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ED Approach to the Dyspneic Patient
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation
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
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
Cases…
Case 1
• 59 yo female• CC:
– left upper chest pain– shortness of breath
• HPI– Sudden onset while watching
television– Increased pain with inspiration– Non productive cough– No fevers or chills– Tried acetaminophen without relief
• PMHx– Hypertension– hypercholesterolemia
Case 1
• Surgical Hx– 2 wks s/p partial colectomy for diverticulitis
• Social Hx– No tobacco, EtOH or drug use– Married– Works in the food industries
• Family Hx– hypertension
Case 1
• ROS: negative
• Vitals: T:37 HR: 62 RR: 20 BP: 120/64 SpO2: 98% room air
• Physical Exam: essentially normal
• Assessment?? Plan?
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
Symptoms of Acute Pulmonary Embolism
Symptoms Massive Emboli Submassive Emboli
(n=197) (n=130)
Chest Pain 85% 82%
Pleuritic 64% 85%
Non Pleuritic 6% 8%
Dyspnea 85% 82%
Apprehension 65% 50%
Cough 53% 52%
Hemoptysis 23% 40%
Sweats 29% 23%
Syncope 20% 4%
Pulmonary Embolism
• Risk factors– Post-op– Inactivity
• casts
– Chronic disease– Hypercoagulable
states• Malignancies• Protein C&S deficiency• Lupus anticoagulants• Estrogen therapy• Factor V Leiden
Signs of Acute Pulmonary EmbolismSigns 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 42% 27%
Edema 23% 25%
Murmur 27% 16%
Cyanosis 25% 9%
Pulmonary Embolism
• ECG findings– S1Q3T3
• 25 % of the time• RV strain
– Tachycardia• Most common
When to test?!?
• Everyone?
• High risk only?
• Who is safe to clinically rule out PE?
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
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
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; 2:1247-1255
Imaging
• CXR
• V/Q Scan
• CT chest
• Angiography
CXR
VQ Scan
Normal excludes PE, otherwise in context of patient
90% sensitive, 95% specific
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):1143-1150
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!
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
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
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?
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
Pathogens
• Typical S pneumoniae, H Flu, Staphylococcus• AtypicalLegionella, Mycoplasma, Chlamydia• EtohKlebsiella pneumoniae• DM/DKAS pneumoniae/S aureus• HIVbased on CD4 count• COPDHaemophilus influenzae/Moraxella
catarrhalis• Sickle CellS pneumoniae/H influenzae
Diagnosis
• History/Physical
• CXR
• CBC
• Blood Cx
• Urine Cx
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?
PNA Severity Score
• Age:– Males: Age – Females: Age -10
• Nursing home : +10• Comorbid illnesses
– Neoplastic disease: +30– Liver disease: +20– CHF: +10– CVA disease: +10– Renal disease: +10
• Physical examination– AMS: +20– RR >30/minute: +20– SBP <90mmHg: +20– Temp <35, >40C: +15– Pulse >125/minute: +10
• Laboratory findings – pH <7.35: +30– BUN >30: +20– Sodium <130 mEq/L: +20– Glucose >250: +10– Hct <30%t: +10– PO2 <60 mmHg: +10– Pleural effusion: +10
PSS30d Mortality Prediciton
Total Score Rank Site or Rx Mortality (%)
None I Outpt 0.1
<70 II Outpt 0.6
71-90 III Outpt 0.9-2.8
90-130 IV Inpt 8.2-9.3
>130 V Inpt 27-29
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
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.
Atypical Pneumonia
RLL Pneumonia
RUL Pneumonia
LUL Pneumonia
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
Case 3
• PMHx: asthma – No prior hospitalizations
• All/Meds: none/albuterol MDI
• Surgical Hx: none
• Social Hx: ½ ppd tobacco, no EtOH or drugs. Single. Waitress
• FHx: COPD
• ROS: negative
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?
Asthma
• chronic, nonprogressive lung disorder characterized by:– Increased airway
responsiveness– Airway inflammation– Reversible airway obstruction
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
Physical Examination
Severe obstruction:– Inability to speak– Use of accessory muscles– Altered mental status– Diaphoresis– The ‘silent chest’
Can we accurately risk stratifyasthma patients with our exam alone?
No… clinicians & patients are notoriouslyinaccurate when assessing severity.
Checking an objective measure of lung function is considered the standard.
Assessment Tools
• Clinical scoring systems
• Peak expiratory flow rates
• Pulse oximetry
• Arterial blood gases
• Chest radiography
• CBC
Peak Expiratory Flow Rates
• Should be measured before and after each treatment
• Easiest test to perform in the ED
Peak Expiratory Flow Rates
• Provides an objective measure– Based on height, age, gender
• Is effort-dependent
• Useful to assess the response to Rx
<25% Severe25%-50% Moderate50%-70% Mild>70% Discharge Goal
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
Arterial Blood Gases
• Respiratory alkalosis typical
• Inaccurate predictor of outcome
• Will seldom alter your treatment plan
• Painful and not free
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
Indications for CXR
• First episode of wheezing
• Unclear diagnosis
• Patients refractory to therapy
• Respiratory failure
• Clinical evidence of infection, pneumothorax, or pneumomediastinum
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
Pharmacotherapy
• Beta-agonists• Corticosteroids• Anticholinergics
Beta Agonists
• Mainstay of acute therapy
• Promote bronchodilation by increasing cAMP
• Primary effect is small airways
• Onset of action < 5 min
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
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
Steroids
• Administer early• Used to treat the
inflammatory component of asthma
• Reduce the rate of relapse and the rate of hospital admission
Oral Versus IV?
• Both routes equally effective– Methylprednisolone 60-125mg IV– Prednisone 1-2mg/kg PO
• Oral route preferred– Easier and faster– Decreases pain/anxiety of IV– Cheaper
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
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
Evidence Supporting the Role of Inhaled Corticosteroids In Controlling Asthma
Singer A. Acad Emerg Med 2005; 45:295-298.
Inhaled Steroids After Discharge?
• Use BID• Always use a spacer• Rinse mouth after use to
reduce complications (dysphonia, S/T, oropharyngeal candidiasis)
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
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
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?
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)
COPD
• Exacerbations– Worsening airflow
obstruction due to• Bronchospasm• Sputum production
(infectious, environmental irritants)
• Cardiovascular deterioration
COPD
• History– Progressive shortness of breath– Increased sputum production– Audible wheezing
• Physical exam– Tachypnea– Hypoxemia– Cyanosis– Agitation – Hypercarbia (confusion, stupor, inadequate respiratory effort)– Sitting up, pursed-lip breathing (PEEP)– Diminished breath sounds, prolonged expiratory phase,
wheezing
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)
COPD Treatment
• Oxygen– Most have baseline sats of 88-91% with mod/severe disease– Hypoxic drive
• Bronchodilation– Beta-agonists i.e. albuterol
• Decrease mucous production– Anticholinergic i.e. atrovent
• Decrease inflammation– Steroid therapy
• Treat infection or underlying cause• Similar to asthma treatment
Combivent or Duoneb
Summary
• Dyspnea = Subjective
• Large differential to consider…– Pulmonary Embolus– Pneumonia– Asthma– COPD– AMI, CHF, Anemia, Tox, pneumothorax,
airway obstruction etc.