What do you do when you re called to see someone with: DYSPNEA. Kenneth P. Steinberg, M.D. Professor of Medicine University of Washington

Transcription

1 What do you do when you re called to see someone with: DYSPNEA Kenneth P. Steinberg, M.D. Professor of Medicine University of Washington

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3 Overview and Learning Goals l Mechanisms l Bedside evaluation l Emergency care

4 DYSPNEA: A definition l An abnormal or uncomfortable sensation of breathing. l A subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity

5 Patients with Dyspnea l Type 1 diabetic with nausea & vomiting l Alcoholic man with acute GI bleed l Chronic liver failure with ascites l College student with severe diarrhea l Elderly woman with CHF l Medical student with pneumonia l Hospitalized man with a PE l Young woman with a pneumothorax l Senator with COPD Why do they all have the same symptom?

6 Pathophysiology l The respiratory system is designed to maintain homeostasis with respect to gas exchange and acid-base status with the least amount of work possible. l Derangements in this balance or in the work required to maintain homeostasis can result in dyspnea.

7 Important Components of the Respiratory System l Brain l Spinal Cord l Nerves l Muscles l Chest Wall l Diaphragm l Pleura l Airways l Alveoli l Heart l Blood Vessels l Blood even the mighty Mitochondria!

8 Pathophysiology Many conditions have more than one mechanism l Increased central drive (dz, meds, psych) l Excess respiratory muscle work (WOB) l Poor airflow and lung stretch l Gas exchange & metabolic demand l Oxygenation of the blood (hypoxemia) l Oxygen delivery to the tissues (tissue hypoxia) l CO 2 clearance (hypercapnia) l Acid production (metabolic acidosis)

9 Case #1 l You are the Night Medicine intern. The RN calls you at 2:30 AM to report that Ms. Petunia Acco, a 68 yo woman admitted 5 days ago for CAP and a mild COPD flare, has worsening dyspnea. The nurse asks you what you would like to do. l You check your sign-out.

10 Case #1 Patient Problem List/PMH Meds Signout Acco, Petunia 68 yo W Code: full NKDA HD 5 CAP, mild COPD flare STABLE Mitral stenosis CAD h/o NSTEMI CHF Hyperlipidemia COPD h/o DVT Osteoarthritis IV antibiotics Prednisone Albuterol/ipratr opium ASA Simvastatin Lisinopril Metoprolol Furosemide KCl WBC improving BCxs negative SCx nonspecific R subclavian line placed today NTD

11 Case #1 - DDx l COPD exacerbation l Progressive pneumonia, ALI/ARDS l Pneumothorax l Pulmonary edema, CHF,?ischemia vs. volume overload l Pulmonary embolus

12 What would you do next? l Order furosemide 40 mg IV x 1 l Order CT angiogram l Go see her l Stop her IV fluids l Activate the cath lab

13 When Called about Dyspnea: Key First Steps l On the phone, ask for: l Vital signs l Oxygen saturation l Mental status / distress l Background - Did something just happen? l Think: What do you want prior to your arrival? l Oxygen, monitor, IV? l Albuterol? l ABG, ECG, CXR, etc? l You must see the patient!

14 Case #1 - Exam l In moderate respiratory distress l T 37.4, HR 108, BP 128/67, RR 24, SpO 2 91% on 4 lpm NC l No JVD l Lungs with right basal crackles, occasional soft wheeze with good airflow l Bilateral pretibial pitting edema, 1+ on the right, trace on the left l What would you order next?

15 Please don t order the CXR as: F/U F/U SOB

16 Case # 1 - Data l CXR - RLL focal opacity unchanged from admission, no evidence of worsening CHF or PTX l ABG /34/62 on 4 lpm NC (baseline on 2 lpm NC was 7.39/43/78) l ECG: no ST-T wave changes, no ischemic changes, no changes from baseline l What next??

17 Three PILLARS of Care for Patients with Dyspnea Primary Safety Net l Oxygen l IV access l Monitors Vital Signs l Pulse l BP l RR l Temp l SpO 2 (ABG) l Mental status Survey A B C D E

18 Dyspnea: A B C D E l Airway l Partial Obstruction l Breathing (Lung) l Asthma, Atelectasis, COPD, Pleural Effusion, Pneumonia, Pneumothorax, Other Infiltrative Processes l Circulation l Anemia, Arrhythmia, CHF, Ischemia, Pericardial Effusion, Shock, PE l Deficits l Neuro & Musculoskeletal Abnormalities (e.g., Myasthenia gravis, Scoliosis) l Electrolytes/extras l Abdominal disorders, Acidosis, Sepsis, Anxiety, Over-feeding, Electrolyte Abnormalities (K+, Phosphate)

19 Case #1 What would you do? l Order a BNP l Order a D-dimer l Order a CT pulmonary angiogram l Order a V/Q scan l Order an echocardiogram

20 Wells Clinical Prediction Model ITEM Wells, et. al. Thromb Haemost 2000;83: POINTS Clinical signs and sx of DVT 3 Alternative dx less likely than PE 3 HR > Immobilization or surgery in past 4 weeks 1.5 Previous PE/DVT 1.5 Hemoptysis 1 Malignancy (on treatment, treated in last 6 months, or receiving palliative care) Probability: Low < 2 points, Mod 2-6 points, High >6 points High

21 Revised Geneva Score Variable Points l l l Risk factor l Age > 65y 1 l Prev. VTE 3 l Recent surgery of Fx 2 l Active malignancy 2 Symptoms l Unilateral leg pain 3 l Hemoptysis 2 Clinical signs l HR bpm 3 l HR 95 5 l LE edema and/or 4 pain on palpation of LE Score Low risk = 0-3 Intermed. = 4-10 High risk = 11 Case # 1 = 13 Le Gal G, et al. Ann Intern Med 2006; 144:

22 D-dimer l Properly used when clinical suspicion is low l If negative, no further tests necessary l If further tests are planned anyway, no need for D-dimer l Positive result is not diagnostic l Chance of negative result decreases with age and comorbid disease l May be unreliable in inpatients

23 PIOPED II Why Clinical Scoring is Necessary Prevalence of PE by Clinical Probability and CTPA Findings True Positive Low 38 7 Moderate High 99 CTA Positive CTA Negative Wells Clinical Probability Score

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25 VTE: Diagnostic Strategy l Determine Pre-Test Probability l Well s score, Revised Geneva score l Pisa Model l Basic Studies: ECG, CXR,? ABG l D-Dimer: probably not helpful for inpatients l Follow a diagnostic algorithm l V/Q Scan vs. LE Duplex vs. CTPA l Always ask: should therapy be started?

26 Case #2 l You are the Night Medicine intern. The RN calls you at 3:30 AM to report that Mr. William Pallor, a 65 yo man admitted early today for an anemia of unclear etiology and COPD has worsening dyspnea. The nurse asks you what you would like to do. l You check your sign-out.

27 Case #2 Patient Problem List/PMH Meds Signout Pallor, William 65 yo M Med Flr rm 2 Code: full NKDA Anemia, HCT 22% COPD, GOLD stage 3 Prednisone Albuterol/ipratr opium s/q heparin Anemia workup ongoing. Does not appear to be GI source. HD 1 anemia of unclear etiology, mild COPD flare NTD

28 Case # 2 - DDx l A l B Worsening COPD, Pneumonia, Aspiration of gastric contents l C Worsening anemia, CHF, ACS l D l E Sepsis

29 What would you do next? l Order furosemide 40 mg IV x 1 l Order 2 u PRBC stat l Order a direct/indirect Coomb s test l Activate the cath lab l Go see him

30 CASE #2 l EXAM: older, ill, overweight male, AOx3. l VS: P 110, BP 160/105, RR 22, T 38.1 C, SpO2 89% on RA l Respiratory distress, diaphoretic, wheezes and rhonchi with scattered crackles and prolonged expiratory phase. No JVD, distant heart sounds, no peripheral edema. l How would you care for him now?

31 What would you not order now? l Bedside spirometry l ABG l Repeat HCT l CXR l Oxygen l ABG 7.29/54/58/27 l HCT 21% l CXR changes c/w hyperinflation but no new opacities or edema

32 COPD: Acute Therapy l Oxygen l Albuterol / Atrovent l Corticosteroids: for non-icu, start 40 mg PO prednisone or IV methylprednisolone l Limited-spectrum antibiotics l? Diuretics dry lungs are happy lungs! l Non-Invasive Ventilation l NPPV, BiPAP l Intubation & mechanical ventilation

33 Other Considerations: COPD l Bedside spirometry usually not helpful l ABG usually needed l CXR & ECG usually needed l Consider: MI, PE, pneumonia, CHF, pneumothorax,

34 Oxygen Saturation Goals l Most patients l SpO2 92% l Neurological dz, myocardial injury, pregnancy, severe anemia l SpO2 94% l COPD patients l at risk for CO 2 retention l What s their baseline? l SpO % l Both over- and under-oxygenation are bad!

35 Case # 3 l 82 yo man with a PMH of dementia l Admitted with fever and a decubitus ulcer over his sacrum, receiving wound care, pipercillin/tazobactam and enteral nutrition l You are called to come see him for dyspnea l DDx?

36 Case # 3 - DDx l A Mucus plug l B Pneumonia, Aspiration of gastric contents l C Volume overload, Pulmonary embolus l D Respiratory muscle fatigue l E Sepsis, Overfeeding

37 Case # 3 - Exam l Somnolent but awake, in moderate respiratory distress l T 38.8, HR 110, BP 95/67, RR 38, SpO 2 97% on 4 lpm O 2 via NC l No JVD l Lungs with a few bibasilar rhonchi, no crackles, no wheezing l Bilateral trace pretibial pitting edema

38 Case # 3 - Data l CXR low lung volumes, clear l ECG: ST, no ischemic changes, no changes from baseline l What next??

39 Case # 3 - Data l ABG 7.47 / 25 / 89 (RA) l What next?? l Basic metabolic panel Sepsis Primary respiratory alkalosis Anion gap metabolic acidosis

40 Case # 4 l You are on long-call and get paged to the ED at 10:58 PM to admit Kristi Leeds l 37 yo W with SLE, Evan s syndrome (AIHA + thrombocytopenia) with recent flares of her AIHA requiring aggressive immunosuppression (MMF, Cytoxan, Rituxan, steroids) l Baseline HCT 18 21% l Came in with severe progressive dyspnea on exertion a/w chest heaviness & lightheadedness l In ED, HCT = 19%. You re called to admit.

41 Case # 4 - Exam l Meds: MMF, Prednisone, Dapsone, Folate l Awake and alert, slightly increased WOB l T 37.1, HR 106, BP 130/84, RR 20, SpO % on 2 5 lpm NC l No JVD l Lungs: clear l 2/6 SEM but no gallop l Extremities: no cyanosis or edema

42 Case # 4 Initial data l CXR clear l ECG sinus tach, no acute changes l HCT 19% l Basic metabolic panel l ABG 7.36 / 30 / 92 (2 lpm NC) l What next?

43 Case # 4: What would you do next? l CT pulmonary angiogram l Transfuse 2 u PRBC l Intubate for impending hypoxemic respiratory failure l Order a repeat blood gas with a co-oximetry panel l Order blood cultures and broad-spectrum antibiotics

44 Case # 4 l Methemoglobin level = 19.6%!!! l Methylene blue 50 mg IV given l Dapsone discontinued

45 Non-Cardiopulmonary Causes Don t forget em! l Metabolic acidosis l Sepsis l Anemia l Absolute l Relative (e.g., methemoglobinemia) l Ascites l Neuromuscular disease l Anxiety

46 Summary l Mechanisms l Bedside evaluation l Emergency care

47 Three PILLARS of Care for Patients with Dyspnea Primary Safety Net l Oxygen l IV access l Monitors Vital Signs l Pulse l BP l RR l Temp l SpO 2 (ABG) l Mental status Survey A B C D E

48 Dyspnea: A B C D E l Airway l Partial Obstruction l Breathing l Asthma, Atelectasis, COPD, Pleural Effusion, Pneumonia, Pneumothorax, Other Infiltrative Processes l Circulation l Anemia, Arrhythmia, CHF, Ischemia, Pericardial Effusion, Shock, PE l Deficits l Neuro & Musculoskeletal Abnormalities (e.g., Myasthenia gravis, Scoliosis) l Electrolytes/extras l Abdominal disorders, Acidosis, Sepsis, Anxiety, Over-feeding, Electrolyte Abnormalities (K+, Phosphate)

49 Thank you!

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51 Case # 5 l 48 yo man with a PMH of C3 HIV l Admitted for severe PJP, was intubated for 12 days, extubated 4 hours ago l You are called for worsening dyspnea l DDx?

52 Case # 5 - DDx l Pneumothorax l Recurrent PCP l Volume overload l Pulmonary embolus l Aspiration of gastric contents l Mucus plug l Respiratory muscle fatigue

53 Case # 5 - DDx l A Mucus plug, UAO/stridor l B Pneumothorax, Aspiration of gastric contents, Worsening PJP l C Volume overload, Pulmonary embolus l D Respiratory muscle fatigue l E Sepsis

54 Case # 5 - Exam l Somnolent but awake, in moderate respiratory distress l T 36.8, HR 110, BP 155/97, RR 38, SpO2 87% on 50% Venti-mask l No JVD l Lungs with bibasilar rhonchi and crackles, no wheezing l Bilateral trace pretibial pitting edema

55 Case # 5 - Data l CXR - bilateral patchy opacities l ABG /64/56 on 50% Venti-mask l ECG: ST, no ischemic changes, no changes from baseline l What next?? l Can we use NPPV?

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57 Post-Extubation Respiratory Failure l Upper airway obstruction l Subglottic and/or laryngeal edema l Pulmonary edema secondary to increased venous return l Respiratory muscle fatigue l Excess work of breathing l Aspiration or mucus plugging Almost always requires reintubation!