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POCUS in Primary Care: A Game-Changer for Differentiating CHF from COPD Exacerbations

February 8, 2025 // Southern Medical Association

Distinguishing between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) exacerbations can be challenging in the primary care setting, as both conditions present with similar symptoms: dyspnea and wheezing. Traditional diagnostic tools, such as chest X-rays (CXR) and BNP testing, may not always be readily available or conclusive. Point-of-care ultrasound (POCUS) has emerged as a highly sensitive and cost-effective tool to aid in this differentiation, allowing for more precise diagnosis and timely treatment.

Case Presentation

A 72-year-old female with a history of CHF with an ejection fraction of 40% and COPD presents to her primary care physician with worsening shortness of breath, weight gain, and mild wheezing over the past few days. Her oxygen saturation is 90%, down from her baseline of 92%. She has minimal edema of the feet. The physician is uncertain whether her symptoms stem from a COPD exacerbation or fluid overload from CHF. Both require vastly different treatments. The physician performs POCUS of the patient’s lungs and inferior vena cava (IVC) to elucidate the etiology of the patient's symptoms.

Below are the representative clips of the patient's lungs (Clip 1) and IVC (Clip 2).

What do you see and what is the diagnosis?

Clip 1. View of right lung apex demonstrating confluent B-lines, abnormal vertical lines initiating from the pleura that signify interstitial fluid or thickening.

 

Clip 2. View of IVC draining into the right atrium demonstrating low respiratory variation.

Within 5 minutes, POCUS reveals diffuse B-lines (abnormal vertical lines initiating from the pleura that signify interstitial fluid or thickening) in both lungs and a dilated inferior vena cava (IVC) with minimal respiratory variation, findings consistent with CHF exacerbation. Based on these results, the physician initiates diuretic therapy and schedules close follow-up, effectively managing her condition without the need for an emergency department visit.

Utilizing POCUS to Differentiate Between COPD and CHF Exacerbations

Lung Ultrasound

  • The presence of B-lines is a hallmark of pulmonary edema, strongly suggestive of CHF exacerbation. In addition, the more B-lines there are, the more severe the fluid overload. 
  • The absence of B-lines may indicate an alternative cause of dyspnea, such as a COPD exacerbation.
  • Other causes of dyspnea that can be accurately diagnosed with lung ultrasound are pneumonia, pleural effusion, and pneumothorax. Refer to a prior post on pneumonia here.

Clip 3. Patient’s lung with annotations demonstrating the location of the confluent B-lines, pleura, and rib shadows.

 

Clip 4. View of a normal lung demonstrating A-lines (horizontal lines), pleural sliding, and lack of B-lines, thus ruling out pulmonary edema and pneumothorax.

IVC Assessment

  • A dilated IVC with reduced collapsibility with respiration suggests elevated central venous pressure, supporting a CHF diagnosis.
  • A normal or highly collapsible IVC may indicate volume depletion or a non-cardiogenic cause of dyspnea.

Clip 5. Patient’s IVC with annotations demonstrating the location of the IVC, hepatic vein, and right atrium (RA). Note the lack of collapsibility of the IVC 2 cm from the RA, or just beyond confluence with the hepatic vein.

 

Clip 6. View of an IVC with high collapsibility with respirations suggesting low fluid volume status.

Cardiac Views

  • Assessment of left ventricular function can help identify systolic dysfunction. In this case, the physician already knew that the patient had CHF with moderate systolic dysfunction and chose not to perform a cardiac ultrasound. 
  • In addition, cardiac POCUS could help rule out pericardial effusion or significant right heart strain.

Evidence

Numerous studies support the diagnostic accuracy of POCUS in assessing pulmonary congestion:

  • Lung ultrasound has a sensitivity and specificity range of 88-97% and 90-98%, respectively for identifying pulmonary edema [1-3].
  • Compared to CXR, lung ultrasound is more sensitive in detecting pulmonary edema, making it a superior tool for CHF evaluation in outpatient settings. A 2019 meta-analysis found that the sensitivity of POCUS was 88%, while that of CXR was 73%. [3]

Impact 

Timely and Accurate Diagnosis

  • POCUS allows for immediate bedside differentiation between COPD and CHF exacerbations, leading to prompt, condition-specific treatment.
  • It avoids unnecessary delays associated with ordering additional imaging or laboratory tests.

Enhanced Patient Experience

  • Patients benefit from reduced uncertainty and immediate diagnosis.
  • POCUS eliminates the need for additional testing or referrals, reducing patient burden and inconvenience.
  • POCUS enhances shared decision-making, as patients can visualize their condition in real-time.

Reduction in Healthcare Costs

  • The average annual cost of caring for a patient with CHF in the United States is nearly $30,000. Emergency department visits and admissions contribute significantly to this number. [4] POCUS can make a big impact by detecting CHF exacerbations promptly and starting earlier interventions in outpatient settings. 
  • POCUS also decreases reliance on costly diagnostic tools such as comprehensive echocardiograms and CT.

Conclusion

Incorporating POCUS into primary care practice enhances clinicians' ability to accurately differentiate between COPD and CHF exacerbations, leading to faster and more effective treatment. Given its high sensitivity in detecting pulmonary edema, its positive impact on patient experience, and its cost-effectiveness, POCUS is an invaluable tool for managing dyspnea in outpatient settings. As healthcare continues to move toward value-based care models, adopting POCUS can lead to improved patient outcomes, reduced hospitalizations, and overall cost savings.

References

  1. Wang Y, Shen Z, Lu X, Zhen Y, Li H. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: a systematic review and meta-analysis. Med Ultrason. 2018 Feb 4;1(1):32-36. doi: 10.11152/mu-1223. PMID: 29400365.
  2. Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014 Aug;21(8):843-52. doi: 10.1111/acem.12435. PMID: 25176151.
  3. Maw AM, Hassanin A, Ho PM, McInnes MDF, Moss A, Juarez-Colunga E, Soni NJ, Miglioranza MH, Platz E, DeSanto K, Sertich AP, Salame G, Daugherty SL. Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019 Mar 1;2(3):e190703. doi: 10.1001/jamanetworkopen.2019.0703. PMID: 30874784; PMCID: PMC6484641.
  4. Heidenreich PA, Fonarow GC, Opsha Y, Sandhu AT, Sweitzer NK, Warraich HJ; HFSA Scientific Statement Committee Members Chair. Economic Issues in Heart Failure in the United States. J Card Fail. 2022 Mar;28(3):453-466. doi: 10.1016/j.cardfail.2021.12.017. Epub 2022 Jan 24. PMID: 35085762; PMCID: PMC9031347.

About the Author

Dr. Havryliuk is an emergency physician with over 15 years of clinical point-of-care ultrasound (POCUS) experience, a past Emergency Ultrasound Director at Brooklyn Hospital in NY, and the founder of Hello Sono. She is on a mission to empower clinicians with POCUS to take better and more efficient care of their patients by addressing two key barriers, lack of competency and infrastructure. 

LinkedIn: https://www.linkedin.com/in/tatiana-havryliuk-md/
Email: tatiana@hellosono.com

*POCUS images and graphics provided courtesy of Hello Sono.

Posted in: 2024POCUS
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