Contralateral Pulmonary Oedema

CASE HISTORY A 68-year-old man presented to the emergency department with severe dyspnoea. He had a 40-yearhistory of reversible chronic obstructive pulmonary disease (COP D) which had worsened over the previous three weeks. His general practitioner had commenced him on a course of prednisolone in addition to his usual medication of inhaled salbutamol, ipatropium and beclamethasone. On the day of admission he developed a sudden deterioration in his breathing and his general practitioner referred him to hospital. In the emergency department he was pale, sweating and tachypnoeic with a respiratory rate of 32 breaths per minute. He was unable to speak in sentences, and was complaining of chest pain. His pulse rate was 120 beats per minute and irregular, jugular venous pressure was raised 5 cm and heart sounds were normal. Coarse inspiratory and expiratory crackles were heard at both lung bases. Arterial blood gases on 60070 inspired oxygen revealed a P02 of 71 mmHg, a PC02 of 65 mmHg and a pH of 7.15. An electrocardiograph (ECG) showed atrial fibrillation with a rate of 120 beats per minute and widespread ST depression. The chest X-ray is shown in Figure 1. In the light of known COPD and the presence of unilateral lung shadowing, a diagnosis of pneumonia was made, with angina secondary to hypoxia. The patient was commenced on oxygen therapy via a continuous positive airway pressure