non - pulmonary causes should be considered especially if symptoms are persistent and refractory to typical treatment regimens . this article presents a case of asthma that was refractory to all treatments in the rural city of tamale , ghana . she typically experienced an increase in symptoms and refractoriness to treatment during the dusty season , when the harmattan , winds carrying sahara sands , envelops northern ghana . this year the patient 's bronchospasm worsened during the harmattan but , unlike in prior years , was unresponsive to her routine medications plus prednisone . she had a blood pressure of 106/70 , heart rate of 98 , and respiratory rate of 22 . she received dialysis and 1 year later had no recurrence of cardiac tamponade but still required medication for asthma . this case is important in that it reminds clinicians that bronchospasm is not always of pulmonary origin and can be due to  cardiac asthma . additionally , it adds to a growing body of literature illustrating how bedside portable ultrasonography is a useful diagnostic tool , especially in areas without access to more expensive modalities such as x - rays . this case serves as a reminder that a normal blood pressure reading can occur with cardiac tamponade if the patient has baseline hypertension . it also highlights the importance of the systems aspect to medical care , noting the interrelation of physical and social environments . a 40-year - old ghanaian female farmer presented to her internist with an exacerbation of asthma . she has lived all of her life in tamale , ghana , and she and her physician were accustomed to asthmatics having increased symptoms at this time , during the dry season when the harmattan , dry desert winds carrying sand off of the sahara , blanket northern ghana . her baseline medication was only an albuterol inhaler , which was used rarely on an as - needed basis . in prior years , she would increase her albuterol to two puffs four times a day , and that would typically control her bronchospasm . for the previous 5 weeks , her medications were albuterol inhaler two puffs four times a day , budesonide 400 g two puffs two times a day , montelukast 10 mg per day , and fluticasone 250 g / salmeterol 50 g one puff two times a day . her respiratory symptoms did not abate , so she was put on two courses of prednisone 20 mg per day for 5 days , the last course ending 2 weeks previously , without relief . she presented to an outpatient medical clinic in tamale , a city with limited access to x - rays or blood tests . the patient complained of mild shortness of breath at rest but severe dyspnea on exertion for 1 month that had increased over the past 2 weeks despite the additional medications ordered by her internist . she denied experiencing orthopnea , chest pain , cough , fever , chills , abdominal pain , heartburn , dyspepsia , leg trauma , or swelling . she had a history of hypertension diagnosed many years ago but never took antihypertensive medication due to financial constraints . she also has had many episodes of malaria , with the last episode 5 months earlier , which was treated with artemether / lumefantrine . her family history is significant for a mother who has had asthma since she was a teenager . the patient is poor , lives in tamale , has never had a chest x - ray , and has had no blood tests for 15 years . controlling her asthma is crucial as she is a farmer who works in the field 7 days a week performing manual labor . the patient is a thin , muscular woman who appeared with mild dyspnea at rest . she was able to speak in full sentences without distress but had a mild increase in shortness of breath when asked to climb onto the exam table . she had a blood pressure of 106/70 , heart rate of 98 , respiratory rate of 22 , and temperature of 37 c ( 98.6 f ) . auscultation of the lungs was remarkable for bilateral wheezing in mid - late expiration in all lung fields with prolonged expiration and 1 + bibasilar inspiratory crackles . cardiac exam revealed a regular rate and rhythm without murmurs , and heart sounds were not muffled . neck veins were unable to be visualized . abdominal exam revealed a scaphoid abdomen with normal bowel sounds , no masses or organomegaly , and no tenderness . she had 2 + carotid , dorsalis pedis , femoral , and radial pulses bilaterally . however , a physician from the united states was visiting and teaching ultrasonography to the ghanaian clinicians . he used a portable bedside ultrasound that had been previously donated to evaluate the patient . subcostal and 4-chamber apical views revealed a swinging heart within a large pericardial effusion with diastolic collapse of the right ventricle . a diagnosis of pericardial tamponade was made , and an emergency pericardiocentesis was performed via a parasternal approach in the left third intercostal space . after 100 cc of straw - colored fluid were removed , the patient was significantly improved . a total of 750 cc was aspirated , and a repeat ultrasound now revealed a trivial effusion with normal ventricular function . post - procedure , the patient had clear lungs , a blood pressure of 180/100 , a heart rate of 72 , and a respiratory rate of 12 . she was referred to accra , the capital of ghana , for blood tests that were performed 10 days later . she had a normal chest x - ray and after an extensive evaluation by a nephrology consultant was diagnosed with renal failure due to hypertensive nephropathy . she received dialysis and 1 year later had no recurrence of cardiac tamponade but still required albuterol inhaler as needed that was increased to every 6 hours during the harmattan to control her bronchospasm . there is increasing compression of all cardiac chambers as fluid fills the pericardial sac with equalization of intracardiac chamber pressures . venous return to the heart diminishes as the low - pressure venous system can not overcome the increase in intrapericardial pressure . less blood enters the ventricles , and increasing intrapericardial pressure compresses the heart , forcing the intraventricular septum to bow into the left ventricle . this intraventricular dependence leads to decreased filling of the left ventricle and decreased ejection fraction . with acute decompensation , the pulmonary - capillary membrane may succumb to increased pressure , with shearing of the capillary and release of fluid , protein , and occasionally red blood cells into the alveoli . pulmonary edema from left ventricular failure can cause bronchiolar compression and increased airway resistance with subsequent coughing or wheezing . cardiac asthma  is a clinical syndrome induced by acute passive congestion and edema of the lungs that occurs when the left side of the heart suffers from a sudden disproportion between workload and work capacity . other potential etiologies for tamponade include infections , hypothyroidism , drugs , cancer , radiation , and collagen vascular disease . this woman had asthma for many years but now also had  cardiac asthma  from cardiac tamponade due to her previously undiagnosed renal failure . she had inspiratory crackles , which can be seen in congestive heart failure and are not typical for asthma . in fact , other physicians did not appreciate inspiratory crackles presumably for this reason . although normotensive at presentation , this patient had a history of hypertension . in view of her possible relative hypotension and her findings of crackles , bronchospasm , and dyspnea , a bedside portable ultrasound was indicated , and it revealed the definitive diagnosis . tamponade can cause hypotension due to decreased stroke volume , jugular - venous distension due to impaired venous return to the heart , and muffled heart tones due to fluid inside the pericardium . the patient did not have visibly distended neck veins , illustrating that these findings , known as beck 's triad , are unreliable for the diagnosis of pericardial tamponade as it is seen only in a minority of patients . although this patient presented with normal blood pressure , it increased substantially to the patient 's baseline hypertensive state after pericardiocentesis . her blood pressure at presentation , while seemingly normal , was actually significantly lower than her baseline . dialysis treatments prevented recurrences of cardiac tamponade . in 2000 , the american medical association passed resolution 108 and reaffirmed policy h-230.960 , providing general acceptance of bedside ultrasound by non - radiology physicians and recognized that  ultra - sound imaging is within the scope of practice of appropriately trained physicians  and not a specialty specific privilege . this report also adds to the growing body of literature illustrating that bedside portable ultrasound is gaining utility as a useful diagnostic modality by non - radiologists in areas without access to radio - graphs . compared to other modalities such as x - rays , it is less costly , requires less training , and uses few consumable items , making it ideal for use in areas with poor access to more advanced diagnostics . this case highlights the importance of the systems aspect of medical care , noting the interrelation of physical and social environments . the patient did have asthma that was worsened each year by environmental winds from the sahara . yet pericardial tamponade , rather than an environmentally related exacerbation of asthma , proved to be the etiology of her dyspnea . because she was indigent she lived in an area without significant diagnostic medical capabilities and therefore did not have access to blood tests to diagnosis her chronic renal disease . yet a portable ultrasound was available in this clinic and was crucial in diagnosing pericardial tamponade . fortunately , the patient was able to procure funds to be cared for at the only dialysis facility in ghana and was doing well without a recurrence of tamponade 1 year after pericardiocentesis . it illustrates that not all bronchospasm has a pulmonary etiology and that  cardiac asthma  should be considered , especially in cases of refractory bronchospasm . it also shows how diagnostic ultrasound can be used by nonradiologists in critically ill patients . furthermore , this case is an example of how environmental changes , occupation , and finances all affect healthcare . the etiology of bronchospasm is not always of pulmonary origin , and non - cardiac etiologies such as pericardial tamponade should be pursued , particularly when wheezing is refractory to treatment . bedside ultrasonography can be used as a diagnostic modality for cardiopulmonary disease , especially in areas without access to x - rays .
asthma has numerous etiologies , and successful treatment requires a proper diagnosis . 
 changes in weather and exposure to dust can make treatment of asthma difficult . 
 this case exemplifies a diagnostic dilemma associated with bronchospasm ; bronchospasm can have an occult cardiac etiology . 
 diagnosis can be particularly challenging in rural sub - saharan africa during the harmattan , when winds are blowing sands from the sahara into nearby villages , especially when radiographs are not available . 
 this case is that of a 40-year - old female ghanaian woman with a lifelong history of asthma . although she has often had exacerbations of bronchospasm during the dusty harmattan season , her bronchospasm was now refractory to usual treatments . 
 x - rays were not available at the clinic in the rural city of tamale , ghana , and bedside ultrasound was utilized . 
 she was found to have cardiac tamponade with secondary  cardiac asthma .  after 750 cc of fluid was aspirated during a bedside pericardiocentesis , her bronchospasm immediately resolved . 
 the cardiac effusion was due to previously unknown renal failure from hyper - tension . 
 the patient was referred for dialysis and 1 year later was well without any recurrence of significant cardiac effusions . 
 healthcare providers should be wary of atypical non - pulmonary etiologies of bronchospasm , especially in cases where there is an inadequate response to usual treatment . 
 bedside ultrasound has great utility for the diagnosis of cardiac tamponade .