Assessment of Dyspnea and Prehospital Use of CPAP

							  Assessment of Dyspnea
and Prehospital Use of CPAP
    Southern Maine Medical Center
  Department of Emergency Medicine
          October 31, 2009
             Overview
WELCOME!



Thank you!



Why are we here?
           Objectives
Discuss the differential diagnosis of
dyspnea
Review relevant pulmonary anatomy
and physiology
Discuss the pathophysiology of
asthma, COPD and CHF
Discuss the physiologic basis of
capnograpy
            Objectives
Discuss how to interpret capnography
Discuss CPAP and how it works
Review the MEMS protocols for
prehospital use of CPAP
          Your Instructors
Michael Schmitz, DO, MS
   Department of Emergency Medicine
   Southern Maine Medical Center

Dennis Swan, RRT, EMT-P
   Portland Fire Department
   SMMC Resp. Therapy

Brian Langerman, NR-CCEMT-P, I/C
    Saco Fire Department
    EMS Coordinator
         Use of CPAP



        Capnography


      Pathophysiology:
     Asthma, CHF, COPD


Pulmonary Anatomy/Physiology


 Definition and Differential
   Diagnosis of Dyspnea
      Scope of the Problem
Dyspnea is one of the most common chief
complaints among patients who access Emergency
Medical Services.
Dyspnea or shortness of breath made up 3.5
percent of the more than 115 million visits to
United States EDs in 2003. Other dyspnea-related
chief complaints (cough, chest discomfort)
comprised 7.6 percent*.

• American College of Emergency Physicians.
  www.acep.org/webportal/Newsroom/NewsMediaResources
  /StatisticsData/default.html
     Scope of the Problem
Dyspnea is one of the most challenging
presenting complaints in the field of
emergency medicine!

• Broad differential diagnosis
• Many potentially life-threatening
  causes
     Goal: Define dyspnea
Dyspnea (dɪsp’ni ə) –noun difficult or
labored breathing
                  (dictionary.com)
Dyspnea is the perception of an inability to
breathe comfortably
                  (uptodateonline.com)

Let’s generate a relevant differential
diagnosis and use it to expand our
understanding of dyspnea
          What is Dyspnea?

• Is dyspnea a sign or a
  symptom?

• Is dyspnea truly just
  “a lung problem”?

• What emergencies
  could cause a patient
  to report dyspnea?
Differential Diagnosis?
    Differential Diagnosis
Foreign Body
Angioedema/Anaphylaxsis
Infections of the Neck
Airway Trauma
Pulmonary Embolism
Pneumothorax
COPD
Asthma
     Differential Diagnosis
Pneumonia
ARDS
Direct Pulmonary Injury
Acute Coronary Syndrome
Acute Heart Failure
Cardiomyopathy
Cardiac Arrythmia
Cardiac Valve Problem
Cardiac Tamponade
     Differential Diagnosis
Stroke
Neuromuscular Disease
Poisoning (Salicylate, CO, Ethylene glycol)
Diabetic Ketoacidosis
Sepsis
Anemia
Pleural Effusion
Abdominal Process (pregnancy, ascites)
Hyperventilation/Anxiety
Number of Systems Involved
Pulmonary
Cardiovascular
GI/GYN
Central Nervous System
Immune
Infectious Disease
Trauma
One Complaint, So Many Systems




           Why?
Reporting is based on a complex
interaction between the central nervous
system, respiratory muscles, the lungs
and cardiovascular system
Problem Originating Within the
Respiratory System (Lungs)
   central controller
   ventilatory pump
   gas exchange
Problem Originating Outside the
Respiratory System
• Heart/Vascular System
• RBC problem (Not enough or defective)
• Infection/Foreign Body
• Pregnancy/ Ascites
Warning: Patient May Have
 More than One Diagnosis!
  Don’t Get BURNED!
Response is based on both
physiology and behavior



Don’t Believe Me?
Some of you just became rather agitated
              Insight
The patient’s WORDS are critical

For each critical diagnosis there are
key questions/descriptions that will
point you in the right direction
          ATS Definition
Dyspnea “is a term used to characterize a
subjective experience of breathing
discomfort that consists of qualitatively
distinct sensations that vary in intensity.
The experience derives from interactions
among multiple physiological,
psychological, social and environmental
factors, and may induce secondary
physiological and behavioral responses.”
   (ATS Consensus Statement)
       Prehospital Goals
EMS providers: priority is to identify
acute, life threatening emergencies

Rapid assessment is ALWAYS driven
by a focused history of the present
illness and physical exam with an
emphasis on the primary survey
       Prehospital Goals
Optimize oxygenation
Determine the need for emergent
airway management and ventilatory
support
Establish the most likely causes of
dyspnea in your patient and treatment
in accordance with MEMS protocols
Appropriate patient monitoring
Timely extraction
Questions?
         Use of CPAP



        Capnography


      Pathophysiology:
     Asthma, CHF, COPD


Pulmonary Anatomy/Physiology


 Definition and Differential
   Diagnosis of Dyspnea
         Use of CPAP



        Capnography


      Pathophysiology:
     Asthma, CHF, COPD


Pulmonary Anatomy/Physiology


 Definition and Differential
   Diagnosis of Dyspnea
       Pathophysiology
Obstructive lung diseases cause
narrowing or blockage of airways
resulting in decrease in exhaled air
flow
COPD and Asthma are two examples
             Asthma
Definition: A disease characterized
by variable airflow limitation and
airway hyperresponsiveness
Airway narrowing is caused by
smooth muscle contraction, airway
wall thickening and increased
secretions resulting in reduced air
flow rates
                             Child and Adult Asthma Prevalence
                                  United States, 1980-2007
                             14  • Child       Lifetime

                             12   Adult
             Prevalence (%




                             10

                             8

                             6                                                        Current
                             4

                             2     12-Month

                             0
                               80




                               86




                               92




                               00




                               06
                               82

                               84



                               88

                               90



                               94
                               96

                               98



                               02

                               04
                             19

                             19

                             19

                             19

                             19

                             19

                             19
                             19

                             19

                             20

                             20

                             20
                             19




                             20
                                                                                                Year

Source: National Health Interview Survey; CDC National Center for Health Statistics
            Asthma
Words to describe:
“chest tightness”
“this feels like my asthma”
“breathing through a straw”

Associated with intermittent
dyspnea, cough and wheezing
Pathophysiology
Airway narrowing is
caused by smooth
muscle contraction,
airway wall thickening
and increased secretions
resulting in reduced air
flow rates

Primarily a disease of
the AIRWAYS with
decreased elastic recoil
of the lungs during
attack
            Treatment
Oxygen
Bronchodilators (Albuterol or Xopenex and
Atrovent)
Steroids (not in this system)
Magnesium (not in this system)
Epinephrine (med-control only)
NIPPV (BiPAP) (not in this system)
Appropriate Monitoring
Selective Intubation
                     COPD
COPD is a disease with
significant extrapulmonary
effects that may contribute
to its severity in individual
patients.

Its pulmonary component is
characterized by airflow
limitation that is NOT fully
reversible.

The airflow limitation is
usually progressive and
associated with an abnormal
inflammatory response
                 Differential Diagnosis:
                   COPD and Asthma
       COPD                                ASTHMA

•   Onset in mid-life            • Onset early in life (often
• Slow Progression                 childhood)
• Strong Association with        • Symptoms vary from day to day
life-time tobacco use            • Family history of asthma
• Largely irreversible airflow   • Largely reversible airflow
    limitation                     limitation
         Epidemiology
Fourth leading cause of death in the
United States (follows heart disease,
cancer and stroke) resulting in
120,000 deaths in 2002
10 million adults report physician
diagnosed COPD
Often under-diagnosed
               Words to Describe
“effort to breathe”
“unsatisfying breaths”
“cannot get a deep breath”




O'Donnell, DE, Bertley, JC, Chau, LK, Webb, KA. Qualitative aspects of exertional
breathlessness in chronic airflow limitation: Pathophysiologic mechanisms. Am J
Respir Crit Care Med 1997; 155:109.
            Pathophysiology
COPD refers to more
than one lung
disorder; (chronic
bronchitis and
emphysema) that are
both characterized by
obstruction to air flow
The conditions
frequently coexist
Pathophysiology
The Great American Smoke-Out!
Thursday, November 19, 2009
  Pathogenesis of COPD
                Noxious particles
                     and gases
                                      Host factors

                Lung inflammation
Anti-oxidants                         Anti-proteinases


  Oxidative stress                  Proteinases

                                 Repair mechanisms

                COPD pathology
       Inflammation IN COPD
     INFLAMMATION in COPD



Small airway disease    Parenchymal destruction
  Airway inflammation    Loss of alveolar attachments
   Airway remodeling      Decrease of elastic recoil




        AIRFLOW LIMITATION
           Treatment
Oxygen
Bronchodilators
Steroids (not in this system)
NIPPV (BiPAP) (not in this system)
Selective Intubation
Appropriate Monitoring
Extricate
   Congestive Heart Failure
Heart failure is a clinical syndrome
that can result from any structural or
functional cardiac disorder that
impairs the ability of the ventricles to
fill with or eject blood.
As a result, the heart cannot
maintain a sufficient output to meet
the metabolic needs of the body.
             Epidemiology
Currently, approximately 5 million
Americans are living with heart
failure
One of the most common causes of
hospitalization in Americans 65 years
of age and older


    - “Living with Heart Failure” American Heart Association 2004
        Epidemiology
Contributes to 5-10% of yearly hospital
admissions
Seen in 1% of adults 50-60
Seen in 10% adults over 80
Over 550,000 new cases annually
               Words to Describe
“air hunger”
“suffocation”




Simon, PM, Schwartzstein, RM, Weiss, JW, et al. Distinguishable types of dyspnea in
patients with shortness of breath. Am Rev Respir Dis 1990; 142:1009.
 Congestive heart failure is a syndrome
caused by multiple underlying diseases:


Congenital heart      Ventricular failure
disease               Hypertension
Atherosclerosis       Coronary Artery
Cardiomyopathy        Disease
Acute and Chronic     Atrial Fibrillation
Valve disorders       Arrythmia
Cardiac
Tamponade
The Great American Smoke-Out!
Thursday, November 19, 2009
       Pathophysiology

When heart failure causes an
increase in pulmonary venous
pressure, it can lead to dyspnea
either by producing hypoxemia or by
stimulating pulmonary vascular
and/or interstitial receptors
Pathophysiology
       EMS Management
Position
Oxygen
Nitroglycerin
Furosemide
CPAP
Narcotics (Fentanyl) (med-control)
Selective Intubation
Appropriate Monitoring
Extricate
            Treatment
CPAP has been successfully
demonstrated as an effective adjunct
in the management of pulmonary
edema secondary to CHF
• Increases pressure within the airway
• Helps to maintain gas exchange
• Decreases work of breathing
Questions?
         Use of CPAP



        Capnography


      Pathophysiology:
     Asthma, CHF, COPD


Pulmonary Anatomy/Physiology


 Definition and Differential
   Diagnosis of Dyspnea
         Use of CPAP



        Capnography


      Pathophysiology:
     Asthma, CHF, COPD


Pulmonary Anatomy/Physiology


 Definition and Differential
   Diagnosis of Dyspnea
            Conclusions
The physiology of
dyspnea is complex
Knowledge of cardio-
pulmonary anatomy
and physiology is
critical to the EMS
provider
History and physical
exam can help the
EMS provider assess
the dyspneic patient
              Conclusions
 Use of capnography can
give the EMS provider
important information
about their patient’s
condition


 CPAP is an effective way
to treat pulmonary
edema resulting from
acute, decompensated
heart failure
            References
“The ICU Book” Marino PL, 2nd Edition
“Respiratory Physiology” West JB, 5th
Edition
“Pulmonary Pathophysiology” Grippi MA
“Textbook of Medical Physiology” Guyton
and Hall 9th Edition
Harrison’s Principles of Internal Medicine
16th Edition
           References
www.uptodateonline.com
“Evaluation of the adult with dyspnea
in the Emergency Department
“Physiology of Dyspnea”
“Pathophysiology of acute
decompensated heart failure”
“Pathogenesis of asthma”
Coming Attractions
MORE INFORMATION AND EDUCATION


             @

www.mainehealth.org/ems
Thanks to Jenn Granata, RN, BSN, CEN (SMMC),
Cynthia Pernice, MPA (MaineHealth) and Jeff
Regis, EMT-P (SMEMS) for helping to organize
and promote this presentation

Thanks to Dennis Swan, RRT, EMT-P and Brian
Langerman, NR-CCEMT-P for volunteering their
time to teach

Again, thank you for your time and participation