{"id":2398,"date":"2025-02-24T18:00:00","date_gmt":"2025-02-24T18:00:00","guid":{"rendered":"https:\/\/emultrasound.sdsc.edu\/?p=2398"},"modified":"2025-02-26T18:04:20","modified_gmt":"2025-02-26T18:04:20","slug":"case-42-shortness-of-breath","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2025\/02\/24\/case-42-shortness-of-breath\/","title":{"rendered":"Case 43: Shortness of Breath"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Molly Chou<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An 83-year-old male presented to our emergency department with shortness of breath. He woke up that morning with symptoms and called EMS. On arrival, the patient was alert and oriented with SpO2 90% on room air. The patient had a recent admission for right middle and lower lobe pneumonia. He also reported a history of heart failure with mildly reduced ejection fraction, coronary artery disease, and chronic kidney disease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vitals: BP 122\/71, HR 92, RR 30, T 98.8F, spO2 90% on room air, 99% on 4LNC<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Exam: Normal heart sounds, tachypnea, rhonchi in bilateral lower lobes, non-tender abdomen, &gt;4mm pitting lower extremity edema<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Labs: Cr 2.23 (from 1.98), BNPP 34,591 (from 19,366), WBC 31<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">EKG: new left bundle branch block<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">CXR: pulmonary edema, bilateral pleural effusions, and opacities that may represent atelectasis, though cannot rule out pneumonia or aspiration.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A bedside ultrasound was performed:<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"376\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.02.12-1024x733.png?resize=525%2C376&#038;ssl=1\" alt=\"\" class=\"wp-image-2401\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.02.12.png?resize=1024%2C733&amp;ssl=1 1024w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.02.12.png?resize=300%2C215&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.02.12.png?resize=768%2C550&amp;ssl=1 768w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.02.12.png?w=1210&amp;ssl=1 1210w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure 1: Right-sided pleural effusion, atelectasis, and pneumonia in seen right lower lobe<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"174\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.03.53-1024x340.png?resize=525%2C174&#038;ssl=1\" alt=\"\" class=\"wp-image-2402\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.03.53.png?resize=1024%2C340&amp;ssl=1 1024w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.03.53.png?resize=300%2C100&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.03.53.png?resize=768%2C255&amp;ssl=1 768w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/02\/Screenshot-2025-02-21-at-20.03.53.png?w=1198&amp;ssl=1 1198w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure 2A: During exhalation. Left-sided pleural effusion, atelectasis. 2B: During inhalation. Pneumonia becomes more visible as air fills alveoli adjacent to consolidated lung tissue (also known as \u201cdynamic air bronchogram\u201d)<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Discussion: Bedside ultrasound demonstrated persistent pneumonia as a likely contributor to his shortness of breath. While other clinical indicators directed the diagnosis toward acute on chronic heart failure, POCUS was instrumental in also identifying persistent pneumonia. The patient was ultimately started on antibiotics and admitted to Cardiology for pneumonia and diuresis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Learning points:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Pneumonia is among the leading causes of hospitalization, and it can be detected on ultrasound if the pleural line is involved, which is in about 99% of cases.<\/li>\n\n\n\n<li>Ultrasound can detect inflammation and lung-tissue thickening of lobar pneumonias and consolidations. Interstitial pneumonias more often manifest as B-lines or white lung areas. Complications such as empyema and lung abscess can also be detected [1].<\/li>\n\n\n\n<li>POCUS is highly sensitive (estimated around 93%) and specific (estimated around 98%) for pneumonia, particularly if done by a skilled sonographer [2,3].<\/li>\n\n\n\n<li>Classic ultrasound findings:<ul><li>\u201cHepatization\u201d of lung parenchyma, when multiple hypoechoic areas give the tissue a \u201cliver-like\u201d or \u201cspleen-like\u201d appearance.<\/li><\/ul><ul><li>\u201cShred sign\u201d (Figure 1), when a clear margin can be detected separating a consolidation with aerated parenchyma.<\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>Air bronchograms (hyperechoic, linear punctate spots) can be detected within a consolidation in over 90% of pneumonia patients, though they are non-specific, as they may indicate any form of airway obstruction [1].<ul><li>However, \u201cdynamic air bronchograms\u201d (Figure 2) where air-filled bronchograms move with respiration, are highly specific (94%) to pneumonia and have a high positive predictive value (97%) when seen [4]. An example can be seen below [5]:<\/li><\/ul><\/li>\n\n\n\n<li><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">References:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Boccatonda A, Cocco G, D'Ardes D, et al. Infectious Pneumonia and Lung Ultrasound: A Review.\u00a0<em>J Clin Med<\/em>. 2023;12(4):1402. Published 2023 Feb 10. doi:10.3390\/jcm12041402<\/li>\n\n\n\n<li>Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study.\u00a0<em>Chest<\/em>. 2012;142(4):965-972. doi:10.1378\/chest.12-0364<\/li>\n\n\n\n<li>Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis.\u00a0<em>Respir Res<\/em>. 2014;15(1):50. Published 2014 Apr 23. doi:10.1186\/1465-9921-15-50<\/li>\n\n\n\n<li>Lichtenstein D, Meziere G, Seitz J. The Dynamic Air Bronchogram: A Lung Ultrasound Sign of Alveolar Consolidation Ruling Out Atelectasis. <em>Chest<\/em>. 2009;135(6):1421-1425. Published 2009 Jan 8. doi:10.1378\/chest.08-2281<\/li>\n\n\n\n<li>Hailey Hobbs, MD. Dynamic Air Bronchograms. NephroPOCUS. Published 2019 Jul 1. Accessed 2024 Dec 13.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"Molly Chou An 83-year-old male presented to our emergency department with shortness of breath. He woke up that morning with symptoms and called EMS. On arrival, the patient was alert and oriented with SpO2 90% on room air. The patient had a recent admission for right middle and lower lobe pneumonia. He also reported a &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2025\/02\/24\/case-42-shortness-of-breath\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Case 43: Shortness of Breath\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[4],"tags":[143,141,142],"class_list":["post-2398","post","type-post","status-publish","format-standard","hentry","category-clinical-cases","tag-lung","tag-pneumonia","tag-pulmonary"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Case 43: Shortness of Breath - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2025\/02\/24\/case-42-shortness-of-breath\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Case 43: Shortness of Breath - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Molly Chou An 83-year-old male presented to our emergency department with shortness of breath. He woke up that morning with symptoms and called EMS. On arrival, the patient was alert and oriented with SpO2 90% on room air. The patient had a recent admission for right middle and lower lobe pneumonia. 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He woke up that morning with symptoms and called EMS. On arrival, the patient was alert and oriented with SpO2 90% on room air. The patient had a recent admission for right middle and lower lobe pneumonia. 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