Help me, I can t breathe!

Transcription

1 Help me, I can t breathe! A differential diagnosis based approach to the patient with dyspnea. Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP

2 Good Morning Scotty!

3 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.

4 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.

5 Case 1 Summary: NH resident with chronic illness, fever, tachypnea, tachycardia, hypotension, hypoxia and localized crackles. DDX: pneumonia, CHF, COPD exacerbation, pneumonitis, pulmonary fibrosis

6 Case 1 ED Evaluation reveals: WBC 21K with elevated bands, Cr 3.4, Anion Gap 20, Lactate 9.

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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.

10 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

11 Reliability of Lung Exam Finding Kappa Value Kappa Value Strength Tachypnea 0.25 Increased Tactile Fremitus Dullness to precusion Decreased BS 0.43 Wheezes 0.51 Crackles Poor Fair Moderate Good Very good

12 PNA Prediction Rules Diehr, et al. Rhinorrhea -2 Sore throat -1 Night sweats 1 Myalgias 1 RR > 25 2 T > >3 = LR Heckerling et al Add the number present: Absence of asthma T > 100 HR > 100 Decreased BS Crackles 0 = <1% 1 = 1% 2 = 3% Probability 3 = 10% of PNA: 4 = 25% 5 = 50%

13 Pneumonia Severity CURB-65 Severity Score Confusion 1 Score 30 day mortality BUN > % RR > % SBP <90 or DBP % Age > 65 2 >4 27.8%

14 A word on sepsis

15 Case 1: Treatment Oxygen titrated to correct hypoxia Ventilatory support as needed: CPAP, RSI IV fluids: NS ml/kg Pressors as needed: norepinephrine 2-10 mcg/ min for refractory hypotension Sepsis Alert.

16 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 nonproductive, hacking cough.

17 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

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19 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

20 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.

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22 Common Causes of Cough Acute Cough Bronchits/URI Asthma Pneumonia Influenza COPD Allergic Rhinitis Chronic Cough Post-viral cough Post-nasal drip Whooping cough GERD COPD/Asthma ACE-inhibitor inducted cough

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24 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.

25 Asthma Treatment Beta-agonists CPAP Steroids Magnesium Titrated oxygen Anticholinergics Ketamine Intubation as last resort

26 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, nonproductive cough. No fever.

27 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

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30 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

31 Case 3 IV fluids for pressure support Analgesia Vasopressors as needed Titrated oxygen CPAP

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33 Pulmonary Embolism Acute thrombosis of pulmonary arteries. V/Q mismatch Decreased LV preload Decreased CO Shock

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36 Virchow s Triad Immobility Surgery Fracture Pregnancy Clotting disorders Hormones

37 PE Exclusion Rules PERC Rule Age < 50 HR < 100 SaO2 > 95% No hemoptysis, OCP, recent surgery/trauma No unilateral leg swelling HAD CLOTS Hormone Age > 50 DVT/PE History Coughing blood Leg swelling O2 > 95% Tachycardia (>100) Surgery < 28 days

38 Case 4 17 year old male with sudden onset of dyspnea, pleuritic, non-radiating chest pain. Strong odor of marijuana

39 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

40 Important Clinical Finding

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44 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.

45 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

46 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.

47 COPD Pathophysiology

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49 COPD Hyperinflation

50 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!

51 LLSA All Pts (Hi vs Titr.) COPD (Hi vs Titr.) Mortality 9% vs 4% 9% vs 2% RR Reduction 58% 78%

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53 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.

54 I m happy to help. William J. Meleski, MD jeffjarvis@wilco.org