CC - Dyspnea

HPI

• 55-year-old female past medical history of COPD, IVDU, CHF (EF 25% on recent echo) presents  with shortness of breath that began this morning

Physical Exam

Vs-BP 198/100, HR–104, RR–22, pulse ox–92% on nasal canula

• Constitutional – patient is agitated, tachypneic and in distress, stating "I can't breathe!" 
• Cardiac – tachycardic, no murmurs
• Pulmonary – rales bilaterally,  speaks in 2-3 word sentences
• Extremities –+2 pitting edema to bilateral lower extremities

Differential Diagnosis

• Acute on chronic chf  
• COPD exacerbation
• Pulmonary embolism
• Pneumonia (COVDI!)

Initial Management

• ECG, IV, 02 via nonrebreather, cardiac monitor
•  Nitroglycerin by sublingual tab
• Point-of-care ultrasound depicted bilateral B-lines
• Second dose of sublingual NTG given given no improvement of symptoms/blood pressure still elevated now to 220/130
• Additionally, patient became tachypneic, hypoxic, and agitated
• BiPAP initiated, patient having difficulty tolerating due to agitation and attempts to take off mask 
• Nitroglycerin infusion started at 300 mcg/min, increased to 600-->700-->800 mcg resulting in breathing/bp markedly improved

Pearls

• SCAPE (sympathetic crashing acute pulmonary edema) is essentially a severe form of hypertensive acute CHF the rapidity and severity often leads to quick deterioration
• SCAPE is recognized by rapid onset of dyspnea, hypoxemia, and hypertension
• At the bedside pts may exhibit rales, cough productive of pink/frothy sputum
• Bedside ultrasound will demonstrate diffuse B lines
• It is reasonable to start with sublingual NTG tabs, but have a low threshold to pivot to high dose intravenous nitroglycerin infusion starting at ~100-300 mcg/min 
• CPAP/BiPAP plus nitroglycerine infusion are usually adequate treatment
• If these measures fail consider: (#1) Clevidipine gtt (preferably) or Nicardipine gtt. (#2) Enalaprilat, 1.25 mg IV (may repeat q15 minutes to a maximal dose of 5 mg). (#3) Low-dose fentanyl (if uncontrolled pain or air hunger)