Respiratory Emergencies Victor Politi, M.D., FACP Medical Director Physican Assistant Program • Dyspnea • the sensation of breathlessness or inadequate breathing • the most common complaint of patients with cardiopulmonary diseases • Dyspnea - common complaint/symptom • “shortness of breath” or “breathlessness” • Defined as abnormal/uncomfortable breathing • Multiple etiologies - • 2/3 of cases - cardiac or pulmonary etiology • When it becomes obvious to us that an individual IS breathing, and it's one of the first things that we noticed about this individual, then THAT needs to be one of the first things that we address. • Any patient who is presenting with some degree of respiratory effort is IN respiratory distress • There is no one specific cause of dyspnea and no single specific treatment • Treatment varies according to patient’s condition • chief complaint • history • exam • laboratory & study results Differential Diagnosis • Composed of four general categories • Cardiac • Pulmonary • Mixed cardiac or pulmonary • non-cardiac or non-pulmonary Pulmonary Etiology • COPD • Asthma • Restrictive Lung Disorders • Hereditary Lung Disorders • Pneumonia • Pneumothorax Cardiac Etiology • CHF • CAD • MI (recent or past history) • Cardiomyopathy • Valvular dysfunction • Left ventricular hypertrophy • Pericarditis • Arrhythmias Mixed Cardiac/Pulmonary Etiology • COPD with pulmonary HTN and/or cor pulmonale • Deconditioning • Chronic pulmonary emboli • Pleural effusion Noncardiac or Nonpulmonary Etiology • Metabolic conditions (e.g. acidosis) • Pain • Trauma • Neuromuscular disorders • Functional (anxiety,panic disorders, hyperventilation) • Chemical exposure Easily Performed Diagnostic Tests • Chest radiographs • Electrocardiograph • Screening spirometry • In cases where test results inconclusive • complete PFTs • ABGs • EKG • Standard exercise treadmill testing/ or complete cardiopulmonary exercise testing • Consultation with pulmonologist/cardiologist may be useful ABGs • Commonly used to evaluate acute dyspnea • can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia • normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea • Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing PULSE OX • Rapid, widely available, noninvasive means of assessment in most clinical situations- • insensitive (may be normal in acute dyspnea) • The % of Oxygen saturation does not always correspond to PaO2 • The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels ASTHMA What is Asthma • A Chronic disease of the airways that may cause: • Wheezing • Breathlessness • Chest tightness • Nighttime or early morning coughing The bronchospasm characteristic of the acute asthmatic attack is typically reversible. It improves spontaneously or within minutes to hours of treatment • Asthma can exist by itself or coexist with chronic bronchitis, emphysema, or bronchiectasis Symptoms/Chief Complaint • Progressive dyspnea • Cough • Chest tightness • Wheezing/coughing • The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction Focus of Therapy • Pharmacologic manipulation of airway smooth muscle • Do not overlook physiologic impairment caused by mucous production and mucosal edema • Bronchospasm can be reversed in minutes • Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - • may lead to atelectasis, infectious bronchitis, pneumonitis Asthma Triggers • Immunologic reaction • Viral respiratory/sinus infections • change in temperature/humidity • Drugs/Chemicals - • aspirin, NSAIDS • Exercise • GE reflux • Laughing/coughing • Environmental factors - • strong odors, pollutants, dust, fumes Patient Exam • Wheezing • may be audible w/o stethoscope • Use of accessory muscles of inspiration • diaphragmatic fatigue • Paradoxical respirations • - reflect impending ventilatory failure • Altered mental status - • lethargy, exhaustion, agitation, confusion Patient Exam • Hypersonance to percussion • decreased intensity of breath sounds • prolongation of expiratory phase w or w/o wheezing Patient Exam • The intensity of the wheeze may not correlate with the severity of airflow obstruction • “quiet chest” - very severe airflow obstruction Asthma Treatment • Nebulized B-adrenergic drugs • Corticosteroids • Nebulized anticholinergics • Magnesium sulfate • Oxygen • Long acting beta-agonists • Inhaled steroids Managing Asthma: • Indications of a severe attack: • Breathless at rest • hunched forward • talking in words rather than sentences • Agitated • Peak flow rate less than 60% of normal Treatment Goals of Severe Asthma • Improve airway function rapidly • Avoid hypoxemia • Prevent respiratory failure and death COPD COPD • Hallmark symptom - Dyspnea • Chronic productive cough • Minor hemoptysis • pink puffer • blue bloater COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat. COPD - Physical Findings • Tachypnea • Accessory respiratory muscle use • Pursed lip exhalation • Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing Dominant Clinical Forms of COPD • Pulmonary emphysema • Chronic bronchitis • Most patients exhibit a mixture of symptoms and signs COPD - Advanced Dx • secondary polycythemia • cyanosis • tremor • somnolence and confusion due to hypercarbia • Secondary pulmonary HTN w or w/o cor pulmonale COPD Treatment Strategy • Elimination of extrinsic irritants • bronchodilator & glucocorticoid therapy • Antibiotics • Mobilization of secretions • “respiratory vaccines” • Oxygen therapy - if oxygen saturation <90% at rest on room air Spirometry PNEUMONIA • 6th leading cause of death in the US • Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases Common types of respiratory infections • Tracheobronchitis • Pneumonia • Effusions • Empyema • Abscess • Cavitary lesions • post-obstructive Common Respiratory Viruses • Influenza A & B • Parainfluenza 1& 3 • Respiratory Syncytial Virus • Adenovirus • Cytomegalovirus • Herpes Simplex & Zoster/varicella • Hanta Virus Infection Respiratory Syncytial Virus • Rapid diagnosis of Respiratory Syncytial Virus Infection by immunofluorescence of respiratory secretions Classic Pneumonia Symptoms • Dyspnea, chills • high fever, cough/sputum • pleuritic chest pain Viral Pneumonia - symptoms • Chest Pain • Fever • Dyspnea • Prodrome - malaise, upper respiratory symptoms, and other GI symptoms Viral pneumonia - Clinical Findings • Minimal/variable • Chest exam - may reveal wheezing • Fine rales if heard can signify interstitial involvement • Chest x-ray - patchy densities or interstitial involvement Viral pneumonia Management /Prophylaxis • Supportive treatment - decrease severity of symptoms • bed rest • analgesics • expectorants • Patients w/ • airway obstruction - treat w/bronchodilators • secondary bacterial infection - antibiotics Atypical Pneumonia • Accounts for 25% of community acquired pneumonias • Mycoplasma/chlamyda/legionella • can case extrapulmonary manifestations - • meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia • typically bilateral infiltrates on chest x-ray • primarily effects younger persons Atypical Pneumonia Treatment • Antibiotics • Macrolides • fluroquinolones • doxycycline Bacterial pneumonia • 3.3 million cases yearly in US • responsible for 10% of hospital admissions • unilateral infiltrate on x-ray • high mortality in elderly population • most common cause pneumococcal followed by haemophilus influenza • Pneumococcus pneumonia accounts for up to 90% of all bacterial pneumonias • Patients with a chronic Dx are at an increased risk of contracting pneumonia Bacterial pneumonia presentation • acute shaking - chills • tachypnea • tachycardia • malaise • anorexia • myalgias • flank or back pain • vomiting Lab Tests • WBC • Chest X-ray • Pulse Ox • ABGs • Sputum exam • Blood cultures • pleural fluid exam Pneumothorax Causes of Spontaneous Pneumothorax • Pleural blebs • Bullae • Emphysema • Interstitial lung disease • Alpha 1 antitrypsin deficiency Traumatic and Iatrogenic Causes • Penetrating wounds • Line placements • Lung biopsies • Mechanical ventilation Two most common symptoms • Dyspnea • Chest pain Physical Examination • Decreased breath sounds • hyperresonance to percussion • decreased tactile fremitus • In patients with emphysema - clinical findings may be subtle Chest X-ray to Confirm Dx • 500ml of air required to visualize pneumothorax on x-ray • Characterized by - • hyperlucency and lack of lung markings at the periphery of the lung and appearance of fine line that represents the retraction of the visceral from the parietal pleura Treatment Options • Observation - if pneumothorax involves < 15-20% of hemithorax and patient relatively asymptomatic • Tube thoracostomy • Simple Aspiration Pulmonary Embolism PE History • PE is so common and deadly that the dx should be considered in any patient who presents with chest symptoms that cannot be proven to have another cause PE Risk Markers • Hypercoagulable states • Prior hx of DVT or PE • Recent surgery or pregnancy • Prolonged immobolization • Underlying malignancy • smoking • birth control pills • trauma Classic triad of signs/symptoms Hemoptysis Dyspnea Chest Pain • These symptoms are not sensitive or specific and occur in fewer than 20% of patients diagnosed with PE PE Physical Exam • Massive PE causes hypotension due to acute cor pulmonale • Physical findings in early submassive PE may be completely normal • Initially, abnomal findings are absent in most patients with PE Massive PE - Signs/Symptoms • Tachypnea -96% • Rales - 58% • Accentuated second heart sound - 53% • Tachycardia - 44% • Fever - 43% • S3 or S4 gallop - 34% • signs/symptoms suggestive of thrombophlebitis - 32% • Lower extremity edema - 24% • Cardiac murmur - 23% • Cyanosis - 19% Massive PE Diagnostic Studies • VQ scan • Pulmonary angiography • CT • Echocardiography (TEE) • Pulmonary artery catheterization • Diagnostic algorithm • D-dimer • blood gases increased A-a gradient A-a gradient A-a gradient = predicted pO2 – observed PO2 PAO2 = (FIO2 X 713) – (PaCO2/0.8) at sealevel PAO2 = 150-(PaCO2/0.8) at sealevel on room air Normal range 10-15mm > 30 years of age Normal range 8mm < 30 years of age Increased A-aDO2=diffusion defect Right to left shunt V/Q mismatch Examples • A doubel overdose brings two 30 yr old patients to the ED. Both have ingested substantial amounts of barbiturates and diazepam. Blood gases drawn on room air revealed these values: • patient 1- pH =7.18, PCO2 = 70mmHg, PO2=50mmHg, HCO3=24mEq/L; • patient2- pH =7.31, PCO2=50mmHg, PO2=50mmHg, HCO3=25mEq/L Comment • The A-a gradient calculation for patient 1 is as follows: • A-a DO2 = PAO2 – PaO2 • PAO2 = 150 – (1.25x PCO2) • PAO2 = 150 – (1.25x 70) • PAO2 = 62 • A-a =62 – 50 • A-a = 12 Comment • The calculation reveals a normal gradient, indicating that the etiology for hypoxemia and hypoventilation is extrinsic to the lung itself. Comment • The A-a gradient calculation for patient 2 is as follows: • PAO2 = 150 – (1.25 x PCO2) • PAO2 = 150 – (1.25 x 50) • PAO2 = 150 – 63 • PAO2 = 87 • Therefore, A-a = 87 – 50 =37 (an abnormally increased gradient) Comment • We can be reasonably confident that patient 1 suffered hypoventilation due to the effect of the ingested drugs on the brain stem. • Temporary mechanical ventilation restored this patient’s gas exchange. Comment • Patient 2, on the other hand, had an increased A-a gradient, indicating a lung problem in addition to any central cause for hypoventilation. • The chest x-ray film revealed that this patient’s overdose was complicated by aspiration pneumonitis and that the patient required treatment with antibiotics in addition to mechanical ventilation. Treatment Strategies • Fluid administration • anticoagulation • Vena caval interruption • Thrombolytics • oxygen • pulse ox CHF Left sided Failure • Blood/fluid back-up into the lungs - result in • SOB • Fatigue • Cough (especially at night) • PND • orthopnea Right sided Failure • Build-up of fluid in the veins - • Edema of feet, legs and ankles • may effect liver/portal circulation and 3rd spacing into soft tissue/ascites/pleural effusion Causes of CHF • Variety of cardiac diseases • Most common cause of CHF - CAD • other causes - valvular heart dx, HTN,cardiomyopathies, myocarditis, renal dx,fluid overload,liver dx w/loss of protein and osmotic forces,high altitude and many others Physical Findings • Peripheral edema • JVD • tachycardia • tachypnea, using accessory muscles of respiration • Skin - diaphoretic/cold/gray/cyanotic • Wheezing/rales on ausculation • Apical impulse displaced laterally • ascites • hepatosplenomegaly Diagnostic Work-Up • History • Physical exam • EKG • Echo • Chest x-ray • BNP • ABG/pulse ox Treatment • Diuretics • Digitalis • Peripheral vasodilators/NTG • Positive inotropic agents • ACE inhibitors • Beta blockers • Oxygen • MS04 • BNP • Respiratory distress is FRIGHTENING! • Feelings of confinement, claustrophobia, restlessness, and anxiety accompany a realization that DEATH may be imminent. • All of this, in a patient that is, most likely, normally mentated and aware of what is happening. • If you never before had any reason to "dig deep" and draw out true human compassion for a patient, THIS IS THE TIME TO DO IT! Questions ?
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