EAJEM-22932: Araştırma Makalesi. Acute onset of breathlessness in emergency department. Page 1 / 15. JournalAgent powered by LookUs

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1 EAJEM-22932: Araştırma Makalesi Acute onset of breathlessness in emergency department AIM: Acute onset of breathlessness is one of the most common potentially life threatening situations with which patients presents to the ER. The aim is to analyze the most common cause of breathlessness and to compare the provisional diagnosis made with the final diagnosis at the time of discharge and to identify the Arterial Blood Gas (ABG) profile in patients presenting with dyspnea to the department of Emergency Department (ED) MATERIALS & METHODS: A cross sectional study was conducted from the medical records of Amrita Institute of Medical Sciences, Kochi, Kerala, India (Tertiary care center). A total of 150 patients were selected dated between 1st March 2009 and 28th February 2011 from the medical records. The data analyzed using SPSS software. Agreement between the provisional diagnosis and final diagnosis was studied by applying Mc Nemars Chisquare test. RESULTS 22% of the study subjects were diagnosed to have pulmonary edema. Pneumonia was the second most common diagnosis constituting 20% of the study population, followed by congestive cardiac failure (12%), COPD (8.7%) and Bronchial Asthma (5.3%). Further analysis using the Mc Nemar Chi Square test found sensitivity of 87.87% and specificity of 93.1%. CONCLUSION: Pulmonary edema was commonest diagnosis of breathlessness in people presenting to the ER that required hospitalization followed by pneumonia, congestive cardiac failure, COPD, bronchial asthma respectively. In more than three fourth of cases initial diagnosis in the ER and final diagnosis at discharge were the same. One third of the people with acute breathlessness had a normal ABG. Key words: Breathlessness, Dyspnoea, Pulmonary edema, COPD, Bronchial asthma, congestive cardiac failure 30 Ref.No: EAJEM Makale Grubu: Makale Türü: Araştırma Makalesi Kayıt Tarihi: :56:24 Page 1 / 15

2 35 Original Files Tam Metin Acute onset of breathlessness Kayıt Tarihi: :39: ACUTE ONSET OF BREATHLESSNESS IN THE EMERGENCY DEPARTMENT INTRODUCTION: Acute onset of breathlessness is one of the most common and potentially life threatening situations with which patients presents to the ER (1). It s alarming to most patients and can arouse great concern about that prompts patients to seek medical evaluation. The range and diversity of pathophysiologic states that produce dyspnea make a simple algorithmic approach difficult. Any initial stabilization and assessment, findings from the history, physical examination and ancillary testing are collected to match patterns of disease that produce dyspnea (2). Dyspnea is most commonly caused by wide variety of conditions like respiratory and cardiac disorders. Other causes may be upper airway obstruction, metabolic acidosis, a psychogenic disorders or a neuromuscular condition. This may indicate a serious and imminently life threatening stage of a disease. At the same time diagnosing the reason for dyspnea requires a significant number of lab studies. The result of most of these studies take time and hence are not available to the ER physician to aid diagnosis. So this study attempts to categorize and quantify the various causes of acute onset of breathlessness in patients presenting to the Emergency Department. It also explores the accuracy of diagnosis made in the ER by a short and directed, history and physical examination; and investigations that are readily available for interpretation to the ER physician. OBJECTIVES: To determine the diagnostic spectrum of people presenting with acute onset of breathlessness. The secondary objective is to compare the the provisional diagnosis made at the time of discharge and to identify the Arterial Blood Gas (ABG) profile in patients presenting with dyspnea to the department of Emergency Department (ED). STUDY TYPE & SETTING: This study is a cross sectional observational study, which consisted of patients presented to the Emergency medicine at Amrita institute of medical sciences, Kochi, Kerala with complaints of breathlessness during the period of 1 st March 2009 and 28 th February 2011 after fulfilling the inclusion and exclusion criteria. Page 2 / 15

3 SAMPLE SIZE: Based on the available information on the most common problem (respiratory infection) in patients presenting with breathlessness (prospective audit of breathlessness in hospitalized patients Singapore med J (1): 21) (3) and with 95% confidence interval and 20% allowable error, minimum sample size is computed as 220. However due to the availability of cases satisfying the inclusion and exclusion criteria the present study is restricted to 150 cases. Consecutive sampling was adopted for recruiting the study subjects. INCLUSION CRITERIA: Any person 18 years of age and above presenting to the Emergency Room of Amrita Institute of Medical Sciences with complaints of acute onset of breathlessness (onset within 48 hours) requiring hospitalization. EXCLUSION CRITERIA: Cases if acute onset of breathlessness not requiring hospitalization as well as improperly documented case sheets were excluded from the study. DATA COLLECTION: After authorization from the research committee for data collection, the study commenced. All the data were collected from the Amrita hospital information system (AHIS). Details like patient s age, sex, short history, clinical examination in the Emergency Room (ER), electrocardiogram (ECG), chest X-ray and ABG, the provisional diagnosis were collected for interpretation. The final diagnosis after detailed evaluation during the hospital stay was also taken for evaluation. All laboratory investigations were performed in the hospital s laboratory, which is NABL, certified. STATISTICAL ANALYSIS: The data analyzed for descriptive and analytical statistics using SPSS software and with the help of a consultant biostatistician. Percentage of cases with respect to the different diagnosis was calculated. Agreement between the provisional diagnosis and final diagnosis was studied by applying Mc Nemars Chi-square test. Sub group analysis stratified by gender was also done. RESULTS: The study population consisted of 150 subjects of which 97 (64.7%) were Page 3 / 15

4 males and 53 (35.3%) were females (Table 1 & Fig 1). The youngest study subject was 20 years of age while the oldest one was 89 years. The mean age of the study population was The most common diagnosis arrived in the ER for acute breathlessness was pulmonary edema which accounted for 23.3% of all cases (35 cases). This was closely followed by congestive cardiac failure which constituted 16.7% (25 cases). In 16% of the study population pneumonia was the cause of breathlessness followed by bronchial asthma which accounted for 8.7% (13 cases). Acute exacerbation of COPD in 7.3% of the cases (11 cases). Hence these 5 most common causes of breathlessness together accounted for 72% of all cases. For the remaining 28% (42 cases), other causes like pleural effusion, foreign body obstruction, myocardial infarction, ARDS were responsible for the breathlessness. (Table 2 & Fig 2) Table shows the frequency and percentage of results of the arterial blood gas analysis. The arterial blood gas analysis revealed 33% of cases presenting with acute breathlessness had a normal ABG which was the most common finding. Metabolic acidosis was noted in 26 cases which constituted 17.3% of the population. Among these 26 cases 22 had pulmonary edema. 16% of the study population i.e., 24 cases had Type 2 respiratory failure and was found that pneumonia and COPD were the most cause of it. Type 1 respiratory failure was observed in 16% of the study group (24 cases), Pneumonia was the cause of Type 1 respiratory failure (7 cases) which was closely followed by Bronchial Asthma with 6 cases. Respiratory alkalosis was found in 15 cases which constituted 10% of the study population. Common causes included myocardial infarction foreign body obstruction, pleural effusion. Respiratory acidosis was found in 7.3% of the study population. Lung malignancies and COPD were the most common cause for respiratory acidosis. Table 4 and Fig 3 reveals the ECG findings and the frequency of presentations in our study population. Fig 4 depicts the various final diagnosis for acute onset of breathlessness arrived detailed evaluation at the end of hospital stay. Sub group analysis was done based on gender and on the cause of most common diagnosis of breathlessness i.e., pulmonary edema. Further analysis was done to reveal the cause of pulmonary edema which is shown in Table 6. Analysis based on gender was also done which is shown in Table 7&8. Comparison of initial diagnosis made in the ER to the final diagnosis made at the time of discharge was done. It showed 76% (114 cases) of the patient s initial diagnosis matched with final diagnosis. (Table 9 & Fig 5). This data was further analyzed by the Mc Nemar Chi Square test. This analysis reveled the p value to be which means that difference the diagnosis in the Page 4 / 15

5 emergency room and the final diagnosis was not statistically significant. The test had a sensitivity of 87.87% and specificity of 93.1%. Positive and negative predictive value were 78.37% and 96.46% respectively. The accuracy of this evaluation method was 92%. Hence Mc nemar analysis proves that this evaluation method adopted in the RR correlates well with the final diagnosis arrived after detailed evaluation DISSCUSSION: Breathlessness is a common complaint which brings people to the ER. There are very few studies that have analyzed the diagnosis of dyspnea in people presenting to the ER. Most of the studies that are available are old ones and a very few have been done in India. The various studies available differ in their conclusion, though in most of the studies either cardiac causes or respiratory infection was the most common cause of breathlessness. This study was done in 150 people who presented with breathlessness that required hospitalization. The study was similar to the one done by A Mukhopadhyay, T K Lim in the year 2001 which included 105 hospitalized patients, of which 49 were men and 56 were women (3). The present study showed that pulmonary edema was the most common cause of breathlessness. This was different from the previous observation by A Mukhopadhyay and T K Lm (3). According to their study the most common cause for breathlessness was respiratory infection which was the diagnosis in 31% of their study population. The probable reason would be that the study was done in Kerala a state which has relatively higher prevalence of lifestyle diseases like Diabetes mellitus, dyslipidemia, coronary artery disease and hypertension all of which can cause diseases or complications that can manifest as pulmonary edema (4). The other reason may be that the center in which the study was done is a tertiary care center with advanced care facilities which may be lacking in other secondary care centers; leading them to refer many of these cases to this hospital. It was revealed from the subgroup analysis that the most of the causes pulmonary edema was due to chronic renal failure. Pneumonia was found to be the second important cause of breathlessness Page 5 / 15

6 among the study group. This difference in the finding may be due to the fact that acute exacerbation of COPD was categorized as a different entity. Most of the cases of COPD were due to infective exacerbations (all except one); if these cases were clubbed along with pneumonia then both these causes of respiratory infection would together be the most common cause of breathlessness which was similar to the Mukhopadhyay and T K Lm study (3). COPD was found almost exclusively in males, this may be due to higher prevalence of smoking among males which contributes to development of COPD (5)(6). Congestive cardiac failure was the 3 rd most common cause of breathlessness in our study. Though a large number of people do come to ER with Bronchial Asthma as their cause of breathlessness, most respond to treatment and do not require hospitalization. Hence they were excluded from study making the bronchial asthma the 4 th common diagnosis. Other causes of breathlessness like carcinoma lung, pleural effusion, myocardial infarction, foreign body obstruction, acute respiratory distress syndrome were also found in the study population. When the population was sub grouped according to gender; males again had pulmonary edema as their leading cause of breathlessness followed by pneumonia and COPD but the diagnostic spectrum in females were slightly different. Here the pneumonia was the most common diagnosis among the females, this may possibly due to the mean age of the female population was lesser than the males, and the difference in hormonal milieu protects them from many of the cardiac diseases (7)(8). This was closely followed by Pulmonary edema and cardiac failure as the second and third common diagnosis respectively affecting the female cases. ABG in many of the patients presenting with acute breathlessness were normal. This is basically due to the respiratory or renal efforts which act to neutralize acidosis or alkalosis. The most common ABG abnormality was found to metabolic acidosis which tallies well with the finding of pulmonary edema, it is found in equal proportions among the study population. In most of the cases of Type 2 respiratory failure COPD was to be diagnosis, but the cause of Type 1 respiratory failure was varied. Respiratory alkalosis was present only in 10% of the study population and this was attributes to anxiety and hyperventilation in patients with dyspnea. Respiratory acidosis was the least common ABG finding. The ECG interpretation showed sinus tachycardia to be the most common ECG finding; this was followed by normal ECG tracings as next most frequent ECG finding. The sinus tachycardia is expected as its part of the elevated sympathetic drive found in breathless individuals. Left ventricular hypertrophy with sinus pattern was the 3 rd common ECG finding and in most of the people with this finding the diagnosis was cardiac failure. It is also worth noticing that a large variety of ECG changes was Page 6 / 15

7 observed in the study population. The initial diagnosis arrived in the ER was compared to the final diagnosis made after detailed evaluation during the period of hospital stay. The initial diagnosis was made with a short history, directed clinical examination, ECG, ABG and chest x- ray. These investigations were selected for formulating the initial diagnosis because these are the only investigations whose results will be available for interpretation to the ER physician with short span of time (within 30 minutes). The comparison of the initial and final diagnosis showed that in most of the cases; the initial diagnosis was the same as the final diagnosis. A study conducted by HS Chiu et al., where initial diagnoses and discharge diagnoses were compared and found that the initial and final diagnoses were partially matched since the history and physical examination remained the most important tool for diagnosis in the ER (9). Though pulmonary edema was the most common diagnosis in both ER evaluation and final evaluation similar to the study conducted by Patrick Ray et al., (10), significant number of cases of pneumonia could be diagnosed through detailed evaluation making it the 2 nd most common cause of breathlessness. Initial evaluation revealed cardiac failure to be the 2 nd most common cause of breathlessness but after detailed evaluation a number of people diagnosed in ER as cardiac failure were suffering from other causes of breathlessness thus in final evaluation cardiac failure becomes the 3 rd prominent cause of breathlessness. More number of study subjects with COPD could be diagnosed only after detailed evaluation. A relatively small number of study subjects with bronchial asthma on initial evaluation, were found to have other causes of breathlessness on detailed evaluation. As the in-hospital evaluation employed a larger number of tests over a longer time period were number of diagnoses could be arrived at. Therefore, the number of people in the other diagnostic category was significantly higher in the final diagnostic category compared to initial diagnosis in ER. These results were further analyzed by Mc Nemar Chi square test which showed a P value of which indicated that there was no statistical difference between two methods of evaluation. The new method of evaluation also had a high sensitivity and specificity. The accuracy of the test was high and positive and negative predictive values were also high. Thus this diagnostic approach can be employed in the ER for correct diagnosis and prompt management of people presenting with acute dyspnea. Page 7 / 15

8 CONCLUSION: Though this evaluation method is proven to be good one by statistical analysis; it cannot replace the wide array of information gathered from the detailed evaluation done during the period of hospital stay which aids not only in diagnosis but also in risk stratification and evaluation of comorbidities in individual patients. It is also evident from the available data that detailed evaluation leads to more number of people being diagnosed accurately. Hence the detailed evaluation prior to forming a final diagnosis is clinically significant. 275 REFERENCES: Mulrow CD et al., Discriminating causes of dyspnea through clinical examination: J Gen Intern Med Jul;8(7): Schmitt BP, Kushner MS, Wiener SL. The diagnostic usefulness of the history of the patient with dyspnea. J Gen Intern Med 1986; 1: Mukhopadhyay A1, Lim TK. A prospective audit of referrals for breathlessness in patients hospitalized for other reasons: Singapore Med J Jan;46(1): National Institute of Medical Statistics, Indian Council of Medical Research (ICMR), 2009, IDSP Non-Communicable Disease Risk Factors Survey, Kerala, National Institute of Medical Statistics and Division of Non- Communicable Diseases, Indian Council of Medical Research, New Delhi, India. 5. A Lokke et al., Developing COPD: a 25 year follow up study of the general population, Thorax 2006;61: S.K. Jindal et al., A Multicentric Study on Epidemiology of Chronic Obstructive Pulmonary Disease and its Relationship with Tobacco Smoking and Environmental Tobacco Smoke Exposure: Indian J Chest Dis Allied Sci 2006; 48: Xiao-Ping Yanand Jane F. Reckelhoff., Estrogen, hormonal replacement therapy and cardiovascular disease: Curr Opin Nephrol Hypertens March; 20(2): A.H.E.M. Maas and Y.E.A. Appelman., Gender differences in coronary heart Page 8 / 15

9 300 disease: Neth Heart J Dec; 18(12): HS Chiu, KF Chan, CH Chung, K Ma, KW Au., A comparison of emergency department admission diagnoses and discharge diagnoses: retrospective study: Hong Kong j.emerg.med. 2003; 10: Patrick Ray et al., Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis: Crit Care. 2006; 10(3): R Page 9 / 15

10 315 Resimler Figures & Tables Kayıt Tarihi: :39:48 FIGURES & TABLES 320 TABLE 1: CHARACTERİSTİCS OF THE STUDY POPULATİON GENDER FREQUENCY PERCENT MALE FEMALE TOTAL TABLE 2: SHOWING FREQUENCY OF EACH DİAGNOSİS ARRİVED İN THE EMERGENCY ROOM EVALUATİON DIAGNOSIS FREQUENCY PERCENT PULMONARY EDEMA CONGESTIVE CARDIAC FAILURE PNEUMONIA BRONCHIAL ASTHMA COPD OTHERS TOTAL TABLE 3: ARTERIAL BLOOD GAS ANALYSIS ABG FINDING FREQUENCY PERCENT NORMAL METABOLIC ACIDOSIS (MA) RESPIRATORY ACIDOSIS (RESP AC) RESPIRATORY ALKALOSIS (RESP ALK) TYPE 1 RESPIRATORY FAILURE (TYPE 1) TYPE 2 RESPIRATORY FAILURE (TYPE 2) TOTAL Page 10 / 15

11 330 TABLE 4: ELECTROCARDIOGRAM ECG FREQUENCY PERCENT INTERPRETATION NORMAL (N) SINUS TACYCARDIA (st) LVH WITH STRAIN 12 8 ST SEGMENT ELEVATION P PULMONALE OTHERS TOTAL TABLE 5: FINAL DIAGNOSIS OF BREATHLESSNESS DIAGNOSIS FREQUENCY PERCENT PULMONARY EDEMA CONGESTIVE CARDIAC FAILURE PNEUMONIA BRONCHIAL ASTHMA COPD OTHERS TABLE 6: CAUSES OF PULMONARY EDEMA CAUSES FREQUENCY PERCENT HYPERTENSION LEFT VENTRICULAR FAILURE MYOCARDIAL INFARCTION ACUTE RENAL 3 2 FAILURE CHRONIC RENAL FAILURE OTHERS Page 11 / 15

12 TABLE 7: FINAL DIAGNOSIS IN MALES 345 DIAGNOSIS FREQUENCY PERCENT PULMONARY EDEMA PNEUMONIA COPD CONGESTIVE CARDIAC FAILURE OTHER TOTAL TABLE 8: FINAL DIAGNOSIS IN FEMALES DIAGNOSIS FREQUENCY PERCENT PNEUMONIA PULMOARY EDEMA CONGESTIVE CARDIAC FAILURE FOREIGN BODY OBSTRUCTION OTHERS TOTAL TABLE 9: COMPARISON OF FINAL DIAGNOSIS AND FINAL DIAGNOSIS DIAGNOSIS FREQUENCY PERCENT YES NO TOTAL FIG 1: Characteristics of the study population Page 12 / 15

13 FIG 2: SHOWING FREQUENCY OF EACH DİAGNOSİS ARRİVED İN THE EMERGENCY ROOM EVALUATİON 375 FIG 3: ECG FINDINGS: Page 13 / 15

14 380 FIG 4: BREATHLESSNESS FINAL DIAGNOSIS: 385 FIG 5: COMPARISON OF FINAL DIAGNOSIS AND FINAL DIAGNOSIS Page 14 / 15

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