Question 1 of 4

In distinguishing a chronic obstructive pulmonary disease (COPD) exacerbation from congestive heart failure (CHF), which of the following clinical or laboratory features is helpful?

B-type natriuretic peptide level

Body habitus

Distended neck veins

History of COPD

Peripheral edema

Given the overlapping epidemiology of patients with COPD and CHF, distinguishing between patients with both comorbidities can be challenging for the emergency physician. Patients may have coexisting COPD and CHF. Patients with COPD may have latent CHF that has previously not been diagnosed or masked by their more prevalent bronchitic symptoms. Distended neck veins are a helpful clinical feature for identifying patients with CHF but unfortunately may also be present in patient with elevated right-sided heart pressures due to right-sided heart failure seen in patients with advance lung disease including COPD and emphysema. Body habitus such as the classic “blue bloater” and “pink puffer” are associations with emphysema more so than COPD. Moreover, patients with advanced CHF develop “cardiac cachexia” that may bear resemblance to a “pink puffer.” Patients with significant fluid retention in CHF may resemble a “blue bloater.” Peripheral edema is often seen in acutely decompensated CHF; however, the cause of peripheral edema can be due to decreased oncotic pressure from decreased protein levels present in patients with significant wasting due to advance lung disease. B-type natriuretic peptide is a useful noninvasive adjunct to differentiate between COPD and CHF due to its release by the left ventricle in response to cardiac stress. When the levels are decreased, it makes CHF very unlikely.