A 63 year old female presents the ER with progressive shortness of breath. She has a past medical history of cholangiocarcinoma with metastatic disease. Her most recent chemotherapy was two weeks ago. She denies any chest pain, review of systems otherwise negative.
Her vitals are notable for tachycardia with a rate 130-140 BPM, BP 153/94, O2 98% on 2L NC, RR 22. On physical exam she has decreased breath sounds through the left lung.
What bedside study could help differentiate the reason for this patient’s shortness of breath and tachycardia?
Bedside echocardiogram and lung ultrasound. Lung ultrasound has proven to be more sensitive and specific when evaluating for pulmonary edema compared to chest x-ray.
The patient’s left lung US is displayed below, what findings can be identified in the two images?
In the first image, you can see B-lines on the left side of the screen near the end of the clip likely representing interstitial edema. In the middle of the screen there is evidence of lung consolidation, termed “hepatization” of the lung, that likely represents a collapsed lung from a complex effusion. Note the air bronchograms that are present, which are not dynamic, and mimic the biliary radicles seen on liver US.
In the second image, you can see a complex pleural effusion adjacent to the diaphragm. There appear to be complex loculations throughout, and posterior to the effusion you can see the tip of the base of the left lung.
Additional Imaging
Case Conclusion
The patient had a CT scan of the chest that confirmed the finding a left sided pleural effusion. This was drained by IR, and a pigtail catheter was placed. Cytology performed on the pleural fluid confirmed a malignant effusion, and the patient was discharged after 3 days.