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DyspneaDyspnea1 2010-11 Dyspnea Diagnosis of Dyspnea Vicken Y. Totten MD MS, FACEP FAAFP Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency.

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Presentation on theme: "DyspneaDyspnea1 2010-11 Dyspnea Diagnosis of Dyspnea Vicken Y. Totten MD MS, FACEP FAAFP Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency."— Presentation transcript:

1 DyspneaDyspnea1 2010-11 Dyspnea Diagnosis of Dyspnea Vicken Y. Totten MD MS, FACEP FAAFP Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency Medicine University Hospitals Case Medical Center

2 DyspneaDyspnea2 Dyspnea – from Latin ‘dyspnoea’ Dyspnea (also SOB, air hunger) Dyspnea (also SOB, air hunger) subjective symptom of breathlessness. subjective symptom of breathlessness. normal in heavy exertion normal in heavy exertion pathological if it occurs in unexpected situations. pathological if it occurs in unexpected situations.

3 DyspneaDyspnea3 April, 992 Definition Dyspnea: unpleasant, subjective sensation of abnormal respiration. Dyspnea: unpleasant, subjective sensation of abnormal respiration. Labored breathing - physical presentation of respiratory distress/ dyspnea Labored breathing - physical presentation of respiratory distress/ dyspnea Many causes Many causes

4 DyspneaDyspnea4 Descriptors of Dyspnea Dyspnea on Exertion (DoE) Dyspnea on Exertion (DoE) Dyspnea after Eating (PPD) Dyspnea after Eating (PPD) Nocturnal Dyspnea Nocturnal Dyspnea Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea Dyspnea in Pregnancy (hormonal, mechanical) Dyspnea in Pregnancy (hormonal, mechanical)

5 DyspneaDyspnea5 What is respiratory distress? Vague term meaning “not breathing well”. A constellation of signs including: Vague term meaning “not breathing well”. A constellation of signs including: using accessory muscles of respiration using accessory muscles of respiration tachypnea tachypnea Gasping Gasping Panting Panting restlessness restlessness Sometimes, also confusion (hypoxemia) Sometimes, also confusion (hypoxemia) Somnolence (hypercarbia) Somnolence (hypercarbia)

6 DyspneaDyspnea6 Respiratory Definitions Eupnea - normal breathing Eupnea - normal breathing Bradypnea - decreased breathing rate Bradypnea - decreased breathing rate Tachypnea – breathing very fast. Pt not always aware of it. Tachypnea – breathing very fast. Pt not always aware of it. Apnea – not breathing at all Apnea – not breathing at all Hyperpnea - faster and/or deeper breathing Hyperpnea - faster and/or deeper breathing Hyperventilation - rapid breathing with hypocarbia Hyperventilation - rapid breathing with hypocarbia

7 DyspneaDyspnea7 April, 99 Goals of this presentation Discuss dyspnea & its differential diagnosis Discuss dyspnea & its differential diagnosis Discuss pathophysiology Discuss pathophysiology Discuss diagnostic tests for dyspnea Discuss diagnostic tests for dyspnea

8 DyspneaDyspnea8 My Philosophy of teaching: Me: make it as simple as you can. No simpler. Me: make it as simple as you can. No simpler. You: Interact, ask questions. You will stay awake ;). You: Interact, ask questions. You will stay awake ;). No question is dumb, and the answer will be just in front of you. No question is dumb, and the answer will be just in front of you.

9 DyspneaDyspnea9 Principles of Emergency Medicine “Air goes in and out.” “Air goes in and out.” “Blood goes round and round.” “Blood goes round and round.” “All bleeding stops eventually.” “All bleeding stops eventually.” “All else is details.” “All else is details.” But…the devil is in the details. But…the devil is in the details.

10 DyspneaDyspnea10 What is NOT Dyspnea? Not the O2 saturation of Hemoglobin Not the O2 saturation of Hemoglobin Not the total amount of O2 attached to Hemoglobin Not the total amount of O2 attached to Hemoglobin Not the amount of O2 in solution in the blood (the PaO2) Not the amount of O2 in solution in the blood (the PaO2) Not the respiratory rate, (not all tachypnea is dyspnea) Not the respiratory rate, (not all tachypnea is dyspnea) But: a subjective sensation of air hunger. But: a subjective sensation of air hunger.

11 DyspneaDyspnea11 Case 1 47 y/o man c/o dyspnea. SOB, worse on exertion 47 y/o man c/o dyspnea. SOB, worse on exertion Also admits to mild left sided CP, maybe respirophasic. Also admits to mild left sided CP, maybe respirophasic. Onset 5-7 days ago. Getting slightly worse Onset 5-7 days ago. Getting slightly worse What else do you want to know? What else do you want to know? What’s your current differential? What’s your current differential? Admit or Discharge? Admit or Discharge?

12 DyspneaDyspnea12 Case 1 – additional history PMHx: none. No asthma PMHx: none. No asthma SHx: Tobacco Smoker. Social drinker. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works at a desk. SHx: Tobacco Smoker. Social drinker. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works at a desk. ROS: needs to see a dentist. No palpitations. No edema. No PND, nor orthopnea. Otherwise negative. ROS: needs to see a dentist. No palpitations. No edema. No PND, nor orthopnea. Otherwise negative. What else do you want to know? What else do you want to know?

13 DyspneaDyspnea13 Case 1 V/S: T=36.9; P=85; RR=20; BP 128/79 V/S: T=36.9; P=85; RR=20; BP 128/79 HEENT: nl HEENT: nl CHEST: WD, nl excursion, lungs hard to hear, but no rales, ronchi, wheezes. CHEST: WD, nl excursion, lungs hard to hear, but no rales, ronchi, wheezes. Cor: RRR w/o RMG. Cor: RRR w/o RMG. Abd: soft & NT, well muscled. Abd: soft & NT, well muscled. Extr/MS/Neuro/Skin: all wnl. Extr/MS/Neuro/Skin: all wnl. How will you approach this? How will you approach this?

14 DyspneaDyspnea14 Approach to the patient with shortness of breath, or respiratory distress: the emergency approach.

15 DyspneaDyspnea15 1: Degree of urgency Is the patient going to live long enough to give you a history? Is the patient going to live long enough to give you a history? If not, intervene. If not, intervene. If yes, try to make a diagnosis. If yes, try to make a diagnosis.

16 DyspneaDyspnea16 2. Assess patient. Is the patient actively trying to breath?  look for mechanical obstruction. Correct it. Is the patient actively trying to breath?  look for mechanical obstruction. Correct it. Is patient hypoxic? If yes,  increase FiO2 Is patient hypoxic? If yes,  increase FiO2 Is the patient not able to breathe adequately? If no,  supplement respiratory efforts. Is the patient not able to breathe adequately? If no,  supplement respiratory efforts.

17 DyspneaDyspnea17 3. Locate the problem Causes of air hunger: Causes of air hunger: mechanical, mechanical, metabolic, metabolic, cerebral, cerebral, Psychological Psychological

18 DyspneaDyspnea18 4. Correct it Topic for another lecture Topic for another lecture After the (correct) diagnosis is made, treatment is (relatively) simple After the (correct) diagnosis is made, treatment is (relatively) simple

19 DyspneaDyspnea19 Suspicion You don’t have to know all the diagnoses, but you do have to evaluate threat to life You don’t have to know all the diagnoses, but you do have to evaluate threat to life Know when & how to intervene. Know when & how to intervene. Understand your tools. Understand your tools. Understand your available interventions. Understand your available interventions. Know when to get help Know when to get help

20 DyspneaDyspnea20 Ask (yourself) questions. Can the chest wall support breathing? Can the chest wall support breathing? Are there barriers preventing the air getting through the airway to the blood? Are there barriers preventing the air getting through the airway to the blood? Are there metabolic reasons to increase respiratory rate? Are there metabolic reasons to increase respiratory rate? Is enough blood, of good quality, going round and round?  if not, assist circulation Is enough blood, of good quality, going round and round?  if not, assist circulation

21 DyspneaDyspnea21 What is the purpose of respiration: Gas exchange Gas exchange To assist in balancing blood (body) pH To assist in balancing blood (body) pH Lesser extent: temperature regulation / cooling the body Lesser extent: temperature regulation / cooling the body Cellular respiration vs Organism respiration Cellular respiration vs Organism respiration

22 DyspneaDyspnea22 Abnormal atmosphere CO: even small amounts of CO can bind with hemoglobin in place of O2 and prevent O2 binding (competitive inhibition) 300 times more tightly than O2 CO: even small amounts of CO can bind with hemoglobin in place of O2 and prevent O2 binding (competitive inhibition) 300 times more tightly than O2 Methemoglobinemia occasionally causes dyspnea; usually just tachypnea Methemoglobinemia occasionally causes dyspnea; usually just tachypnea Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow. Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow.

23 DyspneaDyspnea23 Other substances can injure the airways directly can injure the airways directly Noxious / toxic gases – work in many different ways and levels. Noxious / toxic gases – work in many different ways and levels. Allergens – immune system modulated Allergens – immune system modulated Particulates – “smothering” Particulates – “smothering” Irritants – cause bronchospasm Irritants – cause bronchospasm

24 DyspneaDyspnea24 Mechanical Airway Obstruction External: gagging, strangulation, smothering External: gagging, strangulation, smothering Internal: food bolus, other mechanical airway obstructions: peanuts, beads, Internal: food bolus, other mechanical airway obstructions: peanuts, beads, Internal growths: tumors, infections, abscesses Internal growths: tumors, infections, abscesses Encroachment on the airway Encroachment on the airway Internal substances: pus, blood, mucus, transudates Internal substances: pus, blood, mucus, transudates

25 DyspneaDyspnea25 Muscular / Chest Wall system Diaphragm Diaphragm Chest wall muscles Chest wall muscles Accessory muscles such as supraclaviculars, neck muscles. Accessory muscles such as supraclaviculars, neck muscles. Myesthenia, paralysis other muscular causes Myesthenia, paralysis other muscular causes Increased muscle tension. Increased muscle tension.

26 DyspneaDyspnea26 Air to blood interface: Mechanical filling of alveoli Mechanical filling of alveoli Lack of surfactant: alveoli collapse with exhalation Lack of surfactant: alveoli collapse with exhalation Abnormalities (thickening) of alveolar membranes, Abnormalities (thickening) of alveolar membranes, Interstitium (tissues between the alveolus and the capillary endothelium) Interstitium (tissues between the alveolus and the capillary endothelium) Capillary endothelium Capillary endothelium Blood: enough of it, flowing well enough Blood: enough of it, flowing well enough

27 DyspneaDyspnea27 Causes of dyspnea Psychogenic Psychogenic Hypoxic Hypoxic Metabolic Metabolic Pulmonary Pulmonary Cardiogenic Cardiogenic Hematologic Hematologic Any others? Any others?

28 DyspneaDyspnea28 April, 99 Tools to evaluate dyspnea Suspicion / Clinical knowledge. “If you don’t think of it, you will never find it.” Suspicion / Clinical knowledge. “If you don’t think of it, you will never find it.” History History PE including PE including Vital Signs, pulse ox, PEF Vital Signs, pulse ox, PEF Formal Studies Formal Studies

29 DyspneaDyspnea29 What other tools? PEF PEF ABG ABG Other blood tests Other blood tests CXR CXR EKG EKG CT CT UltraSound UltraSound

30 DyspneaDyspnea30 Additional items of history Cough Cough Vomiting Vomiting Temporal relationship  What does that mean? Temporal relationship  What does that mean? Circadian variations Circadian variations

31 DyspneaDyspnea31 Cough What good is a cough? What good is a cough? What bad is a cough? What bad is a cough? Central & peripheral triggers Central & peripheral triggers Air travels in excess of 150 kilometers per second during a cough Air travels in excess of 150 kilometers per second during a cough can denude respiratory epithelium can denude respiratory epithelium exposed basement membranes stimulate future antigenic response exposed basement membranes stimulate future antigenic response

32 DyspneaDyspnea32 Aphorism Coughing till you vomit is bronchospasm till proven otherwise. Consider cardiac. Coughing till you vomit is bronchospasm till proven otherwise. Consider cardiac. Vomiting AND THEN coughing -> think aspiration Vomiting AND THEN coughing -> think aspiration

33 DyspneaDyspnea33 Vital Signs What are the VS? What are the VS? Normal vs Stable Normal vs Stable How do they change over time? How do they change over time? What does this tell you? What does this tell you?

34 DyspneaDyspnea34 Vital Signs The meaning of each value depends on its context. The meaning of each value depends on its context. A slowing respiratory rate in a bad asthmatic may mean he is about to die. A slowing respiratory rate in a bad asthmatic may mean he is about to die. A slowing respiratory rate in an anxious bystander may mean he is getting better. A slowing respiratory rate in an anxious bystander may mean he is getting better.

35 DyspneaDyspnea35 Vital Signs: Respiratory rate: Do it yourself! Respiratory rate: Do it yourself! Temp. Don’t trust the Triage Temps. Temp. Don’t trust the Triage Temps. HR, BP. What do they tell you about the RR? HR, BP. What do they tell you about the RR?

36 DyspneaDyspnea36 Pulse Ox What is a dangerous level? Why? What is a dangerous level? Why? When is the pulse ox normal and the patient about to die? Why? When is the pulse ox normal and the patient about to die? Why? When is the pulse ox bad and the patient is fine? Why? When is the pulse ox bad and the patient is fine? Why?

37 DyspneaDyspnea37 VS - Combinations: High RR, HR, BP High RR, HR, BP Discussion Discussion Low RR, HR, BP Low RR, HR, BP Discussion Discussion High RR, HR, low BP High RR, HR, low BP Discussion Discussion

38 DyspneaDyspnea38 Focused exam Accessory muscles Accessory muscles Facial expression, color. Facial expression, color. Chest wall, lungs, heart, abd & extr. Chest wall, lungs, heart, abd & extr. (Discussion) (Discussion)

39 DyspneaDyspnea39 Physical Exam Observation Observation Auscultation – with and without a stethoscope. Where? Auscultation – with and without a stethoscope. Where? Palpation – what & where & why? Palpation – what & where & why? Scratch test Scratch test The REST of the exam – habitus, edema, muscle wasting, lots more. The REST of the exam – habitus, edema, muscle wasting, lots more.

40 DyspneaDyspnea40 April, 99 Scratch Test Place stethoscope on mediastinum, gently scratch the anterior chest wall alternate sides, equidistant from the stethoscope. One side may not transmit sounds as well as the other. Place stethoscope on mediastinum, gently scratch the anterior chest wall alternate sides, equidistant from the stethoscope. One side may not transmit sounds as well as the other. What would the scratch test tell you? What would the scratch test tell you?

41 DyspneaDyspnea41 Pathophysiology chemoreceptors, mechanoreceptors, lung receptors chemoreceptors, mechanoreceptors, lung receptors 3 components that contribute to dyspnea: afferent signals, efferent signals, and central information processing. 3 components that contribute to dyspnea: afferent signals, efferent signals, and central information processing. brain compares the afferent and efferent signals, and a "mismatch" results in the sensation of dyspnea. brain compares the afferent and efferent signals, and a "mismatch" results in the sensation of dyspnea.

42 DyspneaDyspnea42 Afferent neurons chemoreceptors chemoreceptors carotid bodies, Various brain organs, juxtacapillary (J) receptors, carotid bodies, Various brain organs, juxtacapillary (J) receptors, chest wall and its musclesMuscle spindles sense stretch chest wall and its musclesMuscle spindles sense stretch Lung parenchymal tissues, Lung parenchymal tissues,

43 DyspneaDyspnea43 Efferent signals motor neurons of respiratory muscles. motor neurons of respiratory muscles. Diaphragm, intercostal, abdominal muscles, accessory muscles. Diaphragm, intercostal, abdominal muscles, accessory muscles.

44 DyspneaDyspnea44 Central Processing Objective data Objective data Subjective data Subjective data Psychiatric is a diagnosis of exclusion Psychiatric is a diagnosis of exclusion

45 DyspneaDyspnea45 April, 99 MRC Breathlessness Scale Grade Grade 0 1 2 3 4 Degree of dyspnea no dyspnea except with strenuous exercise Only when walking up incline or hurryingl Slow on level, or stops after 15 minutes stops few minutes of walking on the level minimal activity such as getting dressed, too dyspneic to leave the house The Modified Borg Scale

46 DyspneaDyspnea46 Causes of dyspnea 4 general categories: 4 general categories: cardiac, cardiac, pulmonary, pulmonary, mixed cardiac or pulmonary, mixed cardiac or pulmonary, Non-cardiac, non-pulmonary Non-cardiac, non-pulmonary

47 DyspneaDyspnea47 Common specific disease entities Asthma Asthma Pneumonia Pneumonia Pleural effusion Pleural effusion Pneumothorax Pneumothorax Interstitial Lung disease Interstitial Lung disease COPD COPD Psychogenic Psychogenic Pericardial effusion Cardiac ischemia CHF Dysrhythmia Mechanical obstruction Anemia

48 DyspneaDyspnea48 Blood tests ABG ABG Vidas d-Dimer Vidas d-Dimer BNP BNP Basic Metabolic Panel Basic Metabolic Panel Cardiac Enzymes Cardiac Enzymes What else, and why? What else, and why?

49 DyspneaDyspnea49 April, 99 Chest radiography (CXR) Insufficient by itself Insufficient by itself Do your own read: the radiologist may not know what you are looking for and may overlook the most important clue. Do your own read: the radiologist may not know what you are looking for and may overlook the most important clue. Look for pneumothorax, aortic dissection, pneumonia, pleural effusions, sub- segmental atelectasis, pulmonary infiltrates or an elevated hemi-diaphragm Look for pneumothorax, aortic dissection, pneumonia, pleural effusions, sub- segmental atelectasis, pulmonary infiltrates or an elevated hemi-diaphragm

50 DyspneaDyspnea50 CXR 1

51 DyspneaDyspnea51 CXR 2

52 DyspneaDyspnea52 CXR 3

53 DyspneaDyspnea53 April, 99 ECG Lots of clues as to cause of dyspnea Lots of clues as to cause of dyspnea Look for pericarditis (S1Q3T3, right axis deviation), Look for pericarditis (S1Q3T3, right axis deviation), myocardial infarction, ST segment elevation myocardial infarction, ST segment elevation new onset atrial fibrillation or right heart strain new onset atrial fibrillation or right heart strain

54 DyspneaDyspnea54 EKGs (TB Inserted)

55 DyspneaDyspnea55 April, 99 Arterial Blood Gases (ABG) Must be interpreted in context. Must be interpreted in context. “Complete” ABG includes lactate “Complete” ABG includes lactate VBG sometimes very useful. VBG sometimes very useful. When? Why? When? Why?

56 DyspneaDyspnea56 ABG and Acid base balance. (This could easily be a few hours’ lecture.) (This could easily be a few hours’ lecture.) 3 important components 3 important components pH, CO2 and O2 pH, CO2 and O2 pH changes because of both metabolic and respiratory causes. Each tries to compensate for abnormalities in the other. pH changes because of both metabolic and respiratory causes. Each tries to compensate for abnormalities in the other.

57 DyspneaDyspnea57 pH pH should be 7.4. pH should be 7.4. If lower  acidotic. If lower  acidotic. If higher  basic. If higher  basic.

58 DyspneaDyspnea58 PaCO2 should be 40, +/- should be 40, +/- If lower, breathing too much. If lower, breathing too much. If higher, not breathing enough. If higher, not breathing enough. CO2 / HCO3 is the end product of oxidative metabolism CO2 / HCO3 is the end product of oxidative metabolism

59 DyspneaDyspnea59 PaO2 O2 % (Pulse Ox) = saturation. O2 % (Pulse Ox) = saturation. Should be 85 -100. Should be 85 -100. If lower  hypoxic. If lower  hypoxic. If higher than 100  getting more than 21% or over-breathing seriously. PaO2 is a measure of oxygen carriage. If higher than 100  getting more than 21% or over-breathing seriously. PaO2 is a measure of oxygen carriage. Oxygen carrying capacity is a function of amount of carrier, and carrier saturation. Oxygen carrying capacity is a function of amount of carrier, and carrier saturation.

60 DyspneaDyspnea60 Respiratory Acidosis and Alkalosis Low pH = acidosis Low pH = acidosis Lo pH, high CO2  respiratory acidosis Lo pH, high CO2  respiratory acidosis Lo ph, low CO2  metabolic alkalosis Lo ph, low CO2  metabolic alkalosis High pH = alkalosis High pH = alkalosis Hi pH, low CO2  respiratory alkalosis Hi pH, low CO2  respiratory alkalosis Hi pH, high CO2  metabolic alkalosis Hi pH, high CO2  metabolic alkalosis

61 DyspneaDyspnea61 April, 99 Ventilation / Perfusion Scanning (V/Q Scan) combined with clinical suspicion combined with clinical suspicion sensitivity is 85 - 90% sensitivity is 85 - 90% positive predictive value depends on clinical suspicion positive predictive value depends on clinical suspicion More radiation than a CT-PE study. More radiation than a CT-PE study.

62 DyspneaDyspnea62 April, 99 CT Scan of the Chest 2 kinds: rapid helical without contrast. Usual speed, with contrast. 2 kinds: rapid helical without contrast. Usual speed, with contrast. CT more rapid, safer, detects other potential causes of dyspnea with better accuracy than VQ CT more rapid, safer, detects other potential causes of dyspnea with better accuracy than VQ helical CT scanning – no contrast needed helical CT scanning – no contrast needed Regular PE protocol requires normal Cr or GFR. Why? Regular PE protocol requires normal Cr or GFR. Why? Always consider Metformin. Why? Always consider Metformin. Why?

63 DyspneaDyspnea63 April, 99 Ultrasonography & Echocardiography Next lecture Next lecture TEE = transesophagyl echocardiogram (TEE) is > 90% sensitive for large clots, very specific. This, we can’t do yet. TEE = transesophagyl echocardiogram (TEE) is > 90% sensitive for large clots, very specific. This, we can’t do yet. TTE = TransThoracic echocardiogram: aortic dissection, cardiac tamponade, acute valvular lesion. This, we can do. TTE = TransThoracic echocardiogram: aortic dissection, cardiac tamponade, acute valvular lesion. This, we can do.

64 DyspneaDyspnea64 Specific entities: Asthma Asthma Pneumonia Pneumonia Acute Pulmonary Edema Acute Pulmonary Edema Pulmonary Embolism Pulmonary Embolism Emphysema Emphysema Pneumo / hemothorax Pneumo / hemothorax Carbon Monoxide (CO) Carbon Monoxide (CO) Cyanide poisoning Cyanide poisoning

65 DyspneaDyspnea65 Asthma: Reversible bronchoconstrictuion Reversible bronchoconstrictuion Air blocked between the large airways to the alveoli. Air blocked between the large airways to the alveoli. Alveoli may collapse. Alveoli may collapse. Treatment: open the airways, prevent stacking (time enough for exhalation). Keep O2 high enough to keep patient’s brain alive. Treatment: open the airways, prevent stacking (time enough for exhalation). Keep O2 high enough to keep patient’s brain alive. Consider steroids, permissive hypercarbia. Consider steroids, permissive hypercarbia.

66 DyspneaDyspnea66 Pulmonary edema: Basic problem: Heart stretches so far it can’t contract well. (Falls off Frank Starling Curve) Basic problem: Heart stretches so far it can’t contract well. (Falls off Frank Starling Curve) Cardiac oxygen demand exceeds availability. Cardiac oxygen demand exceeds availability. Air can’t cross the air-blood interface. Air can’t cross the air-blood interface. Fluid seeps from the blood into the alveoli. Fluid seeps from the blood into the alveoli. Surfactant gets diluted. Surfactant gets diluted. Caused by cardiac and vascular derangements. Caused by cardiac and vascular derangements. Vicious cycle. Vicious cycle.

67 DyspneaDyspnea67 Pulmonary edema: Symptoms: Symptoms: Sudden onset; respiratory distress, Sudden onset; respiratory distress, Rales, ronchi. Foamy sputum. Sometimes blood tinged. Rales, ronchi. Foamy sputum. Sometimes blood tinged. Blood pressure high (vasoconstriction) usually 240/120. Blood pressure high (vasoconstriction) usually 240/120. If onset between 4 pm and 8 pm, likely to be associated with acute MI. If onset between 4 pm and 8 pm, likely to be associated with acute MI.

68 DyspneaDyspnea68 Pulmonary edema Treatment: increase airway pressure, to force fluids back into the vascular system, (BVM with patient effort, CPAP or intubation) increase FiO2, dilate blood vessels and reduce systemic blood pressure (which reduces the work of the heart and reduces oxygen demand). Get excess fluid off via kidneys (if working), via bleeding (bloodletting) or sequester fluid (tourniquets). Treatment: increase airway pressure, to force fluids back into the vascular system, (BVM with patient effort, CPAP or intubation) increase FiO2, dilate blood vessels and reduce systemic blood pressure (which reduces the work of the heart and reduces oxygen demand). Get excess fluid off via kidneys (if working), via bleeding (bloodletting) or sequester fluid (tourniquets).

69 DyspneaDyspnea69 Diabetic KetoAcidosis DKA Tachypnea often without Air hunger Tachypnea often without Air hunger metabolic derangement: blood is too acid. metabolic derangement: blood is too acid. Respiratory system tries to compensate, gets overwhelmed. Respiratory system tries to compensate, gets overwhelmed.

70 DyspneaDyspnea70 Pneumo / hemo thorax. Stuff gets between the inside of the chest wall and the lung. Air can’t get in well, and blood can’t go round and round well enough. Stuff gets between the inside of the chest wall and the lung. Air can’t get in well, and blood can’t go round and round well enough. Treatment: mechanically remove the stuff that keeps the lung collapsed. Needle, needle with flutter valve, or chest tube. Treatment: mechanically remove the stuff that keeps the lung collapsed. Needle, needle with flutter valve, or chest tube. Intubation or BVM may make things worse, if there is a flap. Intubation or BVM may make things worse, if there is a flap.

71 DyspneaDyspnea71 Pneumonia Infection in the lower airway. Consolidation (fluid in alveoli) Infection in the lower airway. Consolidation (fluid in alveoli) often only one part of a lung. often only one part of a lung. Generally SICK. Upper, middle and lower airways clogged by mucus, often tenacious. Generally SICK. Upper, middle and lower airways clogged by mucus, often tenacious. Fever increases metabolic demand for O2. Fever increases metabolic demand for O2. Treatment: Treatment: Antibiotics if bacterial (Abx) Antibiotics if bacterial (Abx) thin the mucus thin the mucus mechanical ventilation if needed. mechanical ventilation if needed.

72 DyspneaDyspnea72 Pulmonary Embolism A blood clot in the pulmonary circulation (often from the systemic venous circulation) blocks. A blood clot in the pulmonary circulation (often from the systemic venous circulation) blocks. Blood can’t go round and round, so there is lack of oxygen in the circulating blood. Blood can’t go round and round, so there is lack of oxygen in the circulating blood. Diagnosis: hypoxemia, tachycardia, tachypnea, sometimes chest pain. Diagnosis: hypoxemia, tachycardia, tachypnea, sometimes chest pain. Treatment: anticoagulation and o2 supplementation. CO2 usually normal. Treatment: anticoagulation and o2 supplementation. CO2 usually normal. Why is CO2 normal? Why is CO2 normal?

73 DyspneaDyspnea73 Emphysema Not enough lung tissue. That is, a paucity of the blood/air interface. Not enough lung tissue. That is, a paucity of the blood/air interface. Optimize all functioning tissue. Optimize all functioning tissue. Treatment: new lungs. Treatment: new lungs.

74 DyspneaDyspnea74 CO poisoning: competitive inhibition of O2 binding at hemoglobin site. competitive inhibition of O2 binding at hemoglobin site. Treatment: overwhelm the CO with 100% O2. Treatment: overwhelm the CO with 100% O2. If not good enough, use hyperbaric O2. If not good enough, use hyperbaric O2.

75 DyspneaDyspnea75 Cyanide poisoning: Mechanism: inhibition of O2 utilization at the cellular level. There can be plenty of O2 in the air, and in the blood, but the cells can’t use it. Mechanism: inhibition of O2 utilization at the cellular level. There can be plenty of O2 in the air, and in the blood, but the cells can’t use it. Treatment: inactivate the cyanide using “BAL” British Anti-Lewisite. Treatment: inactivate the cyanide using “BAL” British Anti-Lewisite. Time is of the essence Time is of the essence

76 DyspneaDyspnea76 Summary: Dyspnea is a subjective Dyspnea is a subjective Think systematically Think systematically Multiple causes / multiple tools to diagnose the problem Multiple causes / multiple tools to diagnose the problem “When you can’t breathe, not much else matters.” “When you can’t breathe, not much else matters.”

77 DyspneaDyspnea77 REFERENCES Saracino A (October 2007). "Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?". Emerg Med Australas 19 (5): 394–404. Saracino A (October 2007). "Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?". Emerg Med Australas 19 (5): 394–404. Stenton C (2008). "The MRC breathless scale.". Occup Med 58 (3): 226–7. doi:10.1093/occmed/kqm162. PMID 18441368. Stenton C (2008). "The MRC breathless scale.". Occup Med 58 (3): 226–7. doi:10.1093/occmed/kqm162. PMID 18441368.doi10.1093/occmed/kqm162 PMID18441368doi10.1093/occmed/kqm162 PMID18441368 Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990. Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990. Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed. Baltimore: Williams & Wilkins, 1986. Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed. Baltimore: Williams & Wilkins, 1986. Tobin MJ. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med 1990;150:1604-13. Tobin MJ. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med 1990;150:1604-13. Silvestri GA, Mahler DA. Evaluation of dyspnea in the elderly patient. Clin Chest Med 1993;14:393-404. Silvestri GA, Mahler DA. Evaluation of dyspnea in the elderly patient. Clin Chest Med 1993;14:393-404. Cockcroft A, Adams L, Guz A. Assessment of breathlessness. Q J Med 1989;72:669-76. Cockcroft A, Adams L, Guz A. Assessment of breathlessness. Q J Med 1989;72:669-76. Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med 1993;8:383-92. Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med 1993;8:383-92. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997. Fauci AS, ed. Harrison's Principles of internal medicine. 14th ed. New York: McGraw-Hill, 1997. Fauci AS, ed. Harrison's Principles of internal medicine. 14th ed. New York: McGraw-Hill, 1997. Enright PL, Hyatt RE, eds. Office spirometry: a practical guide to the selection and use of spirometers. Philadelphia: Lea & Febiger, 1987:253. Enright PL, Hyatt RE, eds. Office spirometry: a practical guide to the selection and use of spirometers. Philadelphia: Lea & Febiger, 1987:253. Baum GL, Wolinsky E, eds. Textbook of pulmonary diseases. 4th ed. Boston: Little, Brown, 1989: 1595-2102. Baum GL, Wolinsky E, eds. Textbook of pulmonary diseases. 4th ed. Boston: Little, Brown, 1989: 1595-2102. Rubenstein E, Federman DD, eds. Respiratory medicine. In: Scientific American medicine. New York: Scientific American, 1995. Rubenstein E, Federman DD, eds. Respiratory medicine. In: Scientific American medicine. New York: Scientific American, 1995.


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