dispnea romana 2015
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UrgenteTRANSCRIPT
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Dispneea severa: diagnostic,evaluare
,tratament
Elisabeta BadilaSpitalul Clinic de Urgenta Bucuresti
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Principles of Emergency Medicine
“Air goes in and out.” “Blood goes round and
round.” “All bleeding stops eventually.” “All else is details.”
But…the devil is in the details!
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Ce este dispneea? Lipsa de aer; “sete de
aer”, “astupare” Simptom (subiectiv) de
lipsa de aer; Adaptare normala la
efort intens; Patologic daca apare in
situatii neobisnuite.
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Ce este efortul respirator? Termen vag care se refera la respiratia dificila (“not
breathing well”). O constelatie de semne:
tahipnee folosirea muschilor accesori respiratii profunde/adanci agitatie uneori confuzie (hipoxemia) somnolenta (hipercapnie)
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Dispneea este un simptom, nu o boala !
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Originea senzatiei
de dispnee
Creierul compara semnalele aferente si
eferente, iar o “nepotrivire” intre
acestea duce la senzatia de dispnee
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Care sunt stimulii respiratiei?
Chemoreceptorii din maduva, bulbul aortic si carotidian raspund la variatii ale presiunilor partiale – cresterea CO2 sau a ionilor H+ sau la scaderea 02.
Receptorii de intindere din plamani Baroreceptorii
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Nu exista o cauza specifica de dispnee si nu exista tratament specific al dispneei!
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Diagnostic Diferential 4 categorii majore:
Cardiace Pulmonare Mixte – cardiace si pulmonare Non-cardiace sau non-pulmonare
Metabolice HematologiceHematologice PsihogenePsihogene
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Cauze de dispnee acuta
Sistemul Cardiovascular Sistemul Respirator
Ischemie miocardica acuta/SCA Bronhospasm (BPOC, astm)
Insuficienta cardiaca/EPAC Embolie pulmonara
Tamponada Cardiaca Pneumotorax
Infectie pulmonara(bronsita, pneumonie)
Detresa respiratorie a adultului
Contuzie pulmonara
Uptodate.com
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Cauze de dispnee acuta
Obstructie de cai aeriene superioare
Perete toracic
Angioedem Fracturi costale
Anafilaxie Volet costal
Infectii faringe/regiune cervicala profunda
Neurologice
Corp strain Accident vascular cerebral
Trauma regiune cervicala Boala neuromusculara (miastenie, Sdr Guillan Barre, poliomielita)
Uptodate.com
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Cauze de dispnee acutaToxice / metabolice Diverse
Intoxicatie cu organofosforice Hiperventilatie
Intoxicatie cu salicilati Anxietate
Intoxicatie cu CO Tumora plaman
Ingestie de substante toxice Revarsat pleural
Cetoacidoza diabetica Procese intra-abdominale
Sepsis Ascita
Anemie Obezitate morbida
Uptodate.com
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Evaluarea adultului cu dispnee in departamentul de urgenta
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Guidelines
American Journal of Respiratory and Critical Care Medicine, vol 185, Iss 4, 435-452,2012
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De Prima Intentie !
Airways, breathing, and circulation (ABC) Evaluarea initiala asupra careia se concentreaza
clinicianul cand evalueaza si “manageriaza” pacientul acut cu dispnee
Odata ce sunt stabilizate, se continua investigatia clinica si tratamentul
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Deci…Ce veti face?
ABC 5 semne vitale: FR, P, TA, T, Sa02.
O2, IV, Monitor, ECG
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Evaluarea Gradul de urgenta
Va trai pacientul suficient timp pentru a obtine o anamneza? Daca nu, interveniti. Daca da, incercati sa formulati un diagnostic.
Evaluati pacientul Face un efort vizibil (activ) ca sa respire? cauta
obstructia mecanica! Corecteaz-o! Este hipoxic? Da creste O2! Poate sa respire adecvat singur? Nu suplimentati
efortul respirator!
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Evaluarea
Localizati problema cardiaca, respiratorie, mecanica, metabolica,
cerebrala, psihologica Corectati problema
Dupa ce aveti un diagnostic corect, tratamentul este (relativ) simplu !
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Scala de evaluare a Dispneei
0 1 2 3
4
Dispnee la efort intens Numai la mers pe teren inclinat sau mers grabit La mers incet pe teren plat, sau se opreste
dupa 15 minute Se opreste la cateva minute la mers pe teren
plat La activitate minima (imbracat)
Prea dispneic sa paraseasca casa
Scala Borg Modificata
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! Tahipneea poate sa nu reprezinte o modificare respiratorie si poate reflecta o
boala non-pulmonara - ex, acidoza metabolica sau hernierea acuta a trunchiului
cerebral !
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Metode de evaluarea a dispneei
Suspiciune / Cunostiinte clinice“Ca sa pui un diganostic trebuie in primul rand
sa te gandesti la el.”
Anamneza Evaluare clinica initiala
Semne Vitale, SaO2
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Semne Vitale Stabil vs instabil Cum se modifica in timp? Ce ne spun?
Semnificatia lor depinde de contextul clinic! O FR scazuta la un astmatic poate semnifica
iminenta decesului ! O FR scazuta la un anxios poate semnifica
ameliorarea starii clinice !
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Semne Vitale Frecventa respiratorie: Numara TU!Frecventa respiratorie: Numara TU!
Temperatura: Nu te increde in cea din Triaj!Temperatura: Nu te increde in cea din Triaj!
AV, TA, SaO2. AV, TA, SaO2.
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Evaluare Rapida – Examen General Posibilitatea de a vorbi Status mental, agitatie, confuzie Pozitie Cianoza:
Centrala - ! Nu este evidenta la anemici Periferica – extremitati marmorate
! Cianoza poate fi observata la pacientii cu hiperpigmentare prin evaluarea mucoasei gingivale si a celei pleoapelor
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Evaluare Rapida Necesita tratament imediat?
Ventolin Nitroglicerina ASA Furosemid Ventilatie non-invaziva (BiPAP) Decompresie pe ac
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Anamneza
Conditii psihiatrice Cauze psihogene de dispnee acuta – dg de
excludere la CG. Cauzele organice TREBUIE luate in considerare la
inceput.
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EXAMEN OBIECTIV
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Examen obiectiv – examinare tintita
Muschii accesori Facies, culoare. Perete toracic, plamani, cord,
abdomen & extremitati. Observatie, Palpare, Auscultatie
Cu si fara stetoscop.
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Modificari la auscultatie
Stridor Wheezing Raluri crepitante/ronflante (crackles)
! Totusi, absenta ralurilor nu exclude prezenta unei pneumonii, IC decompensata, sau a fibrozei pulmonare
Murmur vezicular diminuat
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Retineti ca absenta modificarilor la examenul clinic al sistemului respirator
± cardiac NU exclude o patologie importanta!
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Examen fizic
Semne care sugereaza iminenta stopului respirator: Status mental alterat
Sugereaza hipoxie sau hipercapnie severa Imposibilitatea de a face efortul respirator Cianoza
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Cele mai frecvente diagnostice in randul pacientilor prezentati la CG pentru dispnee, cu semne de disfunctie respiratorie
(FR >25, SaO2 <93%)
Insuficienta cardiaca acuta decompensata BPOC Embolie pulmonara Pneumonie Astm bronsic
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What other tools?What other tools? PEF EAB Analize sange Rx torace ECG Examen CT Ecografie
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PEF – Peek Expiratory Flow Incercari repetate de a masura PEF max poate
agrava bronhospasmul! Limitati nr la cele mai bune 3 expiruri fortate
PEF poate fi util pentru distingerea cauzelor de dispnee (pulmonare vs cardiace) si pentru determinarea severitatii bronhoconstrictiei in cazurile de astm sever.
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Indivizi sanatosi – SaO2 95%; Varstnici / obezi / mari fumatori - 92 – 95%; Boala pulmonara cronica severa - < 92%.
!!! Pulsoximetrele standard NU masoara exact in conditii de hipotermie, soc, intoxicatie cu CO si methemoglobinemie
Pulsoximetrie
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Gaze Arteriale Rezultatele trebuie interpretate in contextul
clinic. Gazometria arteriala “completa” include
masurarea lactatului Gazele venoase pot fi uneori foarte utile.
Evaluarea pacientului somnolent la care se suspicioneata hipercapnia.
Cand? De ce?
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Gazometria arteriala si EAB 3 componente importante:
pH, CO2 si O2 Modificari ale pH datorate atat cauzelor
metabolice cat si respiratorii. fiecare incearca sa compenseze modificarea
celuilalt.
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pH pH ar trebui sa fie 7.4
Mai mic acidoza. Mai mare alcaloza.
PaCO2 Ar trebuie sa fie 40± 5
Mai mic, respira prea mult. Mai mare, nu respira suficient.
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PaO2 O2 % (PulseOx) = saturatie (> 95-96%). Ar trebui sa fie > 85 -100 mmHg.
Mai mica hipoxie. Mai mare de 100 primeste > 21%
suprasatureaza.! PaO2 - o masura a transportului de O2.
Capacitatea de transport a Oxigenului depinde de cantitatea de transportor si de saturatia acestuia.
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Analize de sange d-Dimerid-Dimeri BNPBNP Biochimia uzualaBiochimia uzuala Enzimele CardiaceEnzimele Cardiace
Ce altceva si de ce?
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D-Dimeri Utilizarea D-Dimerilor depinde de probabilitatea
pretest a pacientului pentru EP. La pacientii cu risc scazut conform sistemelor de scor
validate (ex, criteriile Wells modificate) rezultatul NEGATIV la testarea tip ELISA a D-dimerilor exclude EP fara necesitatea altor teste suplimentare.
Nu este adecvata utilizarea D-dimerilor la pacientii cu risc crescut de boala tromboembolica.
Pacientii cu patologii maligne sau interventii chirurgicale recente si pacientii varstnici – probabilitate mare de D-Dimeri fals crescuti.
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Peptidul natriuretic cerebral (BNP) Util cand este discutabil dg de insuficienta
cardiaca. Semnificatie:
BNP < 100 pg/mL valoare predictiva negativa > 90 % for IC decompensata.
BNP > 500 pg/mL sugereaza puternic IC decompensata, cu valoare predictiva pozitiva > 90%.
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SCA: Troponinele
Troponina negativa nu exclude SCA Troponina pozitiva nu este
suficienta pentru Dg SCA Troponina este mai mult
prognostica decat diagnostica
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Radiografia pulmonaraRadiografia pulmonara (Rx pulmonar) Interpreteaza singur Rx:
Radiologul nu stie intotdeauna ce cauti si poate trece cu vederea cel mai important semn!
Cauta: pneumotorax, disectie de aorta, pneumonie,
revarsat pleural, atelectazie, infiltrate pulmonare…
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Rx pulmonar
Si totusi, multe patologii amenintatoare de viata care se prezinta cu dispnee pot asocia Rx pulmonar normal!
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ECG-ul Aduce multe indicii pentru cauza dispneei Cauta:
Pericardita (microvoltaj difuz, alternanta) Embolie pulmonara (S1Q3T3, deviatia axei la dreapta) Infarct miocardic (supradenivelare ST) Fibrilatie atriala cu debut recent “Strain” de ventricul drept
Clinicianul trebuie sa retina ca un ECG nondiagnostic NU exlude o patologie cardiaca la CG!
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Embolie pulmonara S1Q3T3
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IM Acut (STEMI, NSTEMI)
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ACS: ECG
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Pericardita
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Pericardita
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Femeie, 55 ani, dispneica…Pericardita sau IM acut inferior?
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Scintigrafia Ventilatie/Perfuzie (V/Q Scan)
Sensibilitate 85 - 90% Valoarea predictiva pozitiva depinde de
suspiciunea clinica Iradiere mai mare decat un examen CT.
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PE – CT scan
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Examen CT toracic Cu substanta de contrast Mai rapid, mai sigur, deceleaza alte cauze
potentiale pentru dispnee cu o acuratete sporita scintigrafiei
Protocolul obisnuit necesita o valoare creatinina serica sau RFGe. De ce?
Complicatii – nefropatie indusa de contrast, reactie alergica la contrast, iradiere
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Ecografia & Ecocardiografia
TTE = Eco cord transtoracic: Disectie aorta Tamponada cardiaca Leziune valvulara acuta
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Cele mai frecvente diagnostice
Insuficienta cardiaca decompensata Bronhopneumopatie obstructiva cronica Embolie pulmonara Pneumonie Astm bronsic
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Caz 1: Femeie, 60 ani Dispnee progresiva > 6 luni,
agravata in ultimele 24h Tuse cronica
De obicei cu sputa albicioasa Acum agravata, modificare
cantitate si culoare Asociaza febra
Un grad de ortopnee Mare fumatoare (35 pachete an)
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Diagnostic Diferential
BPOC cu exaerbare infectioasa
IC cronica cu decompensare acuta
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Examen clinic & investigatii Facies suferind, FR 26,
T 37.8, AV 90 ritm sinusal, TA 140/80
SaO2 88% Efort respirator cu
folosirea muschilor accesori
Semne de hiperinflatie ampliatii costale hipersonoritate percutie
Expir prelungit + wheezing
EAB & gazometrie: pH 7.28/pCO2 73/ pO2 52/HCO3 26
Ce sugereaza?
Insuficienta respiratorie acuta tip II
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BPOCBPOC
Cord verticalizat
Hipertrans parenta
retrosternal
Diafragm Diafragm aplatizataplatizat
Diafragm aplatizat
Hipertransparenta campurilor pulmonare
Diametru AP crescut
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Diagnostic Exacerbare infectioasa BPOC cu
insuficienta respiratorie acuta (tip 2)
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BPOC – Dg avansat polictemie secundara cianoza tremor, somnolenta si
confuzie secundare hipercapniei
HTN pulmonara secundara ± cord pulmonar
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Administrare Oxigen SaO2 < 90% in aer atmosferic in repaus titrare – 2-4 l/min in IR tip 2; monitorizare pC02
Nu intrerupe oxigenul la pacientii cu BPOC! Tinta pentru SO2 este 90-94%, chiar daca acest lucru se poate solda cu accentuarea hipercapniei ! Daca clinicianul considera ca pacientul cu BPOC necesita
intubatie endotraheala, se va creste oxigenarea indiferent de tinta SaO2 sau de hipercapnie
Ventilatia Noninvaziva (NIV) / mecanica V (MV)
Strategie terapeutica BPOC
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Bronhodilatatoare – Beta-agonisti si anticolinergice salbutamol, bromura de ipratropium (MDI) via nebulizator
Corticosteroizi ex. Solumedrol 125 mg IV
Teofilina: ! Bronhodilator slab Antibiotice – beta-lactami / fluorquinolone
Strategie terapeutica BPOC
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BPOC si TEP
!!! TEP pot fi responsabile de pana la 25% din aparentele “exacerbari BPOC” si ar trebui suspectate cand starea pacientului nu se imbunatateste sub terapia standard a BPOC !
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BPOC - EmfizemBPOC - Emfizem Tesut pulmonar insuficient; Interfata Tesut pulmonar insuficient; Interfata
sange/aer insuficienta. sange/aer insuficienta. Optimizarea tesutului functional. Optimizarea tesutului functional. Tratament… plamani noi. Tratament… plamani noi.
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Caz 2: Barbat, 25 ani
Adus de ambulanta. Acuza dispnee cu debut brusc. Prezenta de cateva ore, dar foarte severa la
momentul prezentarii.
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Anamneza Anterior stare buna, fumator 10 tigari/zi Durere toracica stanga
Moderata Pleuritica Debut odata cu dispneea
Care este diagnosticul?
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Diagnostic Diferential Pneumotorax
Aritmie
Embolie Pulmonara
Astm (mai putin probabil)
Si mai putin probabil Pneumonie
Se va mentiona numai dupa considerarea cauzelor organice Anxietate
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Examen obiectiv Facies suferind, agitat,
dispneic FR 30, AV 125/min, TA
80/60, afebril SaO2 93% in aa Ampliatii reduse hemitorace
stang Hipersonoritate la percutie
hemitorace stang Absenta MV pe
hemitoracele stang
Este grav? Care este managementul in
urgenta?
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Rx pulmonar Deplasarea mediastinului, devierea traheei
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Diagnostic
Pneumotorax
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Pneumotorax: Diagnostic Rx pulmonar: Cauta linia
pleurala 500 ml de aer minim pentru
a fi evident pe Rx Hipertransparenta si lipsa
desenului pulmonar in periferie & linia fina care reprezinta retractia pleurei viscerale de cea parietala
Dificil in BPOC
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Pneumotorax - CT
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Management
Terapie Initiala?
Drenaj pleural de urgenta ! In stare grava se impune drenajul de
urgenta, chiar inainte obtinerii unei Rx pulmonare
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Optiuni terapeutice Observatie
Daca pneumotoraxul implica < 15-20% (< 2 cm) din hemitorace si pacientul este relativ asimptomatic
Repeta Rx pulmonar in 24 h
Aspiratie Simpla Toracostomie pe tub de dren
> 2cm , dren pleural Instabil hemodinamic, tub de dren
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Rx pulmonar
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Caz 3: Femeie, 30 ani Constrictie toracica, dispnee rapid progresiva, prezenta si in
repaus, tuse seaca, wheezing de 14 h Dupa expunerea la un alergen (praf)
SaO2 91% in aa, folosirea muschilor accesori, diaforeza, agitatie, FR 26/min, TA 100/60 mmHg, AV 110/min
Tratament acasa: Salbutamol inhalator in criza (Astm juvenil) La 1 h de la prezentarea la CG (tratata cu GCS + nebulizator
SABA) - puls paradoxal, MV diminuat difuz, incetarea wheezing-ului, FR 12/min, AV 60/min
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Care este diagnosticul?Este pacienta noastra mai bine? Severitatea crizei?
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AstmAstm Bronhoconstrictie reversibila Blocarea aerului intre caile aeriee mari si alveole. Tinte terapeutice:
Reversia rapida a obstructiei prin utilizarea agresiva de agenti beta2-agonisti si utilizarea precoce a corticosteroizilor
Corectarea hipoxemiei prin monitorizarea si suplimentarea O2
Preevnirea si tratarea complicatiilor (pneumotorax, stop respirator).
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SaO2 < 92% in aa sau < 95% sub O2 PEF < 33% din normal Vorbire scurta fragmentata Torace silentios (fara wheezing) Utilizarea muschilor accesori Cianoza; diaforeza profunda Fatigabilitate extrema Status mental alterat Bradicardie, hipotensiune Lipsa de raspus in ciuda tratamentului agresiv
Criza acuta de astm amenintatoare de viata
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Tratamentul in astm Oxigen (pe masca) Nebulizare cu β-agonisti
Repeta: salbutamol 5 mg in nebulizator la 5-15 min pana la obtinerea controlului simptomelor
Corticosteroizi Hidrocortizon 200 mg i.v.
Nebulizare cu anticolinergice Ipratropium 0.5 mg in nebulizare (se poate asocia cu
salbutamol) Sulfat de magneziu Reechilibrare hidrica in caz de deshidratare
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Tratamentul in Astm Administrarea antibioticelor de rutina este descurajata.
Numai in prezenta argumentelor pentru infectie (ex, pneumonie, sinuzita)
Daca pacientul nu poate tolera nebulizatorul, administrati 10–25 puffuri de beta2 agonist (salbutamol) printr-un spacer mare (improvizat la nevoie)
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Status Astmaticus Exacerbare acuta a astmului, care se mentine neresponsiva la
terapia initiala cu bronhodilatatoare 100 % oxigen Ventolin in nebulizare continua plus atrovent Solumedrol 125 mg IV Sulfat de magneziu 2 gm in 2 min Beta2-agonisti neselectivi – adrenalina 0.2mg IV in 5 min
apoi 1-20 μg/min Intubatie endotraheala si ventilatie mecanica in caz de
insuficienta respiratorie.
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Indicatiile intubatiei orotraheale si a ventilatiei mecanice in astm Apnee sau stop respirator
Nivel scazut de constienta
Iminenta de stop respirator – cresterea PaCO2 cu oboseala musculara, transport scazut al aerului si alterarea statusului mental
Hipoxemie semnificativa care raspunde greu sau nu raspunde la suplimentarea cu Oxigen
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Caz 4, Femeie 60 ani Dispnee cu debut acut
de 1 ora, foarte severa Durere torace drept, caracter pleuritic Subfebrilitate Proteza totala genunghi drept in urma cu
3 zile, edem picior persistent de atunci Nefumatoare Fara APP pulmonare/cardiace Fara accidente/leziuni
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Care este diagnosticul diferential?
Cel mai probabil TEP Pneumonie
Mai putin probabil Pneumotorax Aritmie IM acut
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ECG
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Examen clinic & investigatii Stare generala
influentata, dar pacienta tahipneica cu usoara dispnee
FR 24, T 37.6, AV 110, TA 110/70
SaO2 93% in aa Examen pulmonar
normal
Rx pulmonar normal EAB & gaze pH 7.5/
CO2 30mmHg /p02 62mmHg in aa
Cel mai probabil Dg? Ce alte investigatii ati cere?
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What can you see?
Trombembolism pulmonar
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Un diagnostic ce trebuie luat in considerare la orice pacient cu dispnee cu debut acut.
Factori de risc: Istoric de tromboza venoasa profunda sau embolie pulmonara Imobilizare prelungita Trauma recenta sau interventie chirurgicala (in special ortopedica) Sarcina Patologie neoplazica AVC sau pareza Utilizarea de contraceptive orale sau fumat Istoric personal sau familial de hipercoagulabilitate
Trombembolism pulmonar
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Triada clasica
Nu sunt nici sensibile nici specifice, apar in mai putin de 20% din cazurile diagnosticate cu TEP
HemoptizieDispnee
Durere toracica
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TEP masiv – Semne / Simptome Tahipnee - 96% Zgomot II intarit - 53% Tahicardie - 44% Febra - 43% Galop S3 sau S4 - 34% Semne/simptome sugestive de
tromboflebita - 32% Edem de membru inferior - 24% Sufluri cardiace - 23% Cianoza - 19%
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Gazometrie: Hipoxemie, CO2 normal/. Examen obiectiv
TEP masiv duce la hipotensiune prin cord pulmonar acut Examenul clinic la un TEP submasiv precoce poate fi
complet normal Initial, modificarile la examenul clinic lipsesc la
majoritatea pacientilor
Embolie pulmonara
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Diagnosticul TEP masiv Scintigrafia V/Q Angiografie pulmonara Examen CT Ecocardiografie Cateterism artera pulmonara D-dimeri Gazometrie arteriala (gradient A-a crescut)
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Managementul TEP
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Anticoagularea in TEP Enoxaparina 1mg/kg la 12h Heparina nefractionata: 80 IU/kg apoi 18 IU/h
(aPTT x2) Fondaparinux
5mg/zi < 50kg; 7.5mg/zi 50-100kg; 10mg/zi >100kg ! La suspiciune inalta de TEP initiati terapia
anticoagulanta inainte de confirmarea diagnosticului !
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Management pe termen lung Anti-vit K HGMM preferate la
pacientii cu neoplazii si in sarcina
Durata: 1 episod cu cauza evidenta:
3 luni 1 episod, fara cauza
evidenta, neoplazie, TEP recurent, tratament pe durata nedeterminata
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Ce vedeti pe Rx pulmonara?
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Caz 5 Barbat, 65 ani Anamnestic
Ortopnee, dispnee paroxistica noctura, dispnee la efort prezenta de 6 luni, intens agravata in ultimele 24h
Palpitatii – ultimele 24 h IM in urma cu 4 ani Fost fumator, hipertensiv,
diabetic
Cum au schimbat toate acestea judecata clinica, fata de cazul anterior? Cateva indicii pentru
etiologia cardiaca…. Insuficienta cardiaca Aritmie Infarct miocardic
acut/angina BPOC Anemie
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Examen obiectiv Facies suferind, efort respirator evident FR 26, afebril, AV neregulat 130, TA 100/70 SaO2 90% in aa PVC↑, edeme perimaleolare Soc apexian deplasat, fara sufluri, zgomot 3 prezent Ampliatii costale normale, matitate la percutie in
baze (D>S), raluri crepitante in inspir imediat superior de zonele de matitate
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ECG – care este diagnosticul?
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Caz 5 Diagnostic
IC cronica cu decompensare acuta secundara FiA cu debut recent
Tratament FiA & IC Terapie antitrombotica Controlul AV Posibil controlul ritmului
IC acuta decompensata
! IC decompensata este printre cele mai frecvente etiologii ale insuficientei respiratorii acute
la pacientii peste 65 ani.
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IC decompensata - Tratament
Diuretice Inhibitori EC Beta blocant
!!! dupa ameliorarea congestiei
Digitala Vasodilatatoare periferice/NTG Agenti inotrop pozitivi Oxigen
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Edem pulmonar
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110
Edem pulmonar
Debut acut; disfunctie respiratorie Raluri, ronchusuri; sputa perlata; uneori cu
striuri sanguinolente. TA crescuta (vasoconstrictie)
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Principii de tratament in EPA
Pozitie confortabila – sezanda Oxigen pe masca CPAP / BiPAP – ventilatie non-invaziva cu presiune pozitiva
(NIPPV) creste presiunea in caile aeriene fortand fluidele inapoi in sistemul vascular
Luati in considerare asistarea ventilatorie in caz de IR ECG 12 derivatii – exclude SCA 400 μg NTG spray if SBP >
daca TAS > 90 mmHg
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Principii de tratament in EPA
Furosemid 40 mg IV repeta la 10 min pana la max 160 mg
NTG IV - la TAs > 90 mmHg Morfina 2-4 mg IV (pana la 20 mg)
Monitorizarea respiratiilor si ventilatie asistata in caz de IR manifesta
A se considera salbutamol 5 mg in nebulizator in prezenta wheezingului
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Pneumonia
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Pneumonia – examen obiectiv Dispnee progresiva Tuse uscata ce devine productiva Febra Durere toracica pleuritica Frecatura pleurala Matitate la percutie (consolidare) Crackles pe zona afectata
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Principii de tratament in pneumonii
Oxigen pentru mentinerea Sa02 > 95% BiPAP la nevoie Antibiotice
Macrolide Fluroquinolone Cefalosporine de generatia a 2a sau a 3a
Beta agonisti – wheezing Repletie volemica in caz de deshidratare
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Sindromul de Detresa Respiratorie a Adultului/ Edemul Pulmonar Noncardiogen (SDRA)
Cea mai severa forma de leziune pulmonara acuta, forma de leziune alveolara difuza.
Definita ca afectare acuta caracterizata prin infiltrate pulmonare bilaterale si hipoxemie severa in absenta argumentelor pentru edem pulmonar acut cardiogen.
Cauze potentiale: sepsis, soc, trauma severa, inhalare de toxine (aspiratie, injurie termica, amoniac anhidru, clor), infectii (Hantavirus, SARS), transfuzii de sange, supradozaj (cocaina, opiacee, aspirina).
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Rx in Detresa respiratorie
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Detresa respiratorie
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Detresa respiratorie - Tratament Oxigen Ventilatie – noninvaziva / mecanica Traheostoma Extracorporeal Membrane Oxygenation Corticosteroizi – beneficii? Surfactant Oxid Nitric Managementul volemiei Suport Nutritiv
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Take home messages
Dispnea este un simptom (subiectiv) Trebuie sa gandim sistematic Cauzele pot fi multiple, dar avem si mijloace
multiple de diagnostic Intotdeauna trebuie sa fim atenti la
elementele cheie …
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“When you can’t breathe, not much else matters.”
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Intrebari?