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Shortness of Breath UNC Emergency Medicine Medical Student Lecture Series.

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Presentation on theme: "Shortness of Breath UNC Emergency Medicine Medical Student Lecture Series."— Presentation transcript:

1 Shortness of Breath UNC Emergency Medicine Medical Student Lecture Series

2 Objectives Recognizing respiratory distressRecognizing respiratory distress Initial approach to a patient with respiratory distressInitial approach to a patient with respiratory distress Actions to takeActions to take HistoryHistory Physical examinationPhysical examination Specific conditions that present with respiratory distressSpecific conditions that present with respiratory distress

3 Case #1 24 yo F with hx of asthma presenting with shortness of breath, wheezing, dry cough for two days, worsening today; no fever or chills, no chest pain; no congestion. Tried inhaler every 2 hours at home for past 6 hours without relief.24 yo F with hx of asthma presenting with shortness of breath, wheezing, dry cough for two days, worsening today; no fever or chills, no chest pain; no congestion. Tried inhaler every 2 hours at home for past 6 hours without relief. What do you do first?What do you do first?

4 Things you want to know What usually triggers your asthma?What usually triggers your asthma? Prior ED visits, hospitalizations, ICU admissions? Prior intubations?Prior ED visits, hospitalizations, ICU admissions? Prior intubations? Current medicationsCurrent medications Frequency of inhaler useFrequency of inhaler use Recent steroidsRecent steroids Baseline peak flow valuesBaseline peak flow values Fevers, recent infections, and sick contactsFevers, recent infections, and sick contacts

5 Why is all that so important? Risk factors for sudden death from asthma:Risk factors for sudden death from asthma: Past history of sudden severe exacerbationsPast history of sudden severe exacerbations Prior intubation for asthmaPrior intubation for asthma Prior asthma admission to an ICUPrior asthma admission to an ICU In the past year:In the past year: 2 or more hospitalizations for asthma2 or more hospitalizations for asthma 3 or more ED visits for asthma3 or more ED visits for asthma Hospitalization or an ED visit for asthma within the past monthHospitalization or an ED visit for asthma within the past month

6 Start with the ABCs AirwayAirway Breathing: How much respiratory distress?Breathing: How much respiratory distress? Can’t speak in complete sentencesCan’t speak in complete sentences Tachypnea (if not tachypneic may be getting fatigued)Tachypnea (if not tachypneic may be getting fatigued) Accessory muscle useAccessory muscle use Retractions, nasal flaring, gruntingRetractions, nasal flaring, grunting CyanosisCyanosis Hypoxia (decreased pulse ox)Hypoxia (decreased pulse ox) Wheezing (may not hear wheezing if they are not moving any air at all!)Wheezing (may not hear wheezing if they are not moving any air at all!) Decreased air movementDecreased air movement CirculationCirculation

7 Differential Diagnosis for SOB Most Common Obstructive: Asthma, COPDObstructive: Asthma, COPD Congestive heart failureCongestive heart failure Ischemic heart diseaseIschemic heart disease PneumoniaPneumonia Psychogenic: Panic, anxietyPsychogenic: Panic, anxiety Urgently Life Threatening Upper airway obstructionUpper airway obstruction Foreign body Angioedema/anaphylaxis Tension pneumothoraxTension pneumothorax Pulmonary embolismPulmonary embolism Neuromuscular weaknessNeuromuscular weakness Myasthenia gravis Guillain-Barre

8 Immediate Actions (First 10 minutes) Supplemental oxygenSupplemental oxygen Pulse oximetry with complete vital signsPulse oximetry with complete vital signs BVM if decreased RR, shallow/weak respirationsBVM if decreased RR, shallow/weak respirations Decide need for endotracheal intubationDecide need for endotracheal intubation IV access, labs, and ABGIV access, labs, and ABG Portable chest x-ray – STATPortable chest x-ray – STAT EKG if concerned for cardiac etiologyEKG if concerned for cardiac etiology Brief history and focused physical examBrief history and focused physical exam Form initial differential, begin treatmentForm initial differential, begin treatment

9 Focused Physical Exam Vital signsVital signs RR, HR, BP, temp, O2 SatRR, HR, BP, temp, O2 Sat Mental StatusMental Status Alert, confused, lethargicAlert, confused, lethargic HeartHeart JVD, muffled heart sounds, S3, S4JVD, muffled heart sounds, S3, S4 LungsLungs Rales, wheezing, diminished or absent BS, stridorRales, wheezing, diminished or absent BS, stridor Respiratory accessory muscle useRespiratory accessory muscle use AbdomenAbdomen Hepatomegaly, ascites SkinSkin Diaphoresis, cyanosis ExtremitiesExtremities Edema Unilateral leg swelling NeurologicNeurologic Focal neurologic deficits **Reassess respiratory status frequently especially in the first 15 minutes or so

10 Back to our asthma case…. What tests do you want?What tests do you want?

11 Evaluation of acute asthma Peak flowsPeak flows Helpful in determining attack severityHelpful in determining attack severity Can follow after treatments to see if improvedCan follow after treatments to see if improved Want to be >80% of “predicted”Want to be >80% of “predicted” Continuous pulse oximetryContinuous pulse oximetry CXR if you suspect a secondary problemCXR if you suspect a secondary problem PneumothoraxPneumothorax Foreign bodyForeign body PneumoniaPneumonia ABG might be helpful in severe attacksABG might be helpful in severe attacks Tachypnea should lead to decreased PCO2, and a normal or high PCO2 indicates fatigueTachypnea should lead to decreased PCO2, and a normal or high PCO2 indicates fatigue

12 Remember pathophysiology Asthma is an inflammatory diseaseAsthma is an inflammatory disease Bronchospasm is only a symptomBronchospasm is only a symptom Many possible causes:Many possible causes: AllergiesAllergies IrritantsIrritants InfectionsInfections Poiseuille's Law- Radius has a huge affect on flow

13 What medications and treatments do you want to give?

14 Treatments Supplemental oxygenSupplemental oxygen β 2 agonists (Albuterol)β 2 agonists (Albuterol) Nebulized: mg nebs q20 minutes, can be continuous if neededNebulized: mg nebs q20 minutes, can be continuous if needed MDI with spacer: 6-12 puffs from MDI q20 minutes (4-8 in children)MDI with spacer: 6-12 puffs from MDI q20 minutes (4-8 in children) Anti-cholinergics (Atrovent)Anti-cholinergics (Atrovent) Adding Atrovent has been shown to decrease admissionsAdding Atrovent has been shown to decrease admissions Albuterol/Atrovent combination for first treatmentAlbuterol/Atrovent combination for first treatment 500 mcg in adults (250 mcg in kids) q6 hours500 mcg in adults (250 mcg in kids) q6 hours

15 Treatments CorticosteroidsCorticosteroids Decrease airway inflammation (takes 4-8 hrs)Decrease airway inflammation (takes 4-8 hrs) Reduces the need for hospitalization if administered within 1 hour of arrival in the EDReduces the need for hospitalization if administered within 1 hour of arrival in the ED Adults:Adults: Methylprednisolone 125mg IV/Prednisone 60mg POMethylprednisolone 125mg IV/Prednisone 60mg PO Pediatrics:Pediatrics: Methylprednisolone 1 mg/kg IV or Prednisone 1-2 mg/kg POMethylprednisolone 1 mg/kg IV or Prednisone 1-2 mg/kg PO Continue steroids for 5 day courseContinue steroids for 5 day course

16 Treatments MagnesiumMagnesium Bronchodilating propertiesBronchodilating properties Shown to help in severe asthmaShown to help in severe asthma Peak flow < 25% of predictedPeak flow < 25% of predicted Relatively safeRelatively safe Adult dose: 1-2 g IV over 30 minutesAdult dose: 1-2 g IV over 30 minutes

17 Treatments Non-invasive Positive Pressure VentilationNon-invasive Positive Pressure Ventilation Some evidence BiPAP or CPAP may help in severe asthmaSome evidence BiPAP or CPAP may help in severe asthma Temporary until medications start workingTemporary until medications start working Can help avoid intubationCan help avoid intubation Pt must be awake and cooperativePt must be awake and cooperative

18 Treatments IntubationIntubation Mechanical ventilation decreases work of breathing and allows patient to rest Indications: Hypercarbia, acidosis, respiratory fatigue Complications: High peak airways pressures and barotrauma Hemodynamic impairment Atelectasis and pneumonia from frequent mucus plugging Special considerations Increased I:E ratio to help prevent breath stacking Permissive hypoventilation with goal >90% oxygen saturation Heli-oxHeli-ox

19 Admit or not? Depends on: Improvement of symptoms, risk factors for death, social situation, compliance, and patient comfort with going homeDepends on: Improvement of symptoms, risk factors for death, social situation, compliance, and patient comfort with going home In general:In general: HOME if complete resolution of symptoms and peak flow > 70% of predictedHOME if complete resolution of symptoms and peak flow > 70% of predicted ADMIT if poor response to treatment and peak flow < 50% of predictedADMIT if poor response to treatment and peak flow < 50% of predicted ALL OTHERS – Depends on combination of above factors, when in doubt ASK THE PATIENT!ALL OTHERS – Depends on combination of above factors, when in doubt ASK THE PATIENT!

20 Discharge All patients need steroids for at least 5 daysAll patients need steroids for at least 5 days All patients need β 2 agonistsAll patients need β 2 agonists All patients with more than mild intermittent asthma (need inhaler > 2 x week, peak flow 2 x week, peak flow < 80% of predicted) need inhaled steroids Patients with moderate-to-severe asthma (daily symptoms) should measure daily peak flowsPatients with moderate-to-severe asthma (daily symptoms) should measure daily peak flows All patients need close follow upAll patients need close follow up All patients need education about asthmaAll patients need education about asthma Smoking cessation counselingSmoking cessation counseling

21 Case #2 65 yo M with shortness of breath for past several hours, getting increasingly worse; now drowsy and difficult to arouse; pt with hx of smoking 2ppd for many years, is on home oxygen.65 yo M with shortness of breath for past several hours, getting increasingly worse; now drowsy and difficult to arouse; pt with hx of smoking 2ppd for many years, is on home oxygen. T: 99.9, HR: 98, R: 30, BP: 165/70, O2sat: 89% room air, 92% 2LNCT: 99.9, HR: 98, R: 30, BP: 165/70, O2sat: 89% room air, 92% 2LNC Physical exam: barrel chest, pursed lips, wheezing, prolonged expirations, diminished breath sounds throughoutPhysical exam: barrel chest, pursed lips, wheezing, prolonged expirations, diminished breath sounds throughout Likely diagnosis?Likely diagnosis? What else is on your differential diagnosis?What else is on your differential diagnosis?

22 COPD Chronic airway inflammationChronic airway inflammation Inflammatory cells and mediatorsInflammatory cells and mediators Protease / anti-protease imbalanceProtease / anti-protease imbalance Oxidative stressOxidative stress Increases in lung complianceIncreases in lung compliance Becomes an obstructive processBecomes an obstructive process Ask patients about:Ask patients about: History of COPD Change in cough or sputum Fever, infectious signs Medications (steroids) Environmental exposures Smoking history

23 Physical exam findings in COPD Signs of HypoxemiaSigns of Hypoxemia TachypneaTachypnea TachycardiaTachycardia HypertensionHypertension CyanosisCyanosis Signs of HypercapniaSigns of Hypercapnia Altered mental status Hypopnea

24 COPD Chest X-rayChest X-ray HyperinflationHyperinflation Flattened diaphragmsFlattened diaphragms Increased AP diameterIncreased AP diameter EKGEKG Wandering pacemakerWandering pacemaker Multifocal atrial tachycardia (MAT)Multifocal atrial tachycardia (MAT) Right axis deviationRight axis deviation

25 Treatment for COPD Supplemental oxygenSupplemental oxygen Careful in patients that are CO 2 retainersCareful in patients that are CO 2 retainers Loss of hypoxic drive can result in respiratory arrestLoss of hypoxic drive can result in respiratory arrest Goal: 90-92% oxygen saturationGoal: 90-92% oxygen saturation Bronchodilators (Albuterol and atrovent)Bronchodilators (Albuterol and atrovent) AntibioticsAntibiotics (Which antibiotics would be appropriate?)(Which antibiotics would be appropriate?) CorticosteroidsCorticosteroids 7-14 day course improves FEV1 in exacerbations7-14 day course improves FEV1 in exacerbations Hyperglycemia is common side effectHyperglycemia is common side effect

26 Treatment for COPD Positive-pressure ventilationPositive-pressure ventilation Indicated for respiratory fatigue, acidosis, hypoxia, hypercapniaIndicated for respiratory fatigue, acidosis, hypoxia, hypercapnia Can decrease intubation rates and possibly improves survivalCan decrease intubation rates and possibly improves survival Patient needs to be awake, cooperative, and able to handle secretionsPatient needs to be awake, cooperative, and able to handle secretions

27 Case #3 35 yo previously healthy F c/o one week of headache, sore throat and muscle aches, fevers, now with productive cough and increasing fatigue.35 yo previously healthy F c/o one week of headache, sore throat and muscle aches, fevers, now with productive cough and increasing fatigue. On physical exam she is febrile and has decreased breath sounds over the RLL.On physical exam she is febrile and has decreased breath sounds over the RLL. What is your differential and work-up?What is your differential and work-up?

28 Pneumonia Clinical features:Clinical features: Typically: Cough, dyspnea, sputum production, fever, pleuritic chest painTypically: Cough, dyspnea, sputum production, fever, pleuritic chest pain Pneumococcal: sudden onset of fever, rigors, productive cough, tachypneaPneumococcal: sudden onset of fever, rigors, productive cough, tachypnea Atypical pneumonia: Coryza, low grade fevers, non- productive coughAtypical pneumonia: Coryza, low grade fevers, non- productive cough On exam:On exam: Tachypnea, tachycardia, feverTachypnea, tachycardia, fever Inspiratory rales = Alveolar fluidInspiratory rales = Alveolar fluid Bronchial breath sounds = ConsolidationBronchial breath sounds = Consolidation Dullness/decreased BS = Pleural effusionDullness/decreased BS = Pleural effusion Rhonchi = Bronchial congestionRhonchi = Bronchial congestion

29 Pathophysiology Usually inhaled/aspirated pathogensUsually inhaled/aspirated pathogens Risk- Stroke, seizure, intoxicationRisk- Stroke, seizure, intoxication Hematogenous spread- Staph. aureusHematogenous spread- Staph. aureus Infection within alveoli with intense inflammatory responseInfection within alveoli with intense inflammatory response Filling alveoli with bacteria, WBC, exudateFilling alveoli with bacteria, WBC, exudate

30 Which patient groups get which types? PneumococcusPneumococcus Staph aureusStaph aureus KlebsiellaKlebsiella PseudomonasPseudomonas HaemophilusHaemophilus AtypicalAtypical Chlamydia Mycoplasma Legionella

31 Special populations DiabeticsDiabetics HIVHIV Pneumonia more common and has higher morbidity than non-HIV populationPneumonia more common and has higher morbidity than non-HIV population Pneumococcus= Most common bacteriaPneumococcus= Most common bacteria CD4>800: Bacterial more commonCD4>800: Bacterial more common CD : TB, cryptococcus, histoplasmaCD : TB, cryptococcus, histoplasma CD4< 200: PCP, CMVCD4< 200: PCP, CMV Elderly/Nursing homeElderly/Nursing home Predictors for morbidity: Tachycardia, tachypnea, temp>100.4, somnolence, confusion, crackles, leukocytosis Pathogens: Pneumococcus, gram negatives, Haemophilus, influenza May just present with confusion, weakness

32 Pneumonia Chest X-rayChest X-ray Measure O2 sat, CBC, electrolytesMeasure O2 sat, CBC, electrolytes Blood cultures for admitted patients (before antibiotics)Blood cultures for admitted patients (before antibiotics)

33 Treatment Pneumococcal most common, but atypicals becoming more prevalentPneumococcal most common, but atypicals becoming more prevalent OutpatientOutpatient DoxycyclineDoxycycline Newer macrolide (Azithromycin)Newer macrolide (Azithromycin) Fluroquinolone (Levofloxacin)Fluroquinolone (Levofloxacin) Also consider MRSA for severe infectionsAlso consider MRSA for severe infections

34 Treatment InpatientInpatient Early antibiotics lowers mortalityEarly antibiotics lowers mortality 3 rd gen cephalosporin (Ceftriaxone) or PCN w/ beta-lactamase inhibitor (Unasyn/Zosyn) plus macrolide (Azithromycin)3 rd gen cephalosporin (Ceftriaxone) or PCN w/ beta-lactamase inhibitor (Unasyn/Zosyn) plus macrolide (Azithromycin) Fluroquinolone alone (Levofloxacin)Fluroquinolone alone (Levofloxacin) Add pseudomonal coverage (Cefepime) as needed i.e. CF patientAdd pseudomonal coverage (Cefepime) as needed i.e. CF patient

35 Admission or not? 75% CAP do not require admission, can be discharged with follow up75% CAP do not require admission, can be discharged with follow up Admission: Elderly, HIV pts, tachypnea, oxygen requirementAdmission: Elderly, HIV pts, tachypnea, oxygen requirement PORT scorePORT score ICU: Markedly tachypneic, high oxygen requirement, evidence of shockICU: Markedly tachypneic, high oxygen requirement, evidence of shock

36 Case #4 65 yo M with hx of CAD s/p CABG with increasing dyspnea on exertion, orthopnea, increasing swelling in feet and ankles, now today with acute shortness of breath and respiratory distress. No chest pain, no fevers; ROS otherwise negative65 yo M with hx of CAD s/p CABG with increasing dyspnea on exertion, orthopnea, increasing swelling in feet and ankles, now today with acute shortness of breath and respiratory distress. No chest pain, no fevers; ROS otherwise negative Pt in moderate respiratory distress on exam with diffuse crackles in all lung fieldsPt in moderate respiratory distress on exam with diffuse crackles in all lung fields What is your differential diagnosis and approach to this patient?What is your differential diagnosis and approach to this patient?

37 Congestive Heart Failure Can present with acute pulmonary edema and with respiratory distressCan present with acute pulmonary edema and with respiratory distress Due to decreasing CO and rising SVRDue to decreasing CO and rising SVR Sympathetic nervous system and renin- angiotensin-aldosterone system are activatedSympathetic nervous system and renin- angiotensin-aldosterone system are activated Result: Volume overload, pulmonary edema,resp distressResult: Volume overload, pulmonary edema,resp distress

38 Causes of acute decompensation in CHF Non-complianceNon-compliance Medications: diureticsMedications: diuretics Diet: excessive saltDiet: excessive salt CardiacCardiac ArrhythmiaArrhythmia ACSACS Uncontrolled HTNUncontrolled HTN OtherOther Volume overload due to renal failureVolume overload due to renal failure PEPE Exacerbation of other co-morbidity (ex. COPD)Exacerbation of other co-morbidity (ex. COPD)

39 What are some signs and symptoms of CHF?

40 Signs & Symptoms of CHF SymptomsSymptoms Respiratory distressRespiratory distress Cool / diaphoretic skinCool / diaphoretic skin Weight gainWeight gain Peripheral edemaPeripheral edema OrthopneaOrthopnea Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea Abdominal painAbdominal pain SignsSigns Elevated JVD S3 Hypertension Rales +/- peripheral edema +/- RUQ tenderness (congested liver) Tachypnea

41 Evaluation of CHF CXR (portable)CXR (portable) CardiomegalyCardiomegaly Vascular congestionVascular congestion Pulmonary edemaPulmonary edema LabsLabs CBC, electrolytes, cardiac enzymes, BNPCBC, electrolytes, cardiac enzymes, BNP EKGEKG Search for cause of decompensationSearch for cause of decompensation

42 What is the BNP and why do we care? Natriuretic peptide released by RA when heart is stretched i.e. volume overloadNatriuretic peptide released by RA when heart is stretched i.e. volume overload Level correlates with CHF severity, rate of re-hospitalization, and risk of deathLevel correlates with CHF severity, rate of re-hospitalization, and risk of death BNP > 480 = 40% risk of re-hospitalization or death within 6 monthsBNP > 480 = 40% risk of re-hospitalization or death within 6 months Helps to distinguish between other causes of SOB i.e. COPDHelps to distinguish between other causes of SOB i.e. COPD

43 Differential Diagnosis Pulmonary:Pulmonary: Asthma/COPD exacerbationAsthma/COPD exacerbation Pulmonary embolusPulmonary embolus PneumothoraxPneumothorax Pleural effusionPleural effusion PneumoniaPneumonia Cardiac:Cardiac: ACS, arrhythmiaACS, arrhythmia Acute valvular insufficiencyAcute valvular insufficiency Pericardial tamponadePericardial tamponade Fluid retentive states:Fluid retentive states: Liver failure, portal vein thrombosis Renal failure Nephrotic syndrome Hypoproteinemia High output states:High output states: Sepsis Anemia Thyroid dysfunction

44 Treatment Control airway and maintain ventilationControl airway and maintain ventilation Supplemental oxygenSupplemental oxygen Cardiac monitoringCardiac monitoring Pulse oximetryPulse oximetry Establish IV accessEstablish IV access +/- ABG+/- ABG Frequent vital signsFrequent vital signs

45 Which medications are used to treat CHF?

46 Treatment of CHF Preload reductionPreload reduction VasodilatorsVasodilators Inotropic support if neededInotropic support if needed

47 Treatment of CHF Reduce preload and afterload:Reduce preload and afterload: Nitroglycerin by sublingual or IV routeNitroglycerin by sublingual or IV route Volume reductionVolume reduction Lasix- Diuresis starts in minutesLasix- Diuresis starts in minutes If no prior use: 40 mg IVIf no prior use: 40 mg IV Outpatient use: Double last 24 hour usageOutpatient use: Double last 24 hour usage If no effect by 30 minutes, repeat a doubled doseIf no effect by 30 minutes, repeat a doubled dose Clinical endpoint- Rapidly lower filling pressures to prevent need for endotracheal intubationClinical endpoint- Rapidly lower filling pressures to prevent need for endotracheal intubation Place foley catheter and monitor UOPPlace foley catheter and monitor UOP

48 NIPPV Noninvasive Positive Pressure Ventilation Controversial but worth a try in severe respiratory distress Temporizes while medical therapy is working BiPAP may decrease need for intubation Patient cooperation is required

49 The End Any questions?Any questions?


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