1. RESPIRATORY DISTRESS PGI Karen Cas

2. Common Respiratory Symptoms Dyspnea (with assoc hypoxia and hypercapnia) Wheezing Cough Persistent hiccups Cyanosis Pleural effusions 3. Dyspnea Subjective feeling of difficult, labored or uncomfortable breathing, which patients often describe as shortness of breath, breathlessness, or not getting enough air 4. Terminologies Rapid breathing; it may or may not be associated with dyspnea a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 5. Terminologies Rapid breathing; it may or may not be associated with dyspnea a. TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 6. Essentially hyperventilation and is defined as minute ventilation in excess of metabolic demand. a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA Terminologies 7. Essentially hyperventilation and is defined as minute ventilation in excess of metabolic demand. a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA Terminologies 8. Dyspnea in recumbent position Terminologies a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 9. Dyspnea in recumbent position Terminologies a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 10. Terminologies Opposite of orthopnea, dyspnea in upright position. It results from abdominal wall muscular tone and, in rare cases, from right-to-left intracardiac shunting, as occurs from a patent foramen ovale a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 11. Terminologies Opposite of orthopnea, dyspnea in upright position. It results from abdominal wall muscular tone and, in rare cases, from right-to-left intracardiac shunting, as occurs from a patent foramen ovale a.TACHYPNEA b. ORTHOPNEA c. PAROXYSMAL NOCTURNAL DYSPNEA d. TREPOPNEA e. PLATYPNEA f. HYPERPNEA 12. Terminologies Orthopnea that awakens the patient from sleep a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 13. Terminologies Orthopnea that awakens the patient from sleep a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 14. Terminologies Dyspnea associated with only one of several recumbent positions. It can occur with unilateral diaphragmatic paralysis, with ball-valve airway obstruction, or after surgical pneumonectomy a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 15. Terminologies Dyspnea associated with only one of several recumbent positions. It can occur with unilateral diaphragmatic paralysis, with ball-valve airway obstruction, or after surgical pneumonectomy a.TACHYPNEA b. ORTHOPNEA c.PAROXYSMAL NOCTURNAL DYSPNEA d.TREPOPNEA e.PLATYPNEA f. HYPERPNEA 16. DYSPNEA: Clinical features To identify imminent respiratory failure, evaluate for: TACHYPNEA TACHYCARDIA STRIDOR USE OF ACCESSORY REPIRATORY MUSCLE INABILITY TO SPEAK AGITATION or LETHARGY DEPRESSED CONSCIOUSNESS HYPERCAPNIA PARADOXICAL ABDOMINAL WALL MOVEMENT 17. DYSPNEA: Differentiating cardiac from pulmonary causes of dyspnea CONGESTIVE HEART FAILURE PE: S3 gallop, jugular venous distension CXR: pulmonary venous congestion, interstitial edema, alveolar edema B-type Natriuretic Peptide (BNP) 60mmHg and/or arterial oxygen saturation (SaO2) 90% OPIOIDS / BENZODIAZEPINES 20. Differential diagnosis of consequence: DYSPNEA Most common causes Most immediately life threatening Obstructive airway diseas (asthma, COPD) Upper airway obsruction: foreign body, angioedema, hemorrhage Heart failure/cardiogenic pulmonary edema Tension pneumothorax Ischemic heart disease: UA, MI) Pulmonary embolism Pneumonia Neuromuscular weakness: myasthenia gravis, guillain- barre syndrome, botulism Psychogenic Fat embolism 21. HYPOXEMIA HYPOXIA - Insufficient delivery of oxygen to the tissues HYPOXEMIA abnormally low arterial oxygen tension; (PaO2 90%) do not exclude hypoxemia If Hb is in a state which it is unable to bind to oxygen (e.g. Methemoglobin or Carboxyhemoglobin), pulse oximetry analysis not only overestimates the oxygen saturation but also reflects a diminshed response to any supplemental oxygen 29. HYPOXEMIA: TREATMENT Ensuring a patent airway Providing supplemental oxygenation with a goal of maintaining a PaO2 >60mmHg 30. Case CC: Difficulty of Breathing HPI: 74 year old female with 5 days history of cough, yellowish phlegm, persistent fever and back pain. Self medicatedwith paracetamol, and noticed no changes and experienced difficulty of breathing so she sought medical consultation PE: VS: 110/60mmHg, 35.7 C, 78bpm, 26cpm Auscultation reveals bilateral diminished vesicular breath sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. IMPRESSION??? WHAT MECHANISM??? 31. HYPERCAPNIA Exclusively caused by alveolar hypoventilation and defined as PaCo2 >45mmHg Causes: Rapid shallow breathing Small tidal volumes Underventilation of the lung Reduced respiratory drive HYPERCAPNIA IS NEVER A RESULT OF INCREASED CO2 PRODUCTION 32. HYPERCAPNIA: PATHOPHYSIOLOGY ALVEOLAR HYPOVENTILATION can result from: 1. decrease in respiratory rate 2. decrease in tidal volume 3. increase in dead space 33. HYPERCAPNIA: CLINICAL FEATURES Depends on the absolute value of PaCO2 and its rate of change Acute elevations: INCREASED INTRACRANIAL PRESSURE (headache, confusion, lethargy) Severe cases: SEIZURE, COMA, CV COLAPSE Chronic hypercapnia may be well tolerated 34. HYPERCAPNIA: DIAGNOSIS ABG analysis Serum bicarbonate inc in acute setting FORMULA: ACUTE HYPERCAPNIA : (1:10) HCO3 increases about 1 meq/L for each increase of 10mmHg in PaCO2 CHRONIC HYPERCAPNIA: (3.5:10) HCO3 increases 3.5 meq/L for each 10mmHg increase in PaCO2 35. HYPERCAPNIA: TREATMENT Increase minute ventilation, both rate and tidal volume Ensuring patent airway May require noninvasive ventilation, mechanical ventilator or a respiratory stimulant (doxapram) Hypercapnia with CNS symptoms and with neuromuscular disease should be HOSPITALIZED 36. WHEEZING Adventitious lung sounds best described as musical, produced by airlfow through the central and distal airways 37. WHEEZING: CLINICAL FEATURES Usually associated with ASTHMA and other obstructive pulmonary diseases characterized by BRONCHIAL OBSTRUCTION caused by muscular spasm and inflammation Upper airway obstruction causes STRIDOR, loudest at larynx PATIENTS WITH SEVERE AIRFLOW OBSTRUCTION MAY NOT WHEEZE 38. WHEEZING: DIAGNOSIS Bedside spirometry Obtained maximum value should be compared to predicted normal values for age, gender and height PEF or FEV1 valuesn >80% of the predicted value N 50%-80% = mild airflow obstruction 25% - 50% = moderate 0.5 Pleural f/s LDH ratio >0.6 Pleural fluid LDH > 2/3 of upper limit for serum LDH 62. P.E.: TREATMENT (+) dyspnea at rest -> thoracentesis with drainage of 1.0 to 1.5L of fluid Acute drainage of larger volume has been associated with reexpansion pulmonary edema, thus avoided. (+) pleural empyema drainage with large-bore thoracostomy tubes Diuretic therapy resolves >75% of effusions due to CHF within 2-3 days 63. THANK YOU!!!!!