Help me, I cant breathe!
A differential diagnosis based approach to the patient with dyspnea.
Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP
Good Morning Scotty!
Case 1 Dispatched to a nursing home for a 78 year old
woman with advanced dementia and a cough.
Pt cant 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. Theyve all been on break. For a month.
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.
Summary: NH resident with chronic illness, fever, tachypnea, tachycardia, hypotension, hypoxia and localized crackles.
DDX: pneumonia, CHF, COPD exacerbation, pneumonitis, pulmonary fibrosis
ED Evaluation reveals:
WBC 21K with elevated bands, Cr 3.4, Anion Gap 20, Lactate 9.
Pneumonia Inflammation of alveoli from infectious source
Bacteria, viri, fungi
Productive cough, fever, dyspnea, chest pain, confusion, SIRS signs
Tachypnea, tachycardia, fever, crackles.
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
Reliability of Lung ExamFinding Kappa Value
Increased Tactile Fremitus 0.01
Dullness to precusion 0.52
Decreased BS 0.43
Kappa Value Strength
0.0 - 0.2 Poor
0.21 - 0.40 Fair
0.41 - 0.60 Moderate
0.61 - 0.80 Good
0.81 - 1.00 Very good
PNA Prediction RulesDiehr, et al.
Sore throat -1
Night sweats 1
RR > 25 2
T > 100 2>3 = LR + 14.0
Heckerling et al
Add the number present:
Absence of asthma T > 100 HR > 100 Decreased BS Crackles 0 =
Pneumonia SeverityCURB-65 Severity Score
BUN > 19 1
RR > 30 1
SBP 4 27.8%
A word on sepsis
Case 1: Treatment Oxygen titrated to correct hypoxia
Ventilatory support as needed: CPAP, RSI
IV fluids: NS 20 - 40 ml/kg
Pressors as needed: norepinephrine 2 - 10 mcg/min for refractory hypotension
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 non-productive, hacking cough.
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
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
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.
Common Causes of CoughChronic Cough
ACE-inhibitor inducted cough
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.
Intubation as last resort
35 year old woman complains of acute onset of dyspnea (I just cant take a full deep breath).
Reports focal, inspiratory chest pain, non-productive cough.
Case 3 History: No prior medical problems. Smoker.
Takes OCPs. Recent long plan trip from Sierra Leone (no fevercalm down).
VS: BP 92/65, HR 120, RR 33, SaO2 86%, EtCO2 32%, ECG sinus tach
Ext: right calf is swollen, red and tender
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
IV fluids for pressure support
Vasopressors as neededAnalgesia
Acute thrombosis of pulmonary arteries.
Decreased LV preload Decreased CO
Clotting disorders Hormones
PE Exclusion RulesPERC Rule
Age < 50
HR < 100
SaO2 > 95%
No hemoptysis, OCP, recent surgery/trauma
No unilateral leg swelling
HAD CLOTSHormoneAge > 50
DVT/PE HistoryCoughing blood
Leg swellingO2 > 95%
Tachycardia (>100)Surgery < 28 days
17 year old male with sudden onset of dyspnea, pleuritic, non-radiating chest pain.
Strong odor of marijuana
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
Important Clinical Finding
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.
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
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.
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!
All Pts(Hi vs Titr.)
COPD(Hi vs Titr.)
Mortality 9% vs 4% 9% vs 2%
RR Reduction 58% 78%
Summary Presence of fever
History is important. Very important
Lung sounds helpful but not reliable
Not all dyspnea is respiratory
CPAP cures what ailes ya!
Titrate oxygen: use only what the patient needs.
William J. Meleski, MD
Im happy to help.