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ED Approach to the Dyspneic Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation.

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Presentation on theme: "ED Approach to the Dyspneic Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation."— Presentation transcript:

1 ED Approach to the Dyspneic Patient University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

2 Dyspnea Subjective feeling of shortness of breath –Difficult –Labored –Uncomfortable Ventilatory demands exceed respiratory function –Alterations in: Gas exchange Pulmonary circulation Respiratory mechanics O2-carrying capacity of blood Cardiovascular function

3 Differential Diagnosis Upper Airway Obstruction Angioedema Epiglottitis Foreign Body Vocal cord paralysis/spasm Pulmonary Aspiration Asthma COPD exacerbation Pneumonia Pneumothorax Pleural Effusion ARDS Toxic Inhalation Metabolic/Systemic Anaphylaxis Anemia Hyperthyroidism Sepsis Acidosis Salicylate intoxication Obesity Cardiovascular CHF Pulmonary edema Cardiac tamponade Acute MI Dysrhythmia Pulmonary Embolus Neuromuscular Guillain-Barre Syndrome Myasthenia gravis Psychogenic Hyperventilation syndrome

4 Cases…

5 Case 1 59 yo female CC: –left upper chest pain –shortness of breath HPI –Sudden onset while watching television –Increased pain with inspiration –Non productive cough –No fevers or chills –Tried acetaminophen without relief PMHx –Hypertension –hypercholesterolemia

6 Case 1 Surgical Hx –2 wks s/p partial colectomy for diverticulitis Social Hx –No tobacco, EtOH or drug use –Married –Works in the food industries Family Hx –hypertension

7 Case 1 ROS: negative Vitals: T:37 HR: 62 RR: 20 BP: 120/64 SpO2: 98% room air Physical Exam: essentially normal Assessment?? Plan?

8 Pulmonary Embolism Occurs a lot more than we think it does! –1.5 million DVT 30% symptomatic PE, 30% asymptomatic PE –50k deaths/year –2.5% mortality if dxd –30% mortality if not dxd High index of suspicion

9 Symptoms of Acute Pulmonary Embolism SymptomsMassive EmboliSubmassive Emboli (n=197)(n=130) Chest Pain85%82% Pleuritic64%85% Non Pleuritic6%8% Dyspnea85%82% Apprehension65%50% Cough53%52% Hemoptysis23%40% Sweats29%23% Syncope20%4%

10 Pulmonary Embolism Risk factors –Post-op –Inactivity casts –Chronic disease –Hypercoagulable states Malignancies Protein C&S deficiency Lupus anticoagulants Estrogen therapy Factor V Leiden

11 Signs of Acute Pulmonary Embolism SignsMassive PESubmassive PE RR > 16/min95%87% Rales57%60% Increased S258%45% HR >100/min48%38% Temp > %42% Phlebitis36%26% Gallop39%25% Diaphoresis42%27% Edema23%25% Murmur27%16% Cyanosis25%9%

12 Pulmonary Embolism ECG findings –S1Q3T3 25 % of the time RV strain –Tachycardia Most common

13 When to test?!? Everyone? High risk only? Who is safe to clinically rule out PE?

14 PERC/Wells Criteria Clinical rules to limit testing Low risk pts have false positive rates and morbidity/mortality with treatment Directs when to work-up

15 Pulmonary Embolus Wells Criteria – What is the pre-test probability? –3.0 Signs/Symptoms of DVT –1.5 HR>100 –1.5 Immobilization >3d or surgery in past 4 wks. –1.5 Prior DVT or PE –1.0 Hemoptysis –1.0 Malignancy –2.0 PE as likely or more likely than alternative diagnosis High Probability > 6.0 Moderate Probability 2.0 – 6.0 Low Probability < 2.0 Wells et al. Ann Int Med 2001; 135:98-107

16 PERC Rule Age <50 HR <100 RA SpO2 >94% No prior PE/DVT No recent surgery No estrogen No DVT findings No hemoptysis Will have a PTP <2% and therefore will not benefit from an evaluation for PE Kline JA et al. J. Thrombosis Haemostasis 2004; 2:

17 Imaging CXR V/Q Scan CT chest Angiography

18 CXR

19 VQ Scan Normal excludes PE, otherwise in context of patient

20 90% sensitive, 95% specific




24 Pulmonary Embolism Treatment –High suspicion prior to imaging = heparin –Proven with imaging = heparin (LMW or UFH) –Thrombolytics in select cases Perimortem RV dysfunction on echo Pulmonary HTN on echo Pulmonary HTN on R heart cath New ECG signs of RV strain Konstantinides et al NEJM 2002;347(15):

25 Case 1 Summary Risk: age, post-op Pleuritic chest pain Mild tachypnea but vital signs otherwise normal = dont be fooled! High index of suspicion!

26 Case 2 85 yo male CC: Cough, fever HPI: –3 days of progressive cough with green sputum production. –Fevers and chills –Pleuritic R sided chest pain PMHx: CAD, HTN, hypercholesterolemia

27 Case 2 Surg Hx: TURP, Coronary stent x 2, appy Soc Hx: remote tobacco, occasional EtOH, no drug use. Widowed. Retired fisherman. FHx: Coronary disease ROS: no HA, abdominal pain, N/V/D, urinary symptoms

28 Case 2 Vitals: T 38.5 HR 95 RR 20 BP 105/62 SpO2 94% room air Physical: –HEENT: dry mucous membranes –Cor: RRR no murmurs –Lungs: LLL crackles & occ wheeze –Abd: soft NT/ND Assessment?? Plan?

29 Pneumonia #1 infectious mortality –#6 overall –1% as outpt, 25% when needing admission #1 cause nosocomial infectious mortality –Up to 50% mortality –25-50% of all ICU pts get pneumonia

30 Pathogens Typical S pneumoniae, H Flu, Staphylococcus Atypical Legionella, Mycoplasma, Chlamydia Etoh Klebsiella pneumoniae DM/DKA S pneumoniae/S aureus HIV based on CD4 count COPD Haemophilus influenzae/Moraxella catarrhalis Sickle Cell S pneumoniae/H influenzae

31 Diagnosis History/Physical CXR CBC Blood Cx Urine Cx

32 Treatment Ceftriaxone + Macrolide or Fluroquinolone (moxi/levo) –Typical and Atypical coverage –May to Cefepime for better G- Hospital/Nursing Home –Health care associated (includes dialysis pts) –Add Vanco Admit or outpt therapy?

33 PNA Severity Score Age: –Males: Age –Females: Age -10 Nursing home : +10 Comorbid illnesses –Neoplastic disease: +30 –Liver disease: +20 –CHF: +10 –CVA disease: +10 –Renal disease: +10 Physical examination –AMS: +20 –RR >30/minute: +20 –SBP <90mmHg: +20 –Temp 40C: +15 –Pulse >125/minute: +10 Laboratory findings –pH <7.35: +30 –BUN >30: +20 –Sodium <130 mEq/L: +20 –Glucose >250: +10 –Hct <30%t: +10 –PO2 <60 mmHg: +10 – Pleural effusion: +10

34 PSS 30d Mortality Prediciton Total ScoreRankSite or RxMortality (%) NoneIOutpt0.1 <70IIOutpt IIIOutpt IVInpt >130VInpt27-29

35 CURB-65 Confusion? BUN > 19 mg/dL (7 mmol/L)? Respiratory Rate 30? Systolic BP < 90 mmHg orDiastolic BP 60 mmHg? Age 65? For each yes answer pt gets 1 point

36 CURB-65 Score 30 day mortality 1 = 2.7%, outpt treatment 2 = 6.8%, consider inpt vs close outpt tx 3 = 14%, inpt tx, poss ICU 4 = 27.8%, inpt, prob ICU 5 = 27.8%, prob ICU tx CAVEAT: notice the score does not take into account hypoxia.

37 Atypical Pneumonia

38 RLL Pneumonia


40 RUL Pneumonia

41 LUL Pneumonia

42 Case 3 24 yo female CC: Shortness of breath, wheezing HPI: –2 days of gradual increased shortness of breath –Worse today without relief with albuterol MDI –Non productive cough –No fevers –Recently got a new kitten

43 Case 3 PMHx: asthma –No prior hospitalizations All/Meds: none/albuterol MDI Surgical Hx: none Social Hx: ½ ppd tobacco, no EtOH or drugs. Single. Waitress FHx: COPD ROS: negative

44 Case 3 Vitals: T 37.8 HR 105 RR 22 BP 140/90 SpO2 91% RA Exam: +accessory muscle use, decreased air movement and very little wheezing Assessment?? Plan?

45 Asthma chronic, nonprogressive lung disorder characterized by: –Increased airway responsiveness –Airway inflammation –Reversible airway obstruction

46 Physical Exam Tachypnea Tachycardia Cough Prolonged expiratory phase Wheezing –NOT an accurate indicator of the severity of an attack BEWARE of the silent chest!!! –Wheezing may be ABSENT or only barely audible in patients with severe obstruction

47 Physical Examination Severe obstruction: –Inability to speak –Use of accessory muscles –Altered mental status –Diaphoresis –The silent chest

48 Can we accurately risk stratify asthma patients with our exam alone? No… clinicians & patients are notoriously inaccurate when assessing severity. Checking an objective measure of lung function is considered the standard.

49 Assessment Tools Clinical scoring systems Peak expiratory flow rates Pulse oximetry Arterial blood gases Chest radiography CBC

50 Peak Expiratory Flow Rates Should be measured before and after each treatment Easiest test to perform in the ED

51 Peak Expiratory Flow Rates Provides an objective measure –Based on height, age, gender Is effort-dependent Useful to assess the response to Rx <25%Severe 25%-50%Moderate 50%-70%Mild >70%Discharge Goal

52 Pulse Oximetry Used to assess and follow oxygenation O2 sats < 90% indicate a severe asthma attack and significant hypoxemia May have near-normal pulse- ox with impending hypercapneic respiratory failure

53 Arterial Blood Gases Respiratory alkalosis typical Inaccurate predictor of outcome Will seldom alter your treatment plan Painful and not free

54 Chest Radiography Adds little to decision making in most patients The presence of abnormal findings on CXR seldom alters management Should not be ordered routinely

55 Indications for CXR First episode of wheezing Unclear diagnosis Patients refractory to therapy Respiratory failure Clinical evidence of infection, pneumothorax, or pneumomediastinum

56 Complete Blood Count Often elevated from stress of acute asthma attack or chronic steroid use Mild eosinophilia is common NOT routinely ordered Indications: infectious work-up

57 Pharmacotherapy Beta-agonists Corticosteroids Anticholinergics

58 Beta Agonists Mainstay of acute therapy Promote bronchodilation by increasing cAMP Primary effect is small airways Onset of action < 5 min

59 β-Agonists: MDI vs. Nebulizer? Both are equally effective, even in severe asthma MDI is substantially cheaper 6 puffs = 2.5 mg via a holding chamber nebulizer

60 Anticholinergic Agents Produce bronchodilation by inhibition of vagally-mediated bronchoconstriction Decrease cGMP Primarily affect large, central airways Onset of action up to 30 min and peak in 1-2 hrs Use in combination with beta-agonists as first-line therapy

61 Steroids Administer early Used to treat the inflammatory component of asthma Reduce the rate of relapse and the rate of hospital admission

62 Oral Versus IV? Both routes equally effective –Methylprednisolone mg IV –Prednisone 1-2mg/kg PO Oral route preferred –Easier and faster –Decreases pain/anxiety of IV –Cheaper

63 Inhaled Steroids In chronic asthma the regular use of inhaled steroids has been shown to: –Suppress airway inflammation –Decrease beta-agonists use –Decrease the frequency of acute exacerbations –Decrease mortality related to acute asthma

64 The emergency physician can use the rule of two to determine if a patients asthma is well controlled: –Use of a rescue inhaler >2 times a week –Awakening with an asthma attack > 2 times a month –Use of >2 quick-relief β-agonist canisters/year Evidence Supporting the Role of Inhaled Corticosteroids In Controlling Asthma Singer A. Acad Emerg Med 2005; 45:

65 Inhaled Steroids After Discharge? Use BID Always use a spacer Rinse mouth after use to reduce complications (dysphonia, S/T, oropharyngeal candidiasis)

66 Case 4 69 yo male CC: difficulty breathing HPI –Recent cold symptoms x 4 days –Now with cough, increased shortness of breath –Poor exercise tolerance –Cough is productive with yellow sputum –No fevers, N/V/D, or other complaints

67 Case 4 PMHx: HTN, COPD, hypercholesterolemia All: PCN Meds: combivent, lipitor, HCTZ Surgical Hx: cholecystectomy Social Hx: 70 pk-yr tobacco, +EtOH, no drug use; married, retired ship builder FHx: emphysema ROS: negative

68 Case 4 Vitals: T 37.6 HR 100 RR 20 BP 150/94 SpO2 89% room air Physical: pursed-lip breathing, barrel chest, using accessory muscles. Distant heart and lung sounds, occasional wheeze. +clubbing Assessment?? Plan?

69 COPD Definition –Chronic bronchitis: Chronic, productive cough x 3 months in each of 2 successive years in which other causes of chronic cough have been eliminated (Blue bloaters) –Emphysema: abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of bronchiolar walls but without obvious fibrosis (Pink puffers)

70 COPD Exacerbations –Worsening airflow obstruction due to Bronchospasm Sputum production (infectious, environmental irritants) Cardiovascular deterioration

71 COPD History –Progressive shortness of breath –Increased sputum production –Audible wheezing Physical exam –Tachypnea –Hypoxemia –Cyanosis –Agitation –Hypercarbia (confusion, stupor, inadequate respiratory effort) –Sitting up, pursed-lip breathing (PEEP) –Diminished breath sounds, prolonged expiratory phase, wheezing

72 COPD Work-up CBC (r/o anemia) CXR (r/o infection, ptx, CHF) ECG Other labs –Lytes –Cardiac enzymes –BNP –Theophylline level (if on med, uncommon these days)

73 COPD Treatment Oxygen –Most have baseline sats of 88-91% with mod/severe disease –Hypoxic drive Bronchodilation –Beta-agonists i.e. albuterol Decrease mucous production –Anticholinergic i.e. atrovent Decrease inflammation –Steroid therapy Treat infection or underlying cause Similar to asthma treatment Combivent or Duoneb

74 Summary Dyspnea = Subjective Large differential to consider… –Pulmonary Embolus –Pneumonia –Asthma –COPD –AMI, CHF, Anemia, Tox, pneumothorax, airway obstruction etc.

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