ed approach to the dyspneic patient
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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: - PowerPoint PPT PresentationTRANSCRIPT
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.