Differential Diagnosis Dyspnea

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  • 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.

  • Case 1

    Summary: NH resident with chronic illness, fever, tachypnea, tachycardia, hypotension, hypoxia and localized crackles.

    DDX: pneumonia, CHF, COPD exacerbation, pneumonitis, pulmonary fibrosis

  • Case 1

    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

    Classic symptoms:

    Productive cough, fever, dyspnea, chest pain, confusion, SIRS signs

    Classic 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

    Tachypnea 0.25

    Increased Tactile Fremitus 0.01

    Dullness to precusion 0.52

    Decreased BS 0.43

    Wheezes 0.51

    Crackles 0.41

    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.

    Rhinorrhea -2

    Sore throat -1

    Night sweats 1

    Myalgias 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

    Confusion 1

    BUN > 19 1

    RR > 30 1

    SBP 4 27.8%

  • A word on sepsis

    http://www.internalizemedicine.com/2012/02/defining-systemic-inflammatory-response-syndrome-sirs-and-sepsis-criteria.html

  • 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

    Sepsis Alert.

  • Case 2

    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

  • Case 2

    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

  • Case 2

    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

    Post-viral cough

    Post-nasal drip

    Whooping cough

    GERD

    COPD/Asthma

    ACE-inhibitor inducted cough

    Acute CoughBronchits/URI

    Asthma

    Pneumonia

    Influenza

    COPD

    Allergic Rhinitis

  • 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.

  • Asthma Treatment

    Ketamine

    Titrated oxygen

    Beta-agonists

    Anticholinergics

    Steroids

    CPAP

    Magnesium

    Intubation as last resort

  • Case 3

    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.

    No fever.

  • 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

    LS: Clear

    Ext: right calf is swollen, red and tender

  • Case 3

    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

  • Case 3

    Titrated oxygen

    IV fluids for pressure support

    Vasopressors as neededAnalgesia

    CPAP

  • Pulmonary Embolism

    Acute thrombosis of pulmonary arteries.

    V/Q mismatch

    Decreased LV preload Decreased CO

    Shock

  • Virchows Triad

    Clotting disorders Hormones

    Pregnancy

    Surgery

    Immobility

    Fracture

  • 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

  • Case 4

    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

  • Case 6

    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.

  • COPD Pathophysiology

  • COPD Hyperinflation

  • 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!

  • LLSA

    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

    HIB/GIA.

    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.

    jeffjarvis@wilco.org

    mailto:jeffjarvis@wilco.org