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: HPI PMHx 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 Social Hx Family 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 dx’d
30% mortality if not dx’d
High index of suspicion
1.5 million DVTs per year. 30% of those go onto symptomatic PE, 30% asymptomatic, the other 40% no PE sequelae
Dx’d = diagnosed

9. Symptoms of Acute Pulmonary Embolism
Massive Emboli
Submassive Emboli
(n=197)
(n=130)
Chest Pain
85%
82%
Pleuritic
64%
Non Pleuritic 6% 8%
Dyspnea
Apprehension
65%
50%
Cough
53%
52%
Hemoptysis
23%
40%
Sweats
29%
Syncope
20% 4%
Classic findings are not so sensitive…

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

11. Signs of Acute Pulmonary Embolism
Massive PE
Submassive PE
RR > 16/min
95%
87%
Rales
57%
60%
Increased S2
58%
45%
HR >100/min
48%
38%
Temp > 37.8
43%
42%
Phlebitis
36%
26%
Gallop
39%
25%
Diaphoresis
27%
Edema
23%
Murmur
16%
Cyanosis 9%
97% one of the following: Chest pain, RR > 20, Dyspnea

12. Pulmonary Embolism ECG findings S1Q3T3 Tachycardia 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/Well’s Criteria Clinical rules to limit testing
Low risk pts have false positive rates and morbidity/mortality with treatment
Directs when to work-up

15. Wells et al. Ann Int Med 2001; 135:98-107
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. Normal excludes PE, otherwise in context of patient
VQ Scan
Normal excludes PE, otherwise in context of patient

20. 90% sensitive, 95% specific

24. Konstantinides et al NEJM 2002;347(15):1143-1150
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 = don’t 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 Physical examination Age: Nursing home : +10
AMS:
RR >30/minute:
SBP <90mmHg:
Temp <35, >40C:
Pulse >125/minute:
Laboratory findings
pH <7.35:
BUN >30:
Sodium <130 mEq/L:
Glucose >250:
Hct <30%t:
PO2 <60 mmHg:
Pleural effusion:
Age:
Males: Age
Females: Age -10
Nursing home :
Comorbid illnesses
Neoplastic disease:
Liver disease:
CHF:
CVA disease:
Renal disease:

34. PSS 30d Mortality Prediciton
Total Score
Rank
Site or Rx
Mortality (%)
None I
Outpt
0.1
<70 II
0.6
71-90
III
90-130 IV
Inpt
>130 V
27-29

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 All/Meds: none/albuterol MDI Surgical Hx: none
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 Oral route preferred
Methylprednisolone mg IV
Prednisone 1-2mg/kg PO
Oral route preferred
Easier and faster
Decreases pain/anxiety of IV
Cheaper
Indications for IV steroids:
Severe asthma attack, ie dyspnea, use of accessory muscles
Nausea/vomiting

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. Evidence Supporting the Role of Inhaled
Corticosteroids In Controlling Asthma
The emergency physician can use the “rule of two” to determine if a patient’s 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
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 Physical exam 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 Bronchodilation Decrease mucous production
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.
Discussed more of the common complaints