion, with the majority showing elevation in systemic vascular resistance (SVR). Clinical indicators of congestion in the assessment of patients with HF include a recent history of orthopnea and/or evidence on physical examination of jugular venous distention, hepatojugular reflux, ascites, peripheral edema, leftward radiation of the pulmonic heart sound, or a square wave blood pressure response to the Valsalva maneuver.
Initial Emergency Department CourseNon-invasive ventilation was immediately started using bilateral positive airway pressure (BiPAP) with an inspiratory pressure of 12 mmHg and a base pressure of 5 mmHg. He was also given an intravenous (IV) nesiritide 2 mcg/kg bolus, followed by an infusion of 0.0...
