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Dyspnea (PowerPoint)

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					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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posted:8/14/2011
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