DyspneaDyspnea

Victor Politi, M.D., FACPVictor Politi, M.D., FACPMedical Director, St. Anthony’s Medical Director, St. Anthony’s School of Allied Health School of Allied Health Professions, Physician Assistant Professions, Physician Assistant ProgramProgram

• Dyspnea, the sensation of Dyspnea, the sensation of breathlessness or inadequate breathlessness or inadequate breathing, is the most common breathing, is the most common complaint of patients with complaint of patients with cardiopulmonary diseases. cardiopulmonary diseases.

• Dyspnea - common Dyspnea - common complaint/symptomcomplaint/symptom• ““shortness of breath” or shortness of breath” or

“breathlessness”“breathlessness”

• Defined as abnormal/uncomfortable Defined as abnormal/uncomfortable breathing breathing

• Multiple etiologies - Multiple etiologies - • 2/3 of cases - cardiac or pulmonary 2/3 of cases - cardiac or pulmonary

etiology etiology

• There is no one specific cause of There is no one specific cause of dyspnea and no single specific dyspnea and no single specific treatmenttreatment

• Treatment varies according to Treatment varies according to patient’s conditionpatient’s condition• chief complaintchief complaint• historyhistory• examexam• laboratory & study resultslaboratory & study results

Differential Diagnosis Differential Diagnosis

• Composed of four general Composed of four general categoriescategories• CardiacCardiac• PulmonaryPulmonary• Mixed cardiac or pulmonaryMixed cardiac or pulmonary• non-cardiac or non-pulmonarynon-cardiac or non-pulmonary

Pulmonary EtiologyPulmonary Etiology

• COPDCOPD• AsthmaAsthma• Restrictive Lung DisordersRestrictive Lung Disorders• Hereditary Lung DisordersHereditary Lung Disorders• PneumoniaPneumonia• PneumothoraxPneumothorax

Cardiac EtiologyCardiac Etiology• CHFCHF• CADCAD• MI (recent or past history)MI (recent or past history)• CardiomyopathyCardiomyopathy• Valvular dysfunctionValvular dysfunction• Left ventricular hypertrophyLeft ventricular hypertrophy• PericarditisPericarditis• ArrhythmiasArrhythmias

Mixed Cardiac/Pulmonary Mixed Cardiac/Pulmonary EtiologyEtiology

• COPD with pulmonary HTN and/or COPD with pulmonary HTN and/or cor pulmonalecor pulmonale

• DeconditioningDeconditioning• Chronic pulmonary emboliChronic pulmonary emboli• Pleural effusionPleural effusion

Noncardiac or Noncardiac or Nonpulmonary EtiologyNonpulmonary Etiology

• Metabolic conditions (e.g. acidosis)Metabolic conditions (e.g. acidosis)• PainPain• TraumaTrauma• Neuromuscular disordersNeuromuscular disorders• Functional Functional (anxiety,panic disorders, (anxiety,panic disorders,

hyperventilation)hyperventilation)

• Chemical exposureChemical exposure

Easily Performed Easily Performed Diagnostic TestsDiagnostic Tests

• Chest radiographsChest radiographs

• ElectrocardiographElectrocardiograph

• Screening spirometryScreening spirometry

• In cases where test results inconclusiveIn cases where test results inconclusive• complete PFTscomplete PFTs• ABGsABGs• EKGEKG• Standard exercise treadmill testing/ or Standard exercise treadmill testing/ or

complete cardiopulmonary exercise testingcomplete cardiopulmonary exercise testing• Consultation with Consultation with

pulmonologist/cardiologist may be usefulpulmonologist/cardiologist may be useful

• Commonly used to evaluate acute Commonly used to evaluate acute dyspneadyspnea

• can provide information about altered can provide information about altered pH, hypercapnia, hypocapnia or pH, hypercapnia, hypocapnia or hypoxemiahypoxemia

• normal ABGs do not exclude normal ABGs do not exclude cardiac/pulmonary dx as cause of cardiac/pulmonary dx as cause of dyspneadyspnea• Remember- ABGs may be normal even in Remember- ABGs may be normal even in

cases of acute dyspnea - ABGs do not cases of acute dyspnea - ABGs do not evaluate breathing evaluate breathing

ABGsABGs

• Rapid, widely available, noninvasive means Rapid, widely available, noninvasive means of assessment in most clinical situations-of assessment in most clinical situations-• insensitive (may be normal in acute dyspnea)insensitive (may be normal in acute dyspnea)

• The % of Oxygen saturation does not always The % of Oxygen saturation does not always correspond to PaOcorrespond to PaO22

• The hemoglobin desaturation curve can be The hemoglobin desaturation curve can be shifted depending on the pH, temperature or shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide arterial carbon monoxide or carbon dioxide levelslevels

PULSE OXPULSE OX

ASTHMAASTHMA

What is AsthmaWhat is Asthma

• A Chronic disease of the airways A Chronic disease of the airways that may cause:that may cause:• WheezingWheezing• BreathlessnessBreathlessness• Chest tightnessChest tightness• Nighttime or early morning coughingNighttime or early morning coughing

The bronchospasm characteristic The bronchospasm characteristic of the acute asthmatic attack is of the acute asthmatic attack is typically reversible. It improves typically reversible. It improves spontaneously or within minutes to spontaneously or within minutes to hours of treatmenthours of treatment

• Asthma can exist by itself or Asthma can exist by itself or coexist with chronic bronchitis, coexist with chronic bronchitis, emphysema, or bronchiectasisemphysema, or bronchiectasis

Symptoms/Chief Symptoms/Chief ComplaintComplaint

• Progressive dyspneaProgressive dyspnea• CoughCough• Chest tightnessChest tightness• Wheezing/coughingWheezing/coughing

• The rapidly reversible airflow The rapidly reversible airflow obstruction of asthma is mainly obstruction of asthma is mainly due to bronchial smooth muscle due to bronchial smooth muscle contractioncontraction

Focus of TherapyFocus of Therapy

• Pharmacologic manipulation of airway smooth Pharmacologic manipulation of airway smooth musclemuscle

• Do not overlook physiologic impairment caused Do not overlook physiologic impairment caused by mucous production and mucosal edemaby mucous production and mucosal edema

• Bronchospasm can be reversed in minutesBronchospasm can be reversed in minutes• Airflow obstruction due to mucous plugging and Airflow obstruction due to mucous plugging and

inflammatory changes in bronchial walls may not inflammatory changes in bronchial walls may not resolve for days/weeks - resolve for days/weeks - • may lead to atelectasis, infectious bronchitis, may lead to atelectasis, infectious bronchitis,

pneumonitispneumonitis

Asthma TriggersAsthma Triggers• Immunologic reactionImmunologic reaction• Viral respiratory/sinus infectionsViral respiratory/sinus infections• change in temperature/humiditychange in temperature/humidity• Drugs/Chemicals - Drugs/Chemicals -

• aspirin, NSAIDSaspirin, NSAIDS

• ExerciseExercise• GE refluxGE reflux• Laughing/coughingLaughing/coughing• Environmental factors -Environmental factors -

• strong odors, pollutants, dust, fumesstrong odors, pollutants, dust, fumes

Patient ExamPatient Exam

• Wheezing Wheezing • may be audible w/o stethoscopemay be audible w/o stethoscope

• Use of accessory muscles of inspirationUse of accessory muscles of inspiration• diaphragmatic fatiguediaphragmatic fatigue• Paradoxical respirationsParadoxical respirations

• - reflect impending ventilatory failure- reflect impending ventilatory failure

• Altered mental status -Altered mental status -• lethargy, exhaustion, agitation, confusionlethargy, exhaustion, agitation, confusion

Patient ExamPatient Exam

• Hypersonance to percussionHypersonance to percussion• decreased intensity of breath decreased intensity of breath

soundssounds• prolongation of expiratory phase w prolongation of expiratory phase w

or w/o wheezingor w/o wheezing

Patient ExamPatient Exam

• The intensity of the wheeze may The intensity of the wheeze may not correlate with the severity of not correlate with the severity of airflow obstructionairflow obstruction

• ““quiet chest” - very severe airflow quiet chest” - very severe airflow obstructionobstruction

Asthma TreatmentAsthma Treatment

• Nebulized B-adrenergic drugsNebulized B-adrenergic drugs• CorticosteroidsCorticosteroids• Nebulized anticholinergicsNebulized anticholinergics• Magnesium sulfateMagnesium sulfate• OxygenOxygen• Long acting beta-agonistsLong acting beta-agonists• Inhaled steroidsInhaled steroids

Managing Asthma: Managing Asthma:

• Indications of a severe attack:Indications of a severe attack:• Breathless at restBreathless at rest• hunched forwardhunched forward• talking in words rather than talking in words rather than

sentencessentences• AgitatedAgitated• Peak flow rate less than 60% of Peak flow rate less than 60% of

normalnormal

Treatment Goals of Severe Treatment Goals of Severe AsthmaAsthma

• Improve airway function rapidlyImprove airway function rapidly• Avoid hypoxemiaAvoid hypoxemia• Prevent respiratory failure and Prevent respiratory failure and

deathdeath

COPDCOPD

COPDCOPD

• Hallmark symptom - DyspneaHallmark symptom - Dyspnea• Chronic productive coughChronic productive cough• Minor hemoptysisMinor hemoptysis• pink puffer pink puffer • blue bloaterblue bloater

COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat.

COPD - Physical FindingsCOPD - Physical Findings

• TachypneaTachypnea• Accessory respiratory muscle useAccessory respiratory muscle use• Pursed lip exhalationPursed lip exhalation• Weight loss due to poor dietary Weight loss due to poor dietary

intake and excessive caloric intake and excessive caloric expenditure for work of breathingexpenditure for work of breathing

Dominant Clinical Forms of Dominant Clinical Forms of COPDCOPD

• Pulmonary emphysemaPulmonary emphysema• Chronic bronchitisChronic bronchitis

• Most patients exhibit a mixture of Most patients exhibit a mixture of symptoms and signssymptoms and signs

COPD - Advanced DxCOPD - Advanced Dx

• secondary polycythemiasecondary polycythemia• cyanosiscyanosis• tremortremor• somnolence and confusion due to somnolence and confusion due to

hypercarbia hypercarbia • Secondary pulmonary HTN w or Secondary pulmonary HTN w or

w/o cor pulmonalew/o cor pulmonale

COPD Treatment StrategyCOPD Treatment Strategy

• Elimination of extrinsic irritantsElimination of extrinsic irritants• bronchodilator & glucocorticoid bronchodilator & glucocorticoid

therapytherapy• AntibioticsAntibiotics• Mobilization of secretionsMobilization of secretions• ““respiratory vaccines”respiratory vaccines”• Oxygen therapy - if oxygen saturation Oxygen therapy - if oxygen saturation

<90% at rest on room air<90% at rest on room air

SpirometrySpirometry

PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIA

• 6th leading cause of death in the 6th leading cause of death in the USUS

• Respiratory viruses & mycoplasma Respiratory viruses & mycoplasma responsible for greater than 1/3 of responsible for greater than 1/3 of casescases

Common types of respiratory Common types of respiratory infectionsinfections

• TracheobronchitisTracheobronchitis• PneumoniaPneumonia• EffusionsEffusions• EmpyemaEmpyema• AbscessAbscess• Cavitary lesionsCavitary lesions• post-obstructivepost-obstructive

Common Respiratory Common Respiratory VirusesViruses

• Influenza A & BInfluenza A & B• Parainfluenza 1& 3Parainfluenza 1& 3• Respiratory Syncytial VirusRespiratory Syncytial Virus• AdenovirusAdenovirus• CytomegalovirusCytomegalovirus• Herpes Simplex & Zoster/varicellaHerpes Simplex & Zoster/varicella• Hanta Virus InfectionHanta Virus Infection

Respiratory Syncytial Respiratory Syncytial VirusVirus

• Rapid diagnosis of Respiratory Rapid diagnosis of Respiratory Syncytial Virus Infection by Syncytial Virus Infection by immunofluorescence of immunofluorescence of respiratory secretionsrespiratory secretions

Classic Pneumonia Classic Pneumonia SymptomsSymptoms

• Dyspnea, chillsDyspnea, chills• high fever, cough/sputumhigh fever, cough/sputum• pleuritic chest painpleuritic chest pain

Viral Pneumonia - Viral Pneumonia - symptomssymptoms

• Chest PainChest Pain• FeverFever• DyspneaDyspnea• Prodrome - malaise, upper Prodrome - malaise, upper

respiratory symptoms, and other respiratory symptoms, and other GI symptomsGI symptoms

Viral pneumonia - Viral pneumonia - Clinical FindingsClinical Findings

• Minimal/variableMinimal/variable• Chest exam - may reveal wheezingChest exam - may reveal wheezing• Fine rales if heard can signify Fine rales if heard can signify

interstitial involvementinterstitial involvement• Chest x-ray - patchy densities or Chest x-ray - patchy densities or

interstitial involvementinterstitial involvement

Viral pneumoniaViral pneumoniaManagement /ProphylaxisManagement /Prophylaxis

• Supportive treatment - decrease Supportive treatment - decrease severity of symptomsseverity of symptoms

• bed restbed rest• analgesicsanalgesics• expectorantsexpectorants• Patients w/Patients w/

• airway obstruction - treat w/bronchodilatorsairway obstruction - treat w/bronchodilators• secondary bacterial infection - antibioticssecondary bacterial infection - antibiotics

Atypical PneumoniaAtypical Pneumonia• Accounts for 25% of community acquired Accounts for 25% of community acquired

pneumoniaspneumonias• Mycoplasma/chlamyda/legionellaMycoplasma/chlamyda/legionella• can case extrapulmonary manifestations -can case extrapulmonary manifestations -

• meningitis, encephalitis, pericarditis, meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemiahepatitis, hemolytic anemia

• typically bilateral infiltrates on chest x-raytypically bilateral infiltrates on chest x-ray• primarily effects younger personsprimarily effects younger persons

Atypical PneumoniaAtypical PneumoniaTreatmentTreatment

• AntibioticsAntibiotics• MacrolidesMacrolides• fluroquinolonesfluroquinolones• doxycyclinedoxycycline

Bacterial pneumoniaBacterial pneumonia

• 3.3 million cases yearly in US3.3 million cases yearly in US• responsible for 10% of hospital responsible for 10% of hospital

admissionsadmissions• unilateral infiltrate on x-rayunilateral infiltrate on x-ray• high mortality in elderly populationhigh mortality in elderly population• most common cause pneumococcal most common cause pneumococcal

followed by haemophilus influenzafollowed by haemophilus influenza

• Pneumococcus pneumonia Pneumococcus pneumonia accounts for up to 90% of all accounts for up to 90% of all bacterial pneumoniasbacterial pneumonias

• Patients with a chronic Dx are at Patients with a chronic Dx are at an increased risk of contracting an increased risk of contracting pneumoniapneumonia

Bacterial pneumonia Bacterial pneumonia presentationpresentation

• acute shaking - chillsacute shaking - chills• tachypneatachypnea• tachycardiatachycardia• malaisemalaise• anorexiaanorexia• myalgias myalgias • flank or back painflank or back pain• vomitingvomiting

Lab TestsLab Tests

• WBCWBC• Chest X-rayChest X-ray• Pulse OxPulse Ox• ABGsABGs• Sputum examSputum exam• Blood culturesBlood cultures• pleural fluid exampleural fluid exam

PneumothoraxPneumothorax

Causes of Spontaneous Causes of Spontaneous PneumothoraxPneumothorax

• Pleural blebsPleural blebs• BullaeBullae• EmphysemaEmphysema• Interstitial lung diseaseInterstitial lung disease• Alpha 1 antitrypsin deficiencyAlpha 1 antitrypsin deficiency

Traumatic and Iatrogenic Traumatic and Iatrogenic CausesCauses

• Penetrating woundsPenetrating wounds• Line placementsLine placements• Lung biopsiesLung biopsies• Mechanical ventilationMechanical ventilation

Two most common Two most common symptomssymptoms

• DyspneaDyspnea• Chest painChest pain

Physical ExaminationPhysical Examination

• Decreased breath soundsDecreased breath sounds• hyperresonance to percussionhyperresonance to percussion• decreased tactile fremitusdecreased tactile fremitus

• In patients with emphysema - clinical In patients with emphysema - clinical findings may be subtlefindings may be subtle

Chest X-ray to Confirm DxChest X-ray to Confirm Dx

• 500ml of air required to visualize 500ml of air required to visualize pneumothorax on x-raypneumothorax on x-ray

• Characterized by -Characterized by -• hyperlucency and lack of lung markings hyperlucency and lack of lung markings

at the periphery of the lung and at the periphery of the lung and appearance of fine line that represents appearance of fine line that represents the retraction of the visceral from the the retraction of the visceral from the parietal pleuraparietal pleura

Treatment OptionsTreatment Options

• Observation - if pneumothorax Observation - if pneumothorax involves < 15-20% of hemithorax involves < 15-20% of hemithorax and patient relatively and patient relatively asymptomaticasymptomatic

• Tube thoracostomyTube thoracostomy• Simple AspirationSimple Aspiration

Pulmonary EmbolismPulmonary Embolism

PE HistoryPE History

• PE is so common and deadly that PE is so common and deadly that the dx should be considered in any the dx should be considered in any patient who presents with chest patient who presents with chest symptoms that cannot be proven symptoms that cannot be proven to have another causeto have another cause

PE Risk MarkersPE Risk Markers

• Hypercoagulable statesHypercoagulable states• Prior hx of DVT or PEPrior hx of DVT or PE• Recent surgery or pregnancyRecent surgery or pregnancy• Prolonged immobolizationProlonged immobolization• Underlying malignancyUnderlying malignancy• smokingsmoking• birth control pillsbirth control pills• traumatrauma

Classic triad of Classic triad of signs/symptomssigns/symptoms

• These symptoms are not sensitive or specific and These symptoms are not sensitive or specific and occur in fewer than 20% of patients diagnosed occur in fewer than 20% of patients diagnosed with PEwith PE

HemoptysisDyspnea

Chest Pain

PE Physical ExamPE Physical Exam

• Massive PE causes hypotension Massive PE causes hypotension due to acute cor pulmonaledue to acute cor pulmonale

• Physical findings in early Physical findings in early submassive PE may be completely submassive PE may be completely normalnormal

• Initially, abnomal findings are Initially, abnomal findings are absent in most patients with PEabsent in most patients with PE

Massive PE - Massive PE - Signs/SymptomsSigns/Symptoms

• Tachypnea -96%Tachypnea -96%• Rales - 58%Rales - 58%• Accentuated second heart sound - 53%Accentuated second heart sound - 53%• Tachycardia - 44%Tachycardia - 44%• Fever - 43%Fever - 43%• SS3 3 or Sor S44 gallop - 34% gallop - 34%• signs/symptoms suggestive of signs/symptoms suggestive of

thrombophlebitis - 32%thrombophlebitis - 32%• Lower extremity edema - 24%Lower extremity edema - 24%• Cardiac murmur - 23%Cardiac murmur - 23%• Cyanosis - 19%Cyanosis - 19%

Massive PE Diagnostic Massive PE Diagnostic StudiesStudies

• VQ scanVQ scan• Pulmonary angiographyPulmonary angiography• CTCT• Echocardiography (TEE)Echocardiography (TEE)• Pulmonary artery catheterizationPulmonary artery catheterization• Diagnostic algorithmDiagnostic algorithm• D-dimerD-dimer• blood gases increased A-a gradient blood gases increased A-a gradient

A-a gradientA-a gradient

A-a gradient = A-a gradient = predicted pOpredicted pO2 2 – observed PO– observed PO22

PAOPAO22 = (FIO = (FIO22 X 713) – (PaCO X 713) – (PaCO22/0.8) at sealevel/0.8) at sealevel

PAOPAO22 = 150-(PaCO = 150-(PaCO22/0.8) at sealevel on room air/0.8) at sealevel on room air

Normal range 10-15mm > 30 years of ageNormal range 10-15mm > 30 years of ageNormal range 8mm < 30 years of ageNormal range 8mm < 30 years of ageIncreased A-aDOIncreased A-aDO22=diffusion defect=diffusion defectRight to left shunt Right to left shunt V/Q mismatchV/Q mismatch

ExamplesExamples• A doubel overdose brings two 30 yr old A doubel overdose brings two 30 yr old

patients to the ED. Both have ingested patients to the ED. Both have ingested substantial amounts of barbiturates and substantial amounts of barbiturates and diazepam. Blood gases drawn on room diazepam. Blood gases drawn on room air revealed these values: air revealed these values:

• patient 1- pH =7.18, PCOpatient 1- pH =7.18, PCO22 = 70mmHg, = 70mmHg, POPO22=50mmHg, HCO=50mmHg, HCO33=24mEq/L; =24mEq/L;

• patient2- pH =7.31, PCOpatient2- pH =7.31, PCO22=50mmHg, =50mmHg, POPO22=50mmHg, HCO=50mmHg, HCO33=25mEq/L=25mEq/L

CommentComment

• The A-a gradient calculation for patient The A-a gradient calculation for patient 1 is as follows:1 is as follows:

• A-a DOA-a DO22 = PAO = PAO22 – PaO – PaO22

• PAOPAO22 = 150 – (1.25x PCO = 150 – (1.25x PCO22))

• PAOPAO22 = 150 – (1.25x 70) = 150 – (1.25x 70)

• PAOPAO22 = 62 = 62

• A-a =62 – 50A-a =62 – 50• A-a = 12A-a = 12

CommentComment

• The calculation reveals a normal The calculation reveals a normal gradient, indicating that the gradient, indicating that the etiology for hypoxemia and etiology for hypoxemia and hypoventilation is extrinsic to the hypoventilation is extrinsic to the lung itself.lung itself.

CommentComment

• The A-a gradient calculation for The A-a gradient calculation for patient 2 is as follows:patient 2 is as follows:

• PAOPAO22 = 150 – (1.25 x PCO = 150 – (1.25 x PCO22))• PAOPAO22 = 150 – (1.25 x 50) = 150 – (1.25 x 50)• PAOPAO22 = 150 – 63 = 150 – 63• PAOPAO22 = 87 = 87 • Therefore, A-a = 87 – 50 =37 (an Therefore, A-a = 87 – 50 =37 (an

abnormally increased gradient)abnormally increased gradient)

CommentComment

• We can be reasonably confident We can be reasonably confident that patient 1 suffered that patient 1 suffered hypoventilation due to the effect of hypoventilation due to the effect of the ingested drugs on the brain the ingested drugs on the brain stem. stem.

• Temporary mechanical ventilation Temporary mechanical ventilation restored this patient’s gas restored this patient’s gas exchange. exchange.

CommentComment

• Patient 2, on the other hand, had an Patient 2, on the other hand, had an increased A-a gradient, indicating a lung increased A-a gradient, indicating a lung problem in addition to any central cause problem in addition to any central cause for hypoventilation. for hypoventilation.

• The chest x-ray film revealed that this The chest x-ray film revealed that this patient’s overdose was complicated by patient’s overdose was complicated by aspiration pneumonitis and that the aspiration pneumonitis and that the patient required treatment with patient required treatment with antibiotics in addition to mechanical antibiotics in addition to mechanical ventilation.ventilation.

Treatment StrategiesTreatment Strategies

• Fluid administration Fluid administration • anticoagulationanticoagulation• Vena caval interruptionVena caval interruption• ThrombolyticsThrombolytics• oxygenoxygen• pulse oxpulse ox

CHF

Left sided FailureLeft sided Failure

• Blood/fluid back-up into the lungs - Blood/fluid back-up into the lungs - result inresult in• SOBSOB• Fatigue Fatigue • Cough (especially at night)Cough (especially at night)• PNDPND• orthopneaorthopnea

Right sided FailureRight sided Failure

• Build-up of fluid in the veins - Build-up of fluid in the veins - • Edema of feet, legs and anklesEdema of feet, legs and ankles

• may effect liver/portal circulation and may effect liver/portal circulation and 3rd spacing into soft 3rd spacing into soft tissue/ascites/pleural effusiontissue/ascites/pleural effusion

Causes of CHFCauses of CHF

• Variety of cardiac diseases Variety of cardiac diseases

• Most common cause of CHF - CADMost common cause of CHF - CAD

• other causes - valvular heart dx, other causes - valvular heart dx, HTN,cardiomyopathies, myocarditis, renal HTN,cardiomyopathies, myocarditis, renal dx,fluid overload,liver dx w/loss of protein dx,fluid overload,liver dx w/loss of protein and osmotic forces,high altitude and and osmotic forces,high altitude and many othersmany others

Physical FindingsPhysical Findings

• Peripheral edemaPeripheral edema• JVDJVD• tachycardiatachycardia• tachypnea, using accessory muscles of tachypnea, using accessory muscles of

respirationrespiration• Skin - diaphoretic/cold/gray/cyanoticSkin - diaphoretic/cold/gray/cyanotic• Wheezing/rales on ausculationWheezing/rales on ausculation• Apical impulse displaced laterallyApical impulse displaced laterally• ascitesascites• hepatosplenomegalyhepatosplenomegaly

Diagnostic Work-UpDiagnostic Work-Up

• HistoryHistory• Physical exam Physical exam • EKGEKG• EchoEcho• Chest x-rayChest x-ray• BNPBNP• ABG/pulse oxABG/pulse ox

TreatmentTreatment

• DiureticsDiuretics• DigitalisDigitalis• Peripheral vasodilators/NTGPeripheral vasodilators/NTG• Positive inotropic agentsPositive inotropic agents• ACE inhibitorsACE inhibitors• Beta blockersBeta blockers• OxygenOxygen• MS04MS04• BNPBNP

Questions ?Questions ?