Shortness of Shortness of BreathBreath

UNC Emergency MedicineUNC Emergency Medicine

Medical Student Lecture SeriesMedical Student Lecture Series

ObjectivesObjectives

• Recognizing respiratory distressRecognizing respiratory distress• Initial approach to a patient with Initial approach to a patient with

respiratory distressrespiratory distress• Actions to takeActions to take• HistoryHistory• Physical examinationPhysical examination

• Specific conditions that present Specific conditions that present with respiratory distresswith respiratory distress

Case #1Case #1

• 24 yo F with hx of asthma presenting 24 yo F with hx of asthma presenting with shortness of breath, wheezing, with shortness of breath, wheezing, dry cough for two days, worsening dry cough for two days, worsening today; no fever or chills, no chest pain; today; no fever or chills, no chest pain; no congestion. Tried inhaler every 2 no congestion. Tried inhaler every 2 hours at home for past 6 hours without hours at home for past 6 hours without relief.relief.

• What do you do first?What do you do first?

Things you want to Things you want to knowknow

• What usually triggers your asthma?What usually triggers your asthma?• Prior ED visits, hospitalizations, ICU Prior ED visits, hospitalizations, ICU

admissions? Prior intubations?admissions? Prior intubations?• Current medicationsCurrent medications

• Frequency of inhaler useFrequency of inhaler use• Recent steroids Recent steroids

• Baseline peak flow values Baseline peak flow values • Fevers, recent infections, and sick Fevers, recent infections, and sick

contactscontacts

Why is all that so Why is all that so important?important?

• Risk factors for sudden death from Risk factors for sudden death from asthma:asthma:• Past history of sudden severe exacerbations Past history of sudden severe exacerbations • Prior Prior intubationintubation for asthma for asthma • Prior asthma admission to an Prior asthma admission to an ICUICU • In the past year:In the past year:

• 2 or more 2 or more hospitalizationshospitalizations for asthmafor asthma• 3 or more 3 or more EDED visitsvisits for asthma for asthma

• Hospitalization or an ED visit for asthma Hospitalization or an ED visit for asthma within the past within the past monthmonth

Start with the ABCsStart with the ABCs• AirwayAirway• Breathing: How much respiratory distress?Breathing: How much respiratory distress?

• Can’t speak in complete sentencesCan’t speak in complete sentences• Tachypnea (if not tachypneic may be getting fatigued)Tachypnea (if not tachypneic may be getting fatigued)• Accessory muscle useAccessory muscle use• Retractions, nasal flaring, gruntingRetractions, nasal flaring, grunting• CyanosisCyanosis• Hypoxia (decreased pulse ox)Hypoxia (decreased pulse ox)• Wheezing (may not hear wheezing if they are not Wheezing (may not hear wheezing if they are not

moving any air at all!)moving any air at all!)• Decreased air movementDecreased air movement

• CirculationCirculation

Differential Diagnosis Differential Diagnosis for SOBfor SOB

Most Common• Obstructive: Asthma, Obstructive: Asthma,

COPDCOPD• Congestive heart Congestive heart

failurefailure• Ischemic heart Ischemic heart

diseasedisease• PneumoniaPneumonia• Psychogenic: Panic, Psychogenic: Panic,

anxietyanxiety

Urgently Life Threatening

• Upper airway obstructionUpper airway obstruction• Foreign bodyForeign body• Angioedema/anaphylaxisAngioedema/anaphylaxis

• Tension pneumothoraxTension pneumothorax• Pulmonary embolismPulmonary embolism• Neuromuscular weaknessNeuromuscular weakness

• Myasthenia gravis Myasthenia gravis

• Guillain-BarreGuillain-Barre

Immediate Actions Immediate Actions (First 10 minutes)(First 10 minutes)

• Supplemental oxygenSupplemental oxygen• Pulse oximetry with complete vital signsPulse oximetry with complete vital signs• BVM if decreased RR, shallow/weak BVM if decreased RR, shallow/weak

respirationsrespirations• Decide need for endotracheal intubationDecide need for endotracheal intubation• IV access, labs, and ABGIV access, labs, and ABG• Portable chest x-ray – STATPortable chest x-ray – STAT• EKG if concerned for cardiac etiologyEKG if concerned for cardiac etiology• Brief history and focused physical examBrief history and focused physical exam• Form initial differential, begin treatmentForm initial differential, begin treatment

Focused Physical Focused Physical ExamExam

• Vital signsVital signs• RR, HR, BP, temp, O2 SatRR, HR, BP, temp, O2 Sat

• Mental StatusMental Status• Alert, confused, lethargicAlert, confused, lethargic

• HeartHeart• JVD, muffled heart sounds, JVD, muffled heart sounds,

S3, S4S3, S4

• LungsLungs• Rales, wheezing, Rales, wheezing,

diminished or absent BS, diminished or absent BS, stridorstridor

• Respiratory accessory Respiratory accessory muscle usemuscle use

• AbdomenAbdomen• Hepatomegaly, ascitesHepatomegaly, ascites

• SkinSkin• Diaphoresis, cyanosisDiaphoresis, cyanosis

• ExtremitiesExtremities• EdemaEdema• Unilateral leg swellingUnilateral leg swelling

• NeurologicNeurologic• Focal neurologic deficitsFocal neurologic deficits

**Reassess respiratory **Reassess respiratory status frequently status frequently especially in the first especially in the first 15 minutes or so15 minutes or so

Back to our asthma Back to our asthma case….case….

• What tests do you want?What tests do you want?

Evaluation of acute Evaluation of acute asthmaasthma

• Peak flowsPeak flows• Helpful in determining attack severityHelpful in determining attack severity• Can follow after treatments to see if improvedCan follow after treatments to see if improved• Want to be >80% of “predicted”Want to be >80% of “predicted”

• Continuous pulse oximetryContinuous pulse oximetry • CXR if you suspect a secondary problemCXR if you suspect a secondary problem

• PneumothoraxPneumothorax• Foreign bodyForeign body• Pneumonia Pneumonia

• ABG ABG might bemight be helpful in severe attacks helpful in severe attacks • Tachypnea should lead to decreased PCO2, and a Tachypnea should lead to decreased PCO2, and a

normal or high PCO2 indicates fatiguenormal or high PCO2 indicates fatigue

Remember Remember pathophysiologypathophysiology

• Asthma is an Asthma is an inflammatory diseaseinflammatory disease

• Bronchospasm is Bronchospasm is only a symptomonly a symptom

• Many possible Many possible causes: causes: • AllergiesAllergies• IrritantsIrritants• InfectionsInfections

• Poiseuille's Law- Radius has a huge affect on flow

What medications What medications and treatments do and treatments do you want to give?you want to give?

TreatmentsTreatments

• Supplemental Supplemental oxygenoxygen

• ββ22 agonists (Albuterol) agonists (Albuterol)• Nebulized: Nebulized: 2.5- 5 mg nebs q20 minutes, can be 2.5- 5 mg nebs q20 minutes, can be

continuous if needed continuous if needed • MDI with spacer: MDI with spacer: 6-12 puffs from MDI q20 6-12 puffs from MDI q20

minutes (4-8 in children)minutes (4-8 in children)

• Anti-cholinergics (Atrovent)Anti-cholinergics (Atrovent)• Adding Atrovent has been shown to decrease Adding Atrovent has been shown to decrease

admissionsadmissions• Albuterol/Atrovent combination for first treatmentAlbuterol/Atrovent combination for first treatment• 500 mcg in adults (250 mcg in kids) q6 hours500 mcg in adults (250 mcg in kids) q6 hours

TreatmentsTreatments• CorticosteroidsCorticosteroids

• Decrease airway inflammation (takes 4-8 hrs)Decrease airway inflammation (takes 4-8 hrs)• Reduces the need for hospitalization if Reduces the need for hospitalization if

administered within 1 hour of arrival in the administered within 1 hour of arrival in the EDED

• Adults: Adults: • Methylprednisolone 125mg IV/Prednisone 60mg POMethylprednisolone 125mg IV/Prednisone 60mg PO

• Pediatrics: Pediatrics: • Methylprednisolone 1 mg/kg IV or Prednisone 1-2 Methylprednisolone 1 mg/kg IV or Prednisone 1-2

mg/kg POmg/kg PO

• Continue steroids for 5 day courseContinue steroids for 5 day course

TreatmentsTreatments

• MagnesiumMagnesium• Bronchodilating propertiesBronchodilating properties• Shown to help in severe asthma Shown to help in severe asthma • Peak flow < 25% of predictedPeak flow < 25% of predicted• Relatively safeRelatively safe• Adult dose: 1-2 g IV over 30 Adult dose: 1-2 g IV over 30

minutesminutes

TreatmentsTreatments

• Non-invasive Positive Pressure Non-invasive Positive Pressure VentilationVentilation• Some evidence BiPAP or CPAP may Some evidence BiPAP or CPAP may

help in severe asthmahelp in severe asthma• Temporary until medications start Temporary until medications start

workingworking• Can help avoid intubationCan help avoid intubation• Pt must be awake and cooperativePt must be awake and cooperative

TreatmentsTreatments

• IntubationIntubation• Mechanical ventilation decreases work of breathing

and allows patient to rest• Indications: Hypercarbia, acidosis, respiratory fatigue• Complications:

• High peak airways pressures and barotrauma• Hemodynamic impairment• Atelectasis and pneumonia from frequent mucus plugging

• Special considerations• Increased I:E ratio to help prevent breath stacking• Permissive hypoventilation with goal >90% oxygen

saturation

• Heli-oxHeli-ox

Admit or not?Admit or not?• Depends on: Improvement of Depends on: Improvement of

symptoms, risk factors for death, social symptoms, risk factors for death, social situation, compliance, and patient situation, compliance, and patient comfort with going homecomfort with going home

• In general:In general:• HOME if complete resolution of symptoms HOME if complete resolution of symptoms

and peak flow > 70% of predictedand peak flow > 70% of predicted• ADMIT if poor response to treatment and ADMIT if poor response to treatment and

peak flow < 50% of predictedpeak flow < 50% of predicted• ALL OTHERS – Depends on combination of ALL OTHERS – Depends on combination of

above factors, when in doubt ASK THE above factors, when in doubt ASK THE PATIENT!PATIENT!

DischargeDischarge• All patients need steroids for at least 5 days All patients need steroids for at least 5 days • All patients need All patients need ββ22 agonists agonists• All patients with more than mild intermittent All patients with more than mild intermittent

asthma asthma (need inhaler > 2 x week, peak flow < 80% (need inhaler > 2 x week, peak flow < 80% of predicted)of predicted) need inhaled steroids need inhaled steroids

• Patients with moderate-to-severe asthma Patients with moderate-to-severe asthma (daily(daily symptoms)symptoms) should measure daily peak flows should measure daily peak flows

• All patients need close follow upAll patients need close follow up• All patients need education about asthmaAll patients need education about asthma• Smoking cessation counselingSmoking cessation counseling

Case #2Case #2• 65 yo M with shortness of breath for past 65 yo M with shortness of breath for past

several hours, getting increasingly worse; now several hours, getting increasingly worse; now drowsy and difficult to arouse; pt with hx of drowsy and difficult to arouse; pt with hx of smoking 2ppd for many years, is on home smoking 2ppd for many years, is on home oxygen.oxygen.

• T: 99.9, HR: 98, R: 30, BP: 165/70, O2sat: 89% T: 99.9, HR: 98, R: 30, BP: 165/70, O2sat: 89% room air, 92% 2LNCroom air, 92% 2LNC

• Physical exam: barrel chest, pursed lips, Physical exam: barrel chest, pursed lips, wheezing, prolonged expirations, diminished wheezing, prolonged expirations, diminished breath sounds throughoutbreath sounds throughout

• Likely diagnosis?Likely diagnosis?• What else is on your differential diagnosis?What else is on your differential diagnosis?

COPDCOPD• Chronic airway Chronic airway

inflammationinflammation• Inflammatory cells Inflammatory cells

and mediatorsand mediators• Protease / anti-Protease / anti-

protease imbalanceprotease imbalance• Oxidative stressOxidative stress

• Increases in lung Increases in lung compliancecompliance

• Becomes an Becomes an obstructive processobstructive process

• Ask patients Ask patients about:about:

• History of COPD• Change in cough or

sputum • Fever, infectious signs• Medications (steroids)• Environmental

exposures• Smoking history

Physical exam Physical exam findings in COPDfindings in COPD

• Signs of Signs of HypoxemiaHypoxemia• TachypneaTachypnea• TachycardiaTachycardia• HypertensionHypertension• CyanosisCyanosis

• Signs of Signs of HypercapniaHypercapnia• Altered mental Altered mental

statusstatus• HypopneaHypopnea

COPDCOPD• Chest X-rayChest X-ray

• HyperinflationHyperinflation• Flattened diaphragmsFlattened diaphragms• Increased AP Increased AP

diameterdiameter

• EKGEKG• Wandering Wandering

pacemakerpacemaker• Multifocal atrial Multifocal atrial

tachycardia (MAT)tachycardia (MAT)• Right axis deviationRight axis deviation

Treatment for COPDTreatment for COPD• Supplemental Supplemental oxygenoxygen

• Careful in patients that are COCareful in patients that are CO22 retainers retainers• Loss of hypoxic drive can result in respiratory arrestLoss of hypoxic drive can result in respiratory arrest• Goal: 90-92% oxygen saturationGoal: 90-92% oxygen saturation

• BronchodilatorsBronchodilators (Albuterol and atrovent) (Albuterol and atrovent)• AntibioticsAntibiotics

• (Which antibiotics would be appropriate?)(Which antibiotics would be appropriate?)• CorticosteroidsCorticosteroids

• 7-14 day course improves FEV1 in exacerbations7-14 day course improves FEV1 in exacerbations• Hyperglycemia is common side effectHyperglycemia is common side effect

Treatment for COPDTreatment for COPD

• Positive-pressure ventilationPositive-pressure ventilation• Indicated for respiratory fatigue, Indicated for respiratory fatigue,

acidosis, hypoxia, hypercapniaacidosis, hypoxia, hypercapnia• Can decrease intubation rates Can decrease intubation rates

and possibly improves survivaland possibly improves survival• Patient needs to be awake, Patient needs to be awake,

cooperative, and able to handle cooperative, and able to handle secretionssecretions

Case #3Case #3

• 35 yo previously healthy F c/o one 35 yo previously healthy F c/o one week of headache, sore throat and week of headache, sore throat and muscle aches, fevers, now with muscle aches, fevers, now with productive cough and increasing productive cough and increasing fatigue. fatigue.

• On physical exam she is febrile and On physical exam she is febrile and has decreased breath sounds over has decreased breath sounds over the RLL.the RLL.

• What is your differential and work-up?What is your differential and work-up?

PneumoniaPneumonia

• Clinical features:Clinical features:• Typically: Cough, Typically: Cough,

dyspnea, sputum dyspnea, sputum production, fever, production, fever, pleuritic chest painpleuritic chest pain

• Pneumococcal: sudden Pneumococcal: sudden onset of fever, rigors, onset of fever, rigors, productive cough, productive cough, tachypneatachypnea

• Atypical pneumonia: Atypical pneumonia: Coryza, low grade fevers, Coryza, low grade fevers, non-productive coughnon-productive cough

• On exam:On exam:• Tachypnea, Tachypnea,

tachycardia, fevertachycardia, fever• Inspiratory rales = Inspiratory rales =

Alveolar fluidAlveolar fluid• Bronchial breath Bronchial breath

sounds = sounds = ConsolidationConsolidation

• Dullness/decreased BS Dullness/decreased BS = Pleural effusion= Pleural effusion

• Rhonchi = Bronchial Rhonchi = Bronchial congestioncongestion

PathophysiologyPathophysiology

• Usually inhaled/aspirated pathogensUsually inhaled/aspirated pathogens• Risk- Stroke, seizure, intoxicationRisk- Stroke, seizure, intoxication

• Hematogenous spread- Staph. aureusHematogenous spread- Staph. aureus• Infection within alveoli with intense Infection within alveoli with intense

inflammatory responseinflammatory response• Filling alveoli with bacteria, WBC, Filling alveoli with bacteria, WBC,

exudateexudate

Which patient groups Which patient groups get which types?get which types?

• PneumococcusPneumococcus• Staph aureusStaph aureus• KlebsiellaKlebsiella• PseudomonasPseudomonas• HaemophilusHaemophilus

• AtypicalAtypical• ChlamydiaChlamydia• MycoplasmaMycoplasma• LegionellaLegionella

•

Special populationsSpecial populations• DiabeticsDiabetics• HIVHIV

• Pneumonia more Pneumonia more common and has higher common and has higher morbidity than non-HIV morbidity than non-HIV populationpopulation

• Pneumococcus= Most Pneumococcus= Most common bacteriacommon bacteria

• CD4>800: Bacterial CD4>800: Bacterial more commonmore common

• CD4 250-500: TB, CD4 250-500: TB, cryptococcus, cryptococcus, histoplasmahistoplasma

• CD4< 200: PCP, CMVCD4< 200: PCP, CMV

• Elderly/Nursing homeElderly/Nursing home• Predictors for morbidity: Predictors for morbidity:

Tachycardia, tachypnea, Tachycardia, tachypnea, temp>100.4, temp>100.4, somnolence, confusion, somnolence, confusion, crackles, leukocytosiscrackles, leukocytosis

• Pathogens: Pathogens: Pneumococcus, gram Pneumococcus, gram negatives, Haemophilus, negatives, Haemophilus, influenzainfluenza

• May just present with May just present with confusion, weaknessconfusion, weakness

PneumoniaPneumonia

• Chest X-rayChest X-ray• Measure O2 Measure O2

sat, CBC, sat, CBC, electrolyteselectrolytes

• Blood cultures Blood cultures for admitted for admitted patients (before patients (before antibiotics)antibiotics)

TreatmentTreatment

• Pneumococcal most common, but Pneumococcal most common, but atypicals becoming more prevalentatypicals becoming more prevalent

• Outpatient Outpatient • Doxycycline Doxycycline • Newer macrolide (Azithromycin)Newer macrolide (Azithromycin)• Fluroquinolone (Levofloxacin) Fluroquinolone (Levofloxacin)

• Also consider MRSA for severe Also consider MRSA for severe infectionsinfections

TreatmentTreatment

• InpatientInpatient• Early antibiotics lowers mortalityEarly antibiotics lowers mortality• 33rdrd gen cephalosporin (Ceftriaxone) gen cephalosporin (Ceftriaxone)

or PCN w/ beta-lactamase inhibitor or PCN w/ beta-lactamase inhibitor (Unasyn/Zosyn) (Unasyn/Zosyn) plusplus macrolide macrolide (Azithromycin)(Azithromycin)

• Fluroquinolone alone (Levofloxacin)Fluroquinolone alone (Levofloxacin)• Add pseudomonal coverage Add pseudomonal coverage

(Cefepime) as needed i.e. CF patient(Cefepime) as needed i.e. CF patient

Admission or not?Admission or not?

• 75% CAP do not require admission, 75% CAP do not require admission, can be discharged with follow upcan be discharged with follow up

• Admission: Elderly, HIV pts, Admission: Elderly, HIV pts, tachypnea, oxygen requirementtachypnea, oxygen requirement

• PORT scorePORT score• ICU: Markedly tachypneic, high ICU: Markedly tachypneic, high

oxygen requirement, evidence of oxygen requirement, evidence of shockshock

Case #4Case #4• 65 yo M with hx of CAD s/p CABG with 65 yo M with hx of CAD s/p CABG with

increasing dyspnea on exertion, increasing dyspnea on exertion, orthopnea, increasing swelling in feet and orthopnea, increasing swelling in feet and ankles, now today with acute shortness of ankles, now today with acute shortness of breath and respiratory distress. No chest breath and respiratory distress. No chest pain, no fevers; ROS otherwise negativepain, no fevers; ROS otherwise negative

• Pt in moderate respiratory distress on Pt in moderate respiratory distress on exam with diffuse crackles in all lung fieldsexam with diffuse crackles in all lung fields

• What is your differential diagnosis and What is your differential diagnosis and approach to this patient?approach to this patient?

Congestive Heart Congestive Heart FailureFailure

• Can present with acute Can present with acute pulmonary edema and pulmonary edema and with respiratory distresswith respiratory distress

• Due to decreasing CO Due to decreasing CO and rising SVRand rising SVR

• Sympathetic nervous Sympathetic nervous system and renin-system and renin-angiotensin-aldosterone angiotensin-aldosterone system are activatedsystem are activated

• Result: Volume Result: Volume overload, pulmonary overload, pulmonary edema,resp distressedema,resp distress

Causes of acute Causes of acute decompensation in decompensation in

CHFCHF• Non-complianceNon-compliance

• Medications: diureticsMedications: diuretics• Diet: excessive saltDiet: excessive salt

• CardiacCardiac• ArrhythmiaArrhythmia• ACSACS• Uncontrolled HTNUncontrolled HTN

• OtherOther• Volume overload due to renal failureVolume overload due to renal failure• PEPE• Exacerbation of other co-morbidity (ex. COPD)Exacerbation of other co-morbidity (ex. COPD)

What are some signs What are some signs and symptoms of and symptoms of

CHF?CHF?

Signs & Symptoms of Signs & Symptoms of CHFCHF

• Symptoms Symptoms • Respiratory distressRespiratory distress• Cool / diaphoretic Cool / diaphoretic

skinskin• Weight gainWeight gain• Peripheral edemaPeripheral edema• Orthopnea Orthopnea • Paroxysmal Paroxysmal

nocturnal dyspneanocturnal dyspnea• Abdominal painAbdominal pain

• SignsSigns• Elevated JVDElevated JVD• S3 S3 • HypertensionHypertension• Rales Rales • +/- peripheral +/- peripheral

edemaedema• +/- RUQ tenderness +/- RUQ tenderness

(congested liver)(congested liver)• Tachypnea Tachypnea

Evaluation of CHFEvaluation of CHF• CXR (portable)CXR (portable)

• CardiomegalyCardiomegaly• Vascular congestionVascular congestion• Pulmonary edemaPulmonary edema

• LabsLabs• CBC, electrolytes, CBC, electrolytes,

cardiac enzymes, cardiac enzymes, BNPBNP

• EKGEKG• Search for cause of Search for cause of

decompensationdecompensation

What is the BNP and What is the BNP and why do we care?why do we care?

• Natriuretic peptide released by RA Natriuretic peptide released by RA when heart is stretched i.e. volume when heart is stretched i.e. volume overloadoverload

• Level correlates with CHF severity, Level correlates with CHF severity, rate of re-hospitalization, and risk of rate of re-hospitalization, and risk of deathdeath•BNP > 480 = 40% risk of re-BNP > 480 = 40% risk of re-

hospitalization or death within 6 monthshospitalization or death within 6 months• Helps to distinguish between other Helps to distinguish between other

causes of SOB i.e. COPDcauses of SOB i.e. COPD

Differential Diagnosis Differential Diagnosis • Pulmonary:Pulmonary:

• Asthma/COPD Asthma/COPD exacerbationexacerbation

• Pulmonary embolusPulmonary embolus• PneumothoraxPneumothorax• Pleural effusionPleural effusion• PneumoniaPneumonia

• Cardiac:Cardiac:• ACS, arrhythmiaACS, arrhythmia• Acute valvular Acute valvular

insufficiencyinsufficiency• Pericardial tamponadePericardial tamponade

• Fluid retentive Fluid retentive states:states:• Liver failure, portal Liver failure, portal

vein thrombosisvein thrombosis• Renal failureRenal failure• Nephrotic Nephrotic

syndromesyndrome• HypoproteinemiaHypoproteinemia

• High output states:High output states:• SepsisSepsis• AnemiaAnemia• Thyroid dysfunctionThyroid dysfunction

TreatmentTreatment

• Control airway and maintain Control airway and maintain ventilationventilation

• Supplemental oxygenSupplemental oxygen• Cardiac monitoringCardiac monitoring• Pulse oximetryPulse oximetry• Establish IV accessEstablish IV access• +/- ABG+/- ABG• Frequent vital signsFrequent vital signs

Which medications Which medications are used to treat are used to treat

CHF?CHF?

Treatment of CHFTreatment of CHF

• Preload reductionPreload reduction• VasodilatorsVasodilators• Inotropic support if neededInotropic support if needed

Treatment of CHFTreatment of CHF• Reduce preload and afterload:Reduce preload and afterload:

• Nitroglycerin by sublingual or IV routeNitroglycerin by sublingual or IV route• Volume reductionVolume reduction

• Lasix- Diuresis starts in 15-20 minutesLasix- Diuresis starts in 15-20 minutes• If no prior use: 40 mg IVIf no prior use: 40 mg IV• Outpatient use: Double last 24 hour usageOutpatient use: Double last 24 hour usage• If no effect by 30 minutes, repeat a doubled doseIf no effect by 30 minutes, repeat a doubled dose

• Clinical endpoint- Rapidly lower filling Clinical endpoint- Rapidly lower filling pressures to prevent need for pressures to prevent need for endotracheal intubationendotracheal intubation

• Place foley catheter and monitor UOPPlace foley catheter and monitor UOP

NIPPVNIPPV

• Noninvasive Positive Pressure Ventilation• Controversial but worth a try in severe

respiratory distress• Temporizes while medical therapy is

working• BiPAP may decrease need for

intubation • Patient cooperation is required

The EndThe End

• Any questions?Any questions?