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

DyspneaDyspnea 1

2010-11

Dyspnea

Diagnosis of Dyspnea Diagnosis of Dyspnea

Vicken Y. Totten MD MS, FACEP Vicken Y. Totten MD MS, FACEP FAAFPFAAFP

Associate ProfessorAssociate Professor

Emergency MedicineEmergency Medicine

University Hospitals University Hospitals

Case Medical CenterCase Medical Center

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DyspneaDyspnea – from Latin ‘dyspnoea’ – from Latin ‘dyspnoea’

Dyspnea (also SOB, Dyspnea (also SOB, air hungerair hunger)) subjective symptom of subjective symptom of

breathlessnessbreathlessness.. normal in heavy exertionnormal in heavy exertion pathological if it occurs in pathological if it occurs in

unexpected situations.unexpected situations.

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DefinitionDefinition Dyspnea: unpleasant, subjective Dyspnea: unpleasant, subjective

sensation of abnormal sensation of abnormal respiration. respiration.

Labored breathing - physical Labored breathing - physical presentation of respiratory presentation of respiratory distress/ dyspneadistress/ dyspnea

Many causesMany causes

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Descriptors of Dyspnea Descriptors of Dyspnea

Dyspnea on Exertion (DoE)Dyspnea on Exertion (DoE) Dyspnea after Eating (PPD)Dyspnea after Eating (PPD) Nocturnal DyspneaNocturnal Dyspnea Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea Dyspnea in PregnancyDyspnea in Pregnancy

(hormonal, mechanical) (hormonal, mechanical)

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What is respiratory distress?What is respiratory distress? Vague term meaning “not breathing Vague term meaning “not breathing

well”. A constellation of signs well”. A constellation of signs including: including: using accessory muscles of respirationusing accessory muscles of respiration tachypneatachypnea GaspingGasping Panting Panting restlessnessrestlessness Sometimes, also confusion (hypoxemia)Sometimes, also confusion (hypoxemia) Somnolence (hypercarbia)Somnolence (hypercarbia)

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Respiratory DefinitionsRespiratory Definitions

Eupnea - normal breathingEupnea - normal breathing Bradypnea - decreased breathing rateBradypnea - decreased breathing rate Tachypnea – breathing very fast. Pt Tachypnea – breathing very fast. Pt

not always aware of it.not always aware of it. Apnea – not breathing at allApnea – not breathing at all Hyperpnea - faster and/or deeper Hyperpnea - faster and/or deeper

breathingbreathing Hyperventilation - rapid breathing Hyperventilation - rapid breathing

with hypocarbia with hypocarbia

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Goals of this presentationGoals of this presentation

Discuss dyspnea & Discuss dyspnea & its differential its differential diagnosisdiagnosis

Discuss Discuss pathophysiologypathophysiology

Discuss diagnostic Discuss diagnostic tests for dyspneatests for dyspnea

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My Philosophy of teaching:My Philosophy of teaching:

Me: make it as simple as you can. No Me: make it as simple as you can. No simpler.simpler.

You: Interact, ask questions. You You: Interact, ask questions. You willwill stay awake ;).stay awake ;).

No question is dumb, and the answer No question is dumb, and the answer will be just in front of you.will be just in front of you.

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Principles of Emergency MedicinePrinciples of Emergency Medicine

““Air goes in and out.”Air goes in and out.” ““Blood goes round Blood goes round

and round.”and round.” ““All bleeding stops All bleeding stops

eventually.”eventually.” ““All else is details.”All else is details.” But…the devil is in But…the devil is in

the details.the details.

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What is NOT Dyspnea?What is NOT Dyspnea?

Not the O2 saturation of HemoglobinNot the O2 saturation of Hemoglobin Not the total amount of O2 attached to Not the total amount of O2 attached to

HemoglobinHemoglobin Not the amount of O2 in solution in the Not the amount of O2 in solution in the

blood (the PaO2)blood (the PaO2) Not the respiratory rate, (not all Not the respiratory rate, (not all

tachypnea is dyspnea)tachypnea is dyspnea) But: a subjective sensation of air But: a subjective sensation of air

hunger.hunger.

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Case 1Case 1

47 y/o man c/o dyspnea. SOB, worse on 47 y/o man c/o dyspnea. SOB, worse on exertionexertion

Also admits to mild left sided CP, maybe Also admits to mild left sided CP, maybe respirophasic.respirophasic.

Onset 5-7 days ago. Getting slightly Onset 5-7 days ago. Getting slightly worseworse

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?

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Case 1 – additional historyCase 1 – additional history

PMHx: none. No asthmaPMHx: none. No asthma SHx: Tobacco Smoker. Social drinker. SHx: Tobacco Smoker. Social drinker.

Occasional MJ. Married. No Children. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works Likes to jog, last 5 mi run yest. Works at a desk.at a desk.

ROS: needs to see a dentist. No ROS: needs to see a dentist. No palpitations. No edema. No PND, nor palpitations. No edema. No PND, nor orthopnea. Otherwise negative.orthopnea. Otherwise negative.

What else do you want to know?What else do you want to know?

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Case 1Case 1

V/S: T=36.9; P=85; RR=20; BP 128/79V/S: T=36.9; P=85; RR=20; BP 128/79 HEENT: nlHEENT: nl CHEST: WD, nl excursion, lungs hard to CHEST: WD, nl excursion, lungs hard to

hear, but no rales, ronchi, wheezes. 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?

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

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1: Degree of urgency1: Degree of urgency

Is the patient going to live long Is the patient going to live long enough to give you a history?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.

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2. Assess patient.2. Assess patient.

Is the patient actively trying to Is the patient actively trying to breath? breath? look for mechanical look for mechanical obstruction. Correct it.obstruction. Correct it.

Is patient hypoxic? If yes, Is patient hypoxic? If yes, increase increase FiO2FiO2

Is the patient not able to breathe Is the patient not able to breathe adequately? If no, adequately? If no, supplement supplement respiratory efforts.respiratory efforts.

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3. Locate the problem3. Locate the problem

Causes of air hunger: Causes of air hunger: mechanical, mechanical, metabolic, metabolic, cerebral, cerebral, PsychologicalPsychological

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4. Correct it4. Correct it

Topic for another lectureTopic for another lecture After the (correct) diagnosis is made, After the (correct) diagnosis is made,

treatment is (relatively) simpletreatment is (relatively) simple

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SuspicionSuspicion

You don’t have to know all the You don’t have to know all the diagnoses, but you do have to diagnoses, but you do have to evaluate threat to life evaluate threat to life

Know when & how to intervene.Know when & how to intervene. Understand your tools.Understand your tools. Understand your available Understand your available

interventions.interventions. Know when to get helpKnow when to get help

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Ask (yourself) questions.Ask (yourself) questions.

Can the chest wall support breathing?Can the chest wall support breathing? Are there barriers preventing the air Are there barriers preventing the air

getting through the airway to the getting through the airway to the blood?blood?

Are there metabolic reasons to Are there metabolic reasons to increase respiratory rate?increase respiratory rate?

Is enough blood, of good quality, going Is enough blood, of good quality, going round and round? round and round? if not, assist if not, assist circulationcirculation

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What is the purpose of What is the purpose of respiration: respiration:

Gas exchangeGas exchange To assist in balancing blood (body) To assist in balancing blood (body)

pHpH Lesser extent: temperature Lesser extent: temperature

regulation / cooling the bodyregulation / cooling the body Cellular respiration vs Organism Cellular respiration vs Organism

respirationrespiration

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Abnormal atmosphereAbnormal atmosphere

CO: even small amounts of CO can bind CO: even small amounts of CO can bind with hemoglobin in place of O2 and with hemoglobin in place of O2 and prevent O2 binding (competitive prevent O2 binding (competitive inhibition) 300 times more tightly than inhibition) 300 times more tightly than O2O2

Methemoglobinemia occasionally causes Methemoglobinemia occasionally causes dyspnea; usually just tachypneadyspnea; usually just tachypnea

Heliox: helium instead of nitrogen as the Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow.than nitrogen, slicker, less turbulent flow.

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Other substances Other substances

can injure the airways directlycan injure the airways directly Noxious / toxic gases – work in many Noxious / toxic gases – work in many

different ways and levels.different ways and levels. Allergens – immune system Allergens – immune system

modulatedmodulated Particulates – “smothering”Particulates – “smothering” Irritants – cause bronchospasmIrritants – cause bronchospasm

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Mechanical Airway ObstructionMechanical Airway Obstruction

External: gagging, strangulation, External: gagging, strangulation, smotheringsmothering

Internal: food bolus, other mechanical Internal: food bolus, other mechanical airway obstructions: peanuts, beads, airway obstructions: peanuts, beads,

Internal growths: tumors, infections, Internal growths: tumors, infections, abscessesabscesses

Encroachment on the airwayEncroachment on the airway Internal substances: pus, blood, Internal substances: pus, blood,

mucus, transudatesmucus, transudates

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Muscular / Chest Wall systemMuscular / Chest Wall system

DiaphragmDiaphragm Chest wall musclesChest wall muscles Accessory muscles such as Accessory muscles such as

supraclaviculars, neck muscles.supraclaviculars, neck muscles. Myesthenia, paralysis other muscular Myesthenia, paralysis other muscular

causescauses Increased muscle tension.Increased muscle tension.

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Air to blood interface: Air to blood interface:

Mechanical filling of alveoliMechanical filling of alveoli Lack of surfactant: alveoli collapse with Lack of surfactant: alveoli collapse with

exhalation exhalation Abnormalities (thickening) of alveolar Abnormalities (thickening) of alveolar

membranes,membranes, Interstitium (tissues between the Interstitium (tissues between the

alveolus and the capillary endothelium) alveolus and the capillary endothelium) Capillary endothelium Capillary endothelium Blood: enough of it, flowing well Blood: enough of it, flowing well

enoughenough

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Causes of dyspneaCauses of dyspnea

PsychogenicPsychogenic HypoxicHypoxic MetabolicMetabolic PulmonaryPulmonary CardiogenicCardiogenic HematologicHematologic Any others?Any others?


Tools to evaluate dyspneaTools to evaluate dyspnea

Suspicion / Clinical knowledge. Suspicion / Clinical knowledge. “If you don’t think of it, you will “If you don’t think of it, you will never find it.”never find it.”

HistoryHistory PE including PE including

Vital Signs, pulse ox, PEFVital Signs, pulse ox, PEF Formal StudiesFormal Studies

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What other tools?What other tools?

PEFPEF ABGABG Other blood testsOther blood tests CXRCXR EKGEKG CTCT UltraSoundUltraSound

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Additional items of historyAdditional items of history

CoughCough VomitingVomiting Temporal relationship Temporal relationship What does What does

that mean?that mean? Circadian variationsCircadian variations

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Cough Cough

What good is a cough?What good is a cough? What bad is a cough?What bad is a cough? Central & peripheral triggersCentral & peripheral triggers Air travels in excess of 150 Air travels in excess of 150

kilometers per second during a coughkilometers per second during a cough can denude respiratory epitheliumcan denude respiratory epithelium exposed basement membranes exposed basement membranes

stimulate future antigenic responsestimulate future antigenic response

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AphorismAphorism

Coughing till you vomit is Coughing till you vomit is bronchospasm till proven otherwise. bronchospasm till proven otherwise. Consider cardiac.Consider cardiac.

Vomiting AND THEN coughing -> Vomiting AND THEN coughing -> think aspirationthink aspiration

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Vital SignsVital Signs

What are the VS?What are the VS? Normal vs StableNormal vs Stable How do they change over time?How do they change over time? What does this tell you?What does this tell you?

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Vital SignsVital Signs

The meaning of each value depends The meaning of each value depends on its context. on its context.

A slowing respiratory rate in a bad A slowing respiratory rate in a bad asthmatic may mean he is about to asthmatic may mean he is about to die.die.

A slowing respiratory rate in an A slowing respiratory rate in an anxious bystander may mean he is anxious bystander may mean he is getting better.getting better.

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Vital Signs: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 HR, BP. What do they tell you about

the RR?the RR?

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Pulse OxPulse Ox

What is a dangerous level? Why?What is a dangerous level? Why? When is the pulse ox normal and the When is the pulse ox normal and the

patient about to die? Why?patient about to die? Why? When is the pulse ox bad and the When is the pulse ox bad and the

patient is fine? Why?patient is fine? Why?

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VS - Combinations:VS - Combinations:

High RR, HR, BPHigh RR, HR, BP DiscussionDiscussion Low RR, HR, BPLow RR, HR, BP DiscussionDiscussion High RR, HR, low BPHigh RR, HR, low BP DiscussionDiscussion

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Focused examFocused exam

Accessory musclesAccessory muscles Facial expression, color.Facial expression, color. Chest wall, lungs, heart, abd & extr.Chest wall, lungs, heart, abd & extr. (Discussion)(Discussion)

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Physical ExamPhysical Exam

ObservationObservation Auscultation – with and without a Auscultation – with and without a

stethoscope. Where?stethoscope. Where? Palpation – what & where & why?Palpation – what & where & why? Scratch testScratch test The REST of the exam – habitus, The REST of the exam – habitus,

edema, muscle wasting, lots more.edema, muscle wasting, lots more.


Scratch TestScratch Test Place stethoscope on Place stethoscope on

mediastinum, gently scratch mediastinum, gently scratch the anterior chest wall the anterior chest wall alternate sides, equidistant alternate sides, equidistant from the stethoscope. One from the stethoscope. One side may not transmit side may not transmit sounds as well as the other. sounds as well as the other.

What would the scratch test What would the scratch test tell you? tell you?

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PathophysiologyPathophysiology

chemoreceptors, mechanoreceptors, chemoreceptors, mechanoreceptors, lung receptorslung receptors

3 components that contribute to 3 components that contribute to dyspnea: afferent signals, efferent dyspnea: afferent signals, efferent signals, and central information signals, and central information processing. processing.

brain compares the afferent and brain compares the afferent and efferent signals, and a "mismatch" efferent signals, and a "mismatch" results in the sensation of dyspnea. results in the sensation of dyspnea.

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Afferent neurons Afferent neurons

chemoreceptors chemoreceptors carotid bodies, Various brain organs, carotid bodies, Various brain organs,

juxtacapillary (J) receptors, juxtacapillary (J) receptors, chest wall and its musclesMuscle chest wall and its musclesMuscle

spindles sense stretchspindles sense stretch Lung parenchymal tissues, Lung parenchymal tissues,

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Efferent signals Efferent signals

motor neurons of respiratory motor neurons of respiratory muscles.muscles.

Diaphragm, intercostal, abdominal Diaphragm, intercostal, abdominal muscles, accessory muscles.muscles, accessory muscles.

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Central ProcessingCentral Processing

Objective dataObjective data Subjective dataSubjective data Psychiatric is a diagnosis of exclusionPsychiatric is a diagnosis of exclusion


MRC Breathlessness ScaleMRC Breathlessness Scale GradeGrade

00 1 1 2 2 3 3 44

Degree of dyspnea Degree of dyspnea

no dyspnea except with strenuous exerciseno dyspnea except with strenuous exercise Only when walking up incline or hurryinglOnly when walking up incline or hurryingl Slow on level, or stops after 15 minutes Slow on level, or stops after 15 minutes stops few minutes of walking on the levelstops few minutes of walking on the level minimal activity such as getting dressed, minimal activity such as getting dressed, too dyspneic to leave the housetoo dyspneic to leave the house

The Modified Borg ScaleThe Modified Borg Scale

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Causes of dyspnea Causes of dyspnea

4 general categories:4 general categories: cardiac, cardiac, pulmonary, pulmonary, mixed cardiac or pulmonary, mixed cardiac or pulmonary, Non-cardiac, non-pulmonaryNon-cardiac, non-pulmonary

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Common specific disease entitiesCommon specific disease entities

AsthmaAsthma PneumoniaPneumonia Pleural effusion Pleural effusion Pneumothorax Pneumothorax Interstitial Lung Interstitial Lung

diseasedisease COPD COPD PsychogenicPsychogenic

Pericardial effusionPericardial effusion Cardiac ischemiaCardiac ischemia CHFCHF DysrhythmiaDysrhythmia Mechanical Mechanical

obstructionobstruction AnemiaAnemia

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Blood testsBlood tests

ABGABG Vidas d-DimerVidas d-Dimer BNPBNP Basic Metabolic PanelBasic Metabolic Panel Cardiac EnzymesCardiac Enzymes What else, and why?What else, and why?


Chest radiography (CXR) Chest radiography (CXR)

Insufficient by itselfInsufficient by itself Do your own read: the radiologist may Do your own read: the radiologist may

not know what you are looking for and not know what you are looking for and may overlook the most important clue.may overlook the most important clue.

Look for pneumothorax, aortic Look for pneumothorax, aortic dissection, pneumonia, pleural dissection, pneumonia, pleural effusions, sub-segmental atelectasis, effusions, sub-segmental atelectasis, pulmonary infiltrates or an elevated pulmonary infiltrates or an elevated hemi-diaphragmhemi-diaphragm

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CXR 1CXR 1

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CXR 2CXR 2

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CXR 3CXR 3


ECGECG

Lots of clues as to cause of dyspneaLots of clues as to cause of dyspnea Look for pericarditis (S1Q3T3, right Look for pericarditis (S1Q3T3, right

axis deviation), axis deviation), myocardial infarction, ST segment myocardial infarction, ST segment

elevationelevation new onset atrial fibrillation or right new onset atrial fibrillation or right

heart strainheart strain

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EKGs (TB Inserted)EKGs (TB Inserted)


Arterial Blood Gases (ABG) Arterial Blood Gases (ABG)

Must be interpreted Must be interpreted in contextin context.. ““Complete” ABG includes lactateComplete” ABG includes lactate VBG sometimes very useful.VBG sometimes very useful. When? Why?When? Why?

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ABG and Acid base balance.ABG and Acid base balance.

(This could easily be a few hours’ (This could easily be a few hours’ lecture.)lecture.)

3 important components3 important components pH, CO2 and O2pH, CO2 and O2 pH changes because of both pH changes because of both

metabolic and respiratory causes. metabolic and respiratory causes. Each tries to compensate for Each tries to compensate for abnormalities in the other.abnormalities in the other.

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pHpH

pH should be 7.4. pH should be 7.4. If lower If lower acidotic. acidotic. If higher If higher basic. basic.

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PaCO2 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 CO2 / HCO3 is the end product of

oxidative metabolismoxidative metabolism

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PaO2 PaO2

O2 % (Pulse Ox) = saturation.O2 % (Pulse Ox) = saturation. Should be 85 -100. Should be 85 -100. If lower If lower hypoxic. hypoxic. If higher than 100 If higher than 100 getting more than getting more than

21% or over-breathing seriously.21% or over-breathing seriously.PaO2 is a measure of oxygen carriage. PaO2 is a measure of oxygen carriage.

Oxygen carrying capacity is a function Oxygen carrying capacity is a function of amount of carrier, and carrier of amount of carrier, and carrier saturation.saturation.

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Respiratory Acidosis and AlkalosisRespiratory Acidosis and Alkalosis

Low pH = acidosisLow pH = acidosis Lo pH, high CO2 Lo pH, high CO2 respiratory acidosis respiratory acidosis Lo ph, low CO2 Lo ph, low CO2 metabolic alkalosis metabolic alkalosis High pH = alkalosis High pH = alkalosis Hi pH, low CO2 Hi pH, low CO2 respiratory alkalosis respiratory alkalosis Hi pH, high CO2 Hi pH, high CO2 metabolic alkalosis metabolic alkalosis


Ventilation / Perfusion Scanning Ventilation / Perfusion Scanning (V/Q Scan)(V/Q Scan)

combined with clinical suspicioncombined with clinical suspicion sensitivity is 85 - 90%sensitivity is 85 - 90% positive predictive value depends on positive predictive value depends on

clinical suspicionclinical suspicion More radiation than a CT-PE study.More radiation than a CT-PE study.


CT Scan of the ChestCT Scan of the Chest 2 kinds: rapid helical without contrast. 2 kinds: rapid helical without contrast.

Usual speed, with contrast.Usual speed, with contrast. CT more rapid, safer, detects other CT more rapid, safer, detects other

potential causes of dyspnea with better potential causes of dyspnea with better accuracy than VQaccuracy than VQ

helical CT scanning – no contrast neededhelical CT scanning – no contrast needed Regular PE protocol requires normal Cr Regular PE protocol requires normal Cr

or GFR. Why?or GFR. Why? Always consider Metformin. Why?Always consider Metformin. Why?


Ultrasonography & Ultrasonography & EchocardiographyEchocardiography

Next lectureNext lecture TEE = transesophagyl TEE = transesophagyl

echocardiogram (TEE) is > 90% echocardiogram (TEE) is > 90% sensitive for large clots, very sensitive for large clots, very specific. This, we can’t do yet.specific. This, we can’t do yet.

TTE = TransThoracic TTE = TransThoracic echocardiogram: aortic dissection, echocardiogram: aortic dissection, cardiac tamponade, acute valvular cardiac tamponade, acute valvular lesion. This, we can do.lesion. This, we can do.

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Specific entities:Specific entities:

AsthmaAsthma PneumoniaPneumonia Acute Pulmonary EdemaAcute Pulmonary Edema Pulmonary EmbolismPulmonary Embolism EmphysemaEmphysema Pneumo / hemothoraxPneumo / hemothorax Carbon Monoxide (CO)Carbon Monoxide (CO) Cyanide poisoningCyanide poisoning

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Asthma: Asthma:

Reversible bronchoconstrictuionReversible bronchoconstrictuion Air blocked between the large airways Air blocked between the large airways

to the alveoli. to the alveoli. Alveoli may collapse.Alveoli may collapse. Treatment: open the airways, prevent Treatment: open the airways, prevent

stacking (time enough for exhalation). stacking (time enough for exhalation). Keep O2 high enough to keep patient’s Keep O2 high enough to keep patient’s brain alive. brain alive.

Consider steroids, permissive Consider steroids, permissive hypercarbia.hypercarbia.

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Pulmonary edema: Pulmonary edema:

Basic problem: Heart stretches so far it can’t Basic problem: Heart stretches so far it can’t contract well. (Falls off Frank Starling Curve)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 Caused by cardiac and vascular

derangements.derangements. Vicious cycle.Vicious cycle.

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Pulmonary edema:Pulmonary edema:

Symptoms: Symptoms: Sudden onset; respiratory distress,Sudden onset; respiratory distress, Rales, ronchi. Foamy sputum. Rales, ronchi. Foamy sputum.

Sometimes blood tinged.Sometimes blood tinged. Blood pressure high Blood pressure high

(vasoconstriction) usually 240/120.(vasoconstriction) usually 240/120. If onset between 4 pm and 8 pm, If onset between 4 pm and 8 pm,

likely to be associated with acute MI.likely to be associated with acute MI.

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Pulmonary edemaPulmonary edema

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

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Diabetic KetoAcidosis DKADiabetic KetoAcidosis DKA

Tachypnea often without Air hungerTachypnea often without Air hunger metabolic derangement: blood is too metabolic derangement: blood is too

acid. acid. Respiratory system tries to Respiratory system tries to

compensate, gets overwhelmed.compensate, gets overwhelmed.

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Pneumo / hemo thorax.Pneumo / hemo thorax.

Stuff gets between the inside of the chest Stuff gets between the inside of the chest wall and the lung. Air can’t get in well, wall and the lung. Air can’t get in well, and blood can’t go round and round well and blood can’t go round and round well enough.enough.

Treatment: mechanically remove the Treatment: mechanically remove the stuff that keeps the lung collapsed. stuff that keeps the lung collapsed. Needle, needle with flutter valve, or Needle, needle with flutter valve, or chest tube. chest tube.

Intubation or BVM may make things Intubation or BVM may make things worse, if there is a flap. worse, if there is a flap.

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PneumoniaPneumonia

Infection in the lower airway. Consolidation Infection in the lower airway. Consolidation (fluid in alveoli)(fluid in alveoli)

often only one part of a lung. often only one part of a lung. Generally SICK. Upper, middle and lower Generally SICK. Upper, middle and lower

airways clogged by mucus, often tenacious. 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.

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Pulmonary EmbolismPulmonary Embolism

A blood clot in the pulmonary circulation A blood clot in the pulmonary circulation (often from the systemic venous (often from the systemic venous circulation) blocks. circulation) blocks.

Blood can’t go round and round, so there Blood can’t go round and round, so there is lack of oxygen in the circulating blood. is lack of oxygen in the circulating blood.

Diagnosis: hypoxemia, tachycardia, Diagnosis: hypoxemia, tachycardia, tachypnea, sometimes chest pain.tachypnea, sometimes chest pain.

Treatment: anticoagulation and o2 Treatment: anticoagulation and o2 supplementation. CO2 usually normal. supplementation. CO2 usually normal.

Why is CO2 normal?Why is CO2 normal?

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EmphysemaEmphysema

Not enough lung tissue. That is, a Not enough lung tissue. That is, a paucity of the blood/air interface. paucity of the blood/air interface.

Optimize all functioning tissue. Optimize all functioning tissue. Treatment: new lungs. Treatment: new lungs.

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CO poisoning: CO poisoning:

competitive inhibition of O2 binding competitive inhibition of O2 binding at hemoglobin site. at hemoglobin site.

Treatment: overwhelm the CO with Treatment: overwhelm the CO with 100% O2. 100% O2.

If not good enough, use hyperbaric If not good enough, use hyperbaric O2.O2.

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Cyanide poisoning: Cyanide poisoning:

Mechanism: inhibition of O2 Mechanism: inhibition of O2 utilization at the cellular level. There utilization at the cellular level. There can be plenty of O2 in the air, and in can be plenty of O2 in the air, and in the blood, but the cells can’t use it.the blood, but the cells can’t use it.

Treatment: inactivate the cyanide Treatment: inactivate the cyanide using “BAL” British Anti-Lewisite.using “BAL” British Anti-Lewisite.

Time is of the essenceTime is of the essence

DyspneaDyspnea 76

Summary:Summary:

Dyspnea is a subjectiveDyspnea is a subjective Think systematicallyThink systematically Multiple causes / multiple tools to Multiple causes / multiple tools to

diagnose the problemdiagnose the problem ““When you can’t breathe, not much When you can’t breathe, not much

else matters.”else matters.”

DyspneaDyspnea 77

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Documents

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