differential diagnosis dyspnea

Help me, I can’t breathe!

A differential diagnosis based approach to the patient with dyspnea.

Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP

Good Morning Scotty!

Case 1• Dispatched to a nursing home for a 78 year old

woman with advanced dementia and a cough.

• Pt can’t provide any information.

• NH staff just came on shift but can confirm that she is a full code.

• Pt is more confused than normal. No one knows how long this has been present. They’ve all been on break. For a month.

Case 1• History = Veterinary Medicine. Good luck.

• Exam: Frail, elderly woman with moderate respiratory distress. Intermittent productive cough. Skin is warm to the touch. Tongue is furrowed. Skin is tenting

• VS: BP 88/64, HR 128, RR 28, SaO2 86%, EtCO2 32, T 101. ECG Non-diagnostic sinus tachycardia.

• Lungs: Crackles RLL, scattered wheezing elsewhere.

• Ext: No pitting edema.

Case 1

• Summary: NH resident with chronic illness, fever, tachypnea, tachycardia, hypotension, hypoxia and localized crackles.

• DDX: pneumonia, CHF, COPD exacerbation, pneumonitis, pulmonary fibrosis

Case 1

• ED Evaluation reveals:

• WBC 21K with elevated bands, Cr 3.4, Anion Gap 20, Lactate 9.

Pneumonia• Inflammation of alveoli from infectious source

• Bacteria, viri, fungi

• Classic symptoms:

• Productive cough, fever, dyspnea, chest pain, confusion, SIRS signs

• Classic signs:

• Tachypnea, tachycardia, fever, crackles.

Lung Exam• Crackles (rales) are from delayed opening of

alveoli as result of inflammation and “stickiness”.

• Caused by any disease with stiff or sticky alveoli:

• CHF, fibrosis, PNA, obstructive diseases

• Dullness to percussion

• May be normal or may be normally crappy

Reliability of Lung ExamFinding Kappa Value

Tachypnea 0.25

Increased Tactile Fremitus 0.01

Dullness to precusion 0.52

Decreased BS 0.43

Wheezes 0.51

Crackles 0.41

Kappa Value Strength

0.0 - 0.2 Poor

0.21 - 0.40 Fair

0.41 - 0.60 Moderate

0.61 - 0.80 Good

0.81 - 1.00 Very good

PNA Prediction RulesDiehr, et al.

Rhinorrhea -2

Sore throat -1

Night sweats 1

Myalgias 1

RR > 25 2

T > 100 2>3 = LR + 14.0

Heckerling et al

Add the number present:

Absence of asthma T > 100 HR > 100 Decreased BS Crackles 0 = <1%

1 = 1% 2 = 3% 3 = 10% 4 = 25% 5 = 50%

Probability of PNA:

Pneumonia SeverityCURB-65 Severity Score

Confusion 1

BUN > 19 1

RR > 30 1

SBP <90 or DBP

<60

1

Age > 65 2

Score 30 day mortality

1 2.7%

2 6.8%

3 14.0%

>4 27.8%

A word on sepsis…

http://www.internalizemedicine.com/2012/02/defining-systemic-inflammatory-response-syndrome-sirs-and-sepsis-criteria.html

Case 1: Treatment• Oxygen titrated to correct hypoxia

• Ventilatory support as needed: CPAP, RSI

• IV fluids: NS 20 - 40 ml/kg

• Pressors as needed: norepinephrine 2 - 10 mcg/min for refractory hypotension

• Sepsis Alert.

Case 2

• Called to a home for 57 year old with SOB.

• Sudden onset of dyspnea while cleaning out garage.

• No fever, chest pain or confusion. He has a non-productive, hacking cough.

Case 2• PMH: childhood asthma (no treatment in years), HTN

• Exam: Moderate respiratory distress. Speaking in 2-3 word sentences. Appears frightened. Skin cool, dry. Appears well hydrated. Diffuse expiratory & inspiratory wheezing.

• VS: BP 128/72, HR 108, RR 28, SaO2 90%, EtCO2 46. ECG sinus tach.

• Ext: mild pitting edema bilaterally

Case 2

• Summary: Tachypnea, non-productive cough, no fever, hypoxia, hypercapnia, wheezing and shark-fin pattern on capnography.

• DDX: asthma, FB obstruction, COPD, pneumonia, PTX, CHF, PE

Case 2

• EMS treats with albuterol, ipratropium, oxygen, methylprednisolone and CPAP.

• Subjective improvement in symptoms.

• VS: BP 132/74, HR 106, RR 18, SaO2 97%, EtCO2 36. ECG sinus tach.

Common Causes of CoughChronic Cough

Post-viral cough

Post-nasal drip

Whooping cough

GERD

COPD/Asthma

ACE-inhibitor inducted cough

Acute CoughBronchits/URI

Asthma

Pneumonia

Influenza

COPD

Allergic Rhinitis

Asthma & CO2

• Hyperventilation should lower CO2

• CO2 should be low - normal for mild - moderate asthma.

• When it begins to rise, begin to get very nervous… impending respiratory failure.

Asthma Treatment

Ketamine

Titrated oxygen

Beta-agonists

Anticholinergics

Steroids

CPAP

Magnesium

Intubation as last resort

Case 3

• 35 year old woman complains of acute onset of dyspnea (“I just can’t take a full deep breath”).

• Reports focal, inspiratory chest pain, non-productive cough.

• No fever.

Case 3• History: No prior medical problems. Smoker.

Takes OCPs. Recent long plan trip from Sierra Leone (no fever…calm down).

• VS: BP 92/65, HR 120, RR 33, SaO2 86%, EtCO2 32%, ECG sinus tach

• LS: Clear

• Ext: right calf is swollen, red and tender

Case 3

• Summary: Young woman with recent travel, swollen & tender leg, dyspnea, pleuritic chest pain, tachycardia, hypoxia, hypercapnia.

• DDX: PE, PTX, pericardial effusion, pericarditis, salicylate toxicity, pleuritis

Case 3

Titrated oxygen

IV fluids for pressure support

Vasopressors as neededAnalgesia

CPAP

Pulmonary Embolism

Acute thrombosis of pulmonary arteries.

V/Q mismatch

Decreased LV preload Decreased CO

Shock

Virchow’s Triad

Clotting disorders Hormones

Pregnancy

Surgery

Immobility

Fracture

PE Exclusion RulesPERC Rule

Age < 50

HR < 100

SaO2 > 95%

No hemoptysis, OCP, recent surgery/trauma

No unilateral leg swelling

HAD CLOTSHormoneAge > 50

DVT/PE HistoryCoughing blood

Leg swellingO2 > 95%

Tachycardia (>100)Surgery < 28 days

Case 4

• 17 year old male with sudden onset of dyspnea, pleuritic, non-radiating chest pain.

• Strong odor of marijuana

Case 4• History: No medical problems. Smokes tobacco.

Adamantly denies marijuana use. Adamantly.

• VS BP 112/45, HR 124, RR 28, SaO2 88%, EtCO2 34, ECG sinus tach

• PE: Obvious distress, diaphoretic. BS decreased on right. JVD.

• DDX: PE, asthma,PTX, FB obstruction, aspiration

Important Clinical Finding

Case 6

• 68 y/o male complains of several hours of progressive dyspnea that is associated with dry, non-productive, hacking cough. He denies fever, runny nose or chest pain. He has had this frequently in the past and is on oxygen at night at home.

• PMH: CHF, HTN, COPD, CAD

• Exam: Thin, frail male appears much older than stated age. Moderate respiratory distress. Wearing nasal cannula attached to empty cylinder. Using accessory muscles. 2-3 word sentences.

• VS: BP 145/83, HR 114. RR 30, SaO2 80%, EtCO2 35. ECG afib with RVR

• LS: Expiratory and inspiratory wheezing, diminished in lower lobes.

• Ext: bilateral pitting edema.

• DDX: COPD, CHF, PNA, ACS

COPD Pathophysiology• Chronic, inflammatory disease of bronchi, alveoli and cilia

in response to toxic stimuli.

• Increased mucus production/edema, secretions and bronchospasm.

• Decreased ciliary clearance = infection risk

• Chronic bronchitis: bronchial inflammation, plugging. Relatively intact alveoli.

• Emphysema: alveolar damage w/ distention, loss of recoil, narrowing leads to airway obstruction and blebs.

COPD Pathophysiology

COPD Hyperinflation

Air-Trapping• Inspiratory volume > expiratory volume =

increased lung volume and pressure

• Increased intra-thoracic pressure leads to decreased preload

• Decreased preload leads to hypotension

• Beware hypotension following intubation of COPD patient!

LLSA

All Pts(Hi vs Titr.)

COPD(Hi vs Titr.)

Mortality 9% vs 4% 9% vs 2%

RR Reduction 58% 78%

Summary• Presence of fever

• History is important. Very important

• “HIB/GIA”.

• Lung sounds helpful but not reliable

• Not all dyspnea is respiratory

• CPAP cures what ailes ya!

• Titrate oxygen: use only what the patient needs.

–William J. Meleski, MD

“I’m happy to help.”

jeffjarvis@wilco.org