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Difficulty: EasyPulmonary and Critical Care

A 7575-year-old retired teacher arrives at the outpatient clinic reporting a one-week history of worsening shortness of breath. He states that he has been waking up gasping for air in the middle of the night and now must sleep propped up on three pillows. He has a 4040-pack-year smoking history and suffered an anterior myocardial infarction 44 years ago. Vital signs show a blood pressure of 150/90150/90 mmHg, heart rate of 105105/min, respiratory rate of 2424/min, and oxygen saturation of 91%91\% on ambient air. Pulmonary auscultation reveals dependent, coarse crackles in both lower lung fields with absent wheezing and a normal expiratory phase. Cardiovascular examination is notable for an S3 gallop and jugular venous distention to 1212 cm H2OH_2O. Which of the following is the most appropriate initial pharmacological intervention?

  1. Intravenous furosemideAnswer
  2. B
    Inhaled albuterol and ipratropium
  3. C
    Oral prednisone
  4. D
    Intravenous piperacillin-tazobactam
  5. E
    Oral azithromycin

Answer

Intravenous furosemide
The correct intervention is intravenous furosemide. This patient presents with classic signs and symptoms of acute decompensated heart failure (ADHF), including orthopnea, paroxysmal nocturnal dyspnea, an S3 gallop, elevated jugular venous pressure, and bibasilar crackles. Given his history of a myocardial infarction, he likely has ischemic cardiomyopathy. The cornerstone of initial therapy for patients presenting with ADHF and volume overload is intravenous loop diuretics, which rapidly decrease preload and relieve pulmonary congestion.

Step-by-Step Solution

1
Identify the primary clinical syndrome from the patient's signs and symptoms.
The patient exhibits orthopnea, paroxysmal nocturnal dyspnea, an S3 gallop, elevated jugular venous pressure, and bibasilar crackles, which point to acute decompensated heart failure (ADHF).
Recognizing the constellation of signs associated with volume overload and left ventricular failure is necessary to guide therapy.
2
Differentiate the presentation from other potential respiratory causes, specifically COPD.
Although the patient has a significant smoking history, the absence of wheezing, a normal expiratory phase, and the presence of prominent cardiac signs (S3, elevated JVP) make a COPD exacerbation highly unlikely.
Differentiating between ADHF and COPD is critical because their treatments (diuresis vs. bronchodilators/steroids) are vastly different.
3
Select the appropriate initial pharmacological intervention for the diagnosed condition.
Intravenous loop diuretics (like furosemide) should be administered.
Loop diuretics rapidly reduce volume overload, thereby decreasing ventricular preload and relieving pulmonary congestion.

Key Concept

Differentiating acute decompensated heart failure from a COPD exacerbation based on clinical signs, and initiating prompt diuresis.
Estimated Time:1m 0s
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Topics

Pulmonary and Critical Care

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