HPI: 66 yo M with pmhx lifelong smoker, COPD (“baseline SpO2 85%, supposed to be on home O2”), and questionable history of CHF p/w scrotal swelling, BLE edema, and dyspnea on exertion for “months” Came in today because he promised his daughter he would Denies fever, cough, sputum, URI sxs, wheezing, calf pain, or chest pain

Physical Exam

BP 129/76 | HR 85 | Temp 97.6F | SpO2 65% on RA -->80s on NRB | RR 18 | BMI 33

DDx:

• CHF exacerbation
• COPD exacerbation
• PE

Management: 

• Pt placed on NIPPV with improvement in O2 sats to 90s
• Orders: Basic labs (CBC, BMP, VBG, pro-BNP, troponins), EKG, CXR, CT PE

Results: ECG suggestive of right sided heart changes: Right axis deviation, R sided precordial leads have T wave inversions (V1-V3), prominent R wave in V1 

CXR read as “hazy bibasilar opacities could be related to atelectasis, aspiration, or pneumonia; cardiomegaly without venous congestion”. Also, it appears he has an enlarged right heart border

CT chest results:

Pathophysiology of cor pulmonale take home points:

• RV is a better VOLUME pump than a pressure pump
• Adapts to a changing preload rather than a changing afterload
• Therefore, RV failure is very preload dependent, so keep this in mind when: initiating nitro/bipap for presumed flash pulmonary edema,
• Cor pulmonale can cause acute or chronic heart failure → acute = sudden increase in pulmonary vascular resistance (eg ARDS or massive PE) vs chronic is more insidious and caused by COPD or chronic VTE burden

How to manage in the ED:

• optimize fluid status (IVF vs diuresis)
• keep MAP up with norepi
• enhance RV inotropy (dobutamine or milrinone)
• reduce RV afterload (usually people already on prostenoids at home for pulmonary vasodilation)
• support oxygenation and ventilation (sum of effect of PPV in RV failure unpredictable), avoid intubation, and treat underlying cause