Approach to the Dyspneic Patient

Dan Crouch

Kristi Kuhn

Kate Lindley

Ben Voss

First and Foremost…

Identify the correct patient

Obtain the most recent vitals

Ask the nurse about the acuity of the episode

Does an ACT Now or CODE need to be called?

Requiring Quick Diagnosis and Intervention

Pulmonary Embolism

Acute Coronary Syndromes

Aortic Dissection

Pneumothorax

Things You Have A Little Time For

The Exacerbations: Asthma/Reactive Airway Disease COPD CHF/Tamponade

Pneumonia (CAP vs HAP) ARDS Less Common Causes:

Anxiety

Anemia

Armed with this knowledge…

You walk into the patient’s room - 02 sat=80%

Start supplemental oxygen ASAP! Get an idea of all the vitals (BP, HR, RR, Temp) Look at the patient:

Is he/she markedly tachypneic? Is he/she hypotensive? Is he/she mentating well? Is he/she cyanotic?

While you quickly peruse the chart, obtain an ABG, ECG and order a STAT portable CXR

Unlike your usual admission, the history comes second here

Do I Have Time for a Physical Exam? Key is to be FOCUSED

General Appearance - how distressed do they lookVitals - Repeat Vitals, q

10 minAssess for pulsus

paradox and BP in both arms

Cardiac - Rhythm, JVP, capillary refill, new gallops, murmurs or rubsPulmonary - air

movement, crackles, wheezes, breath soundsExtremity - presence of

edema, cyanosis

Therapy - Oxygen

Oxygen Relieves pulmonary vasoconstriction Increases myocardial reserveStart with high-flow NC, then proceed to

non-rebreather facemask delivering 100% If oxygen saturation does not improve, plan

NPPV or intubation

Therapy - Diuretics

Can decrease preload and also reduce cardiac filling pressures

Dosing regimen: Lasix 40-80mg IVP (may need more if in renal failure) Bumetanide 1-2 mg IVP Torsemide 10-20 mg IVP

If a patient is on chronic diuretics, simply change the PO to a IV regimen

Continuous infusion leads to modest improvement in urine output but no change in mortality

Therapy - Vasodilators

Nitrates work well by decreasing both afterload and preload Nitroglycerin - develop tolerance Nitroprusside - develop cyanide toxicity

Hydralazine acts as a direct arteriolar vasodilator Watch out for reflex sympathetic tachycardia

Other Pharmacologic Options

Steroids are useful in COPD and Asthma exacerbations Start with methylprednisolone 60 mg IV q6h

Bronchodilators are also useful Start with nebulized albuterol (2.5mg q1-2h) Add on Atrovent (2 puffs q 2-4h or 0.5mg q 2-4 h)

Opioid antagonists - narcan 0.4 mg IVP

Benzo reversal – flumazenil 0.2 mg IVP

Antibiotics for Pneumonia

Other options before intubation

Aggressive chest physical therapy Useful for mucus plugs, cystic fibrosis patients, and

excessive secretions

BiPAP Remember, it should be used primarily for

hypercarbic respiratory failure secondary to COPD or hypoxemic respiratroy failure secondary to cardiogenic pulmonary edema

Situations to avoid BiPAP; Somnolent, lethargic mental status Hemodynamic instability Profounnd acidemia (pH < 7.1)

Mechanical Ventilation Make sure you have the

following ready:Suction catheterOxygen monitorCrash Cart and Airway Box

ET Tube with StyletOP Airway10ml SyringeCO2 Detector

IV AccessSedative support (Fentanyl,

Versed)Paralytic supportAnesthesia

Start with preoxygenation Administer

sedative/paralytic Intubate Observe for color change

and bilateral breath sounds Recheck vitals Obtain CXR

Case 1

R.D. is a 32 y.o male with PMHx of asthma admitted for asthma exacerbation within the past 12 hours.

Vitals stable, O2 = 93%RALess than 12 hours into admission,

nurse calls you stating “His oxygen sat is 81% on 4L NC”

What do you do?

Examine the patientHis vitals are BP 140/75, HR 113, RR 38,

O2 = 86% on 6L NCExam: mentating well, bilateral faint

expiratory wheezing, using accessory muscles

Obtain a portable CXR and ABG

What is the likely diagnosis?Asthma Exacerbation

What else?

Supplemental oxygen to 8 L NC His oxygen sat increases to 90%

Call RT to administer: Albuterol 2.5 mg nebulizer Atrovent 0.5 mg nebulizer

Steroids Methylprednisolone 60 mg IV q6h if not previously

started No need for antibiotics in asthma exacerbation

Asthma Management - Summary

Nebulizers

Supplemental Oxygen

Steroids

Magnesium (minimal benefit)

No Antibiotics

Close monitoring - q4h vitals/peak flows

Case 2

G.B. is a 56 y.o AAF with PMHx of CRI (Cr 3.3 at baseline), HTN, DM2, admitted for cellulitis

On HD#2, during morning rounds, you find the patient markedly tachypneic and unable to speak in full sentences…

What do you want to do?

Get a set of vitals BP 200/115, HR 105, RR 32, O2=89% 2L NC Exam: JVP 11 cm, bilateral rales, S3 gallop, no LE

edema, 2/6 SEM at apex radiating to axilla

Supplemental oxygen, ABG

Order an ECG

Stat pCXR

While you await the CXR…

Hypertension Control: IV Metoprolol/Diltiazem IV Nitroglycerin gtt IV Labetalol gttPO Clonidine

Diuresis:Lasix 40 mg IV x 1

What is the likely diagnosis? Pulmonary Edema

Acute Cardiogenic Pulmonary Edema

Ischemia

Valvular – MR/AR/AS

Renovascular hypertension

Dysrythmias: AVB, Afib, V-tach, SVT

Overhydration with crystalloid or colloid

What is the next step?

Assess response to diuresis within 30 min to 1 hour

Assess response to afterload reduction within 15 min

If no response to either, tx to ICU for closer monitoring and likely BiPAP or mechanical ventilation

Case 3

N.M is a 28 yo WM with hx of Marfan’s syndrome who p/w sudden onset chest pain and SOB.

You are called to see him in the ER

He is afebrile, but tachycardic (HR 120). BP 110/65, 0x Sat 90 % RA, RR 28

CXR

What is the diagnosis?

Pneumothorax

What is your approach?

Assess oxygenation Is current oxygen requirement stable

Assess size of PTX Call Thoracic Surgery consult

Are there signs of tension: hyperlucent, overly expanded hemithorax mediastinal shift to the opposite side radiographic signs of pneumothorax - heart elevated from the

sternum, lung lobes retracted from the thoracic wall

Summary Points

Always recheck vitals immediately Close monitoring is essential

Assess ability to oxygenate Try oxygen, diuretics, nitrates, bronchodilators,

steroid, afterload reduction Have an end-point ready Evaluate probability of requiring mechanical ventilation

Have an ICU bed available Coordinate with nursing supervisor