Help me, I can’t 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 can’t 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. They’ve 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 = <1%
1 = 1% 2 = 3% 3 = 10% 4 = 25% 5 = 50%
Probability of PNA:
Pneumonia SeverityCURB-65 Severity Score
Confusion 1
BUN > 19 1
RR > 30 1
SBP <90 or DBP
<60
1
Age > 65 2
Score 30 day mortality
1 2.7%
2 6.8%
3 14.0%
>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 can’t 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 fever…calm 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
Virchow’s 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.
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