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Respiratory Distress
Resident Teaching Conference
July 16, 2010
Outline
• Definitions and Case Presentation
• Review Causes of Respiratory Distress
• Work Up/Evaluation
• Interventions/Management
Respiratory Distress
• Outwardly evident, physically labored breathing– Tachypnea ‐‐
Anxious
– Dyspnea ‐‐
Accessory Muscle Use
– Air Hunger ‐‐
Short Sentences
• Hypoxemic Respiratory Failure– PaO2 <60
• Hypercarbic Respiratory Failure– PaCO2 >45
Mrs. Jones9south: ‘having some difficulty breathing’
• 65 y/o woman
• POD 3 – Low Anterior Resection – Rectal Ca.• PMHx: HTN, HLD, PVD, TIA, Rectal Ca.
• PSHx: LAR, TAH‐BSO (Hormone Replacement)
• SocHx: Tobacco 60 pk yrs, No EtOH, Retired• Exam: AF 110 140/68 28 86% 6LPM
– Generally anxious, sitting upright in bed– Wheezes throughout, Accessory mm use
Other Information….• Hospital Course First event? Nebs?
• Timing if SOB Acute vs. Gradual; Vitals Trend
• Associated Sx Chest Pain/Tightness, Leg Pain
• Meds Heparin Sub‐Q? SCD? (Ambulating?)
• Prior episodes of SOB (pre‐operative)? Admits?
Differential Diagnosis
‐
Pulmonary
‐
Cardiac
‐
Other
Differential Diagnosis• Pulmonary
– Atelectasis– Pulmonary Embolism– Pneumothorax ‐> Central Line? Thoracic Operation?– Pneumonia (CAP vs. HAP vs. VAP)– COPD– Pleural Effusion– Asthma– Aspiration– Mucous Plugging
Differential Diagnosis
• Cardiac– Acute MI
• SOB = Anginal Equivalent– CHF
• Volume Overload
– Tamponade• Aortic Dissection? Trauma? Cardiac Surgery?
Differential Diagnosis
• Other Causes of SOB/Resp. Distress/Desat.– Oversedation
• Anesthesia• Narcotics• Other Sedating Meds
– Phenergan– Benadryl– Benzodiazepines– Ambien
– CO2 Narcosis
Work‐Up
• CXR• ECG• ABG• Cardiac Enzymes
• BNP• HCT• Lytes/Creatinine• Additional Steps: LE Duplex/CT Chest
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
CXR QUIZ
A.
Pneumothorax
B.
Atelectasis
C.
Pulmonary Edema
D.
Pleural Effusions
E.
Pneumonia
F.
Mucous Plugging/Whole Lung Atelectasis
G.
COPD
ECG QUIZ
ABG 101• pH
– Acidemia (<7.35) – Normal – Alkalemia (>7.45)
• PCO2– Low (<35) – Normal – High (>45)
• HCO3 (Calculated)– Normal 24
– Check BMP CO2
ABG QUIZ• 7.21 / 68 / 26
– Acute Respiratory Acidosis
• 7.29 / 30 / 14– Metabolic Acidosis with Resp. Compensation
• 7.20 / 60 / 18– Mixed Metabolic and Respiratory Acidosis
• 7.40 / 65 / 30– Chronic, Compensated Respiratory Acidosis
DO2 = CO x [1.34 x Hb x O2Sat] + [0.003 x PaO2]
Oxygenation vs. Ventilation
PaO2 and O2Sat PCO2
Management ‐
Oxygenation• Supplemental Oxygen
– Nasal Cannula
– Simple Mask
– Venturi Mask
– Non‐Rebreather
Mask
– Intubation
CPAP and BIPAP
• CPAP (PEEP)– Upper airway obstruction (Sleep Apnea)– Maintenance of functional residual capacity
(atelectatsis)
• BIPAP– Rapidly reversible causes of respiratory distress
• Pulmonary Edema
• COPD Exacerbation
9 North and SICU Transfers
• Physiological Instability– Need monitoring or advanced nursing care
• Unclear Etiology– Need further workup/procedures
• Advanced Interventions– CPAP/BIPAP and Intubation
• Lack of Response to Basic Interventions
Review
• Respiratory Distress: Always See the Patient• Focused History and Examination
– Gather Data ‐> Patient, Nurse, Chart• Differential Diagnosis and Interventions• Work‐Up
• Interventions• Notify Upper Level & Consider SICU Transfer