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46 JULY 2016 | EMSWORLD.com background generally translates to a weak- ened immune system and large opportu- nity for infection to spread. Patients who have lost their ability to swallow normally are generally given a feeding tube. While that tube solves the issue of nutrition, what happens to the saliva? They have to try to swallow it. Often they aspirate this infectious liquid into their lungs, which can cause aspiration pneumonia. Consider any patient you see with a feeding tube and a chief complaint of SOB to have aspiration pneumonia until proven otherwise. While fevers do not last 24 hours a day or 7 days a week, and the absence of a fever does not rule out an infection. If a fever is present, consider the cause of shortness of breath to likely be an infection, and there- fore consider the diagnosis to be pneu- monia. However, do not be lulled into the false idea that an absence of fever means absence of pneumonia. Many chronically ill patients are too ill and their immune systems too weak to ever create a fever. If present, consider pneumonia. If not, don't rule it out. Patients who are not ambulatory are at high risk for infections. Look for evidence of poor ambulation. Are there wheelchairs present, walkers, special boots to prevent bedsores for bedridden patients? If so, con- sider pneumonia high on the list of possible causes of SOB. Timing is important. Infections usual present gradually. Slowly increasing SOB over days is more likely to be pneumonia than CHF. This is especially true if there is also a history of recent viral upper respira- tory tract infection. Vital signs give clues as well. Low sys- tolic BP, diastolic hypotension, wide pulse pressure and fever all favor pneumonia over CHF. The skin exam in pneumonia is often dry. If fever is present, the skin may feel hot as well. CHF Just as pneumonia can be considered a dis- ease of the lungs, CHF should be considered a disease of the heart. Patients with a history of heart disease are more likely to go on to have more heart disease. Look for signs of cardiac surgery (sternal scar) and evidence of cardiac medications such as beta block- ers and prior diuretic use like furosemide. Unlike the often chronically debilitated pneumonia patients from the nursing homes, many of these patients are quite healthy between CHF exacerbations. They tend to come from private residences. After they get treated for an episode of CHF, they usually get to go back to their home. If their residence has been converted to look like a nursing home or hospice care environment, strongly consider pneumonia, because the chronically ill patient is more likely to succumb to it. Otherwise, a normal private residence may indicate a generally healthy patient, which favors a diagnosis of CHF. Consider the address when deciding between these two diseases. The living environment can give clues to their baseline health. Fever does not generally occur with CHF. If it is present, it likely means the SOB patient has pneumonia. Diuretics should generally be avoided in patients who pres- ent with a fever. The physical exam in CHF is likely to reveal some combination of JVD, hepato - jugular ref lux, ascites and pedal edema. The history may suggest orthopnea (SOB when supine) or paroxysmal nocturnal dys- pnea (SOB waking up after lying supine). All of these are evidence of fluid overload and point to CHF. T hei r complete absence shou ld ma ke the para- medic doubt that CHF is the prob- lem, and therefore diuretics should likely be withheld. Timing of the illness is impor- tant to consider. There is a subset of patients with chronic CHF who have weak hearts with chronically very low ejection fractions. These patients generally live constantly with some degree of CHF. In this subset, a gradual worsening may occur. They typically will have several of the f luid overload signs noted above to assist in differentiating them from those with the characteristic gradual onset seen in pneumonia. More typically, CHF patients have a rather acute onset of worsening. The deterioration is faster than in pneumonia, and in extreme cases patients can have TABLE 1: GENERAL CHARACTERISTICS OF PNEUMONIA VS. CHF Pneumonia CHF Fever Normal temperature Low BP/wide pulse pressure High BP History of lung disease History of heart disease Pulmonary medications (e.g., albuterol) Cardiac medications (e.g., diuretics) Nursing home Home Aspiration risk Orthopnea/paroxysmal nocturnal dyspnea Bedridden Edema Altered LOC JVD/HJR Gradual onset More rapid onset Dry/hot skin Clammy skin JVD is an indicator of CHF, not pneumonia.