Download What is Dyspnea?

30.11.14 Dyspnea Management
in the ED
Haldun Akoglu, Assoc. Prof., MD
Marmara University
Department of Emergency Medicine
December, 2014
What is Dyspnea?
▪  Sensation of breathlessness and patient’s reaction to
that sensation.
▪  Uncomfortable awareness of breathing which, in the
extreme, manifests as “air hunger.”
▪  Often ill defined by pts,
– shortness of breath,
– chest tightness,
– or difficulty breathing.
1 30.11.14 Degree of Dyspnea vs
Severity of the Dis
▪  Etio: ranging from nonurgent to life-threatening.
▪  Neither the clinical severity nor the patient’s
perception correlates well with the seriousness of
underlying pathology and may be affected by
– emotions,
– behavioral and cultural influences,
– and external stimuli.
Definitions in a Dyspnea Pt
▪  Tachypnea: RR > Normal. Newborn: 44 /min, Adult: 14-18/min
▪  Hyperpnea: RR > N to meet metabolic requirements.
▪  Hyperventilation: A minute ventilation (determined by RR and
TV) that exceeds metabolic demand. ABGs show a N PO2 with
an uncompensated respiratory alkalosis (low [PCO2] and
elevated pH).
▪  Dyspnea on exertion: Dyspnea provoked by physical effort or
exertion. Number of stairs or number of blocks a patient can
manage before the onset of dyspnea.
▪  Orthopnea: Dyspnea in a recumbent position. Number of pillows
the patient uses to lie in bed (e.g., two-pillow orthopnea).
▪  Paroxysmal nocturnal dyspnea: Sudden onset of dyspnea
occurring while reclining at night, usually related to the presence
of congestive heart failure.
2 30.11.14 3 30.11.14 Dx Approach
▪  Dyspnea is subjective and has many different potential
causes.
▪  DDx can be divided into
– acute and
– chronic causes, of which many are pulmonary.
▪  Other causes include
– cardiac,
– metabolic,
– infectious,
– neuromuscular,
– traumatic, and
– hematologic conditions
4 30.11.14 Hx
▪  Duration of Dyspnea.
– Chronic or progressive dyspnea:
▪ primary cardiac or pulmonary disease
– Acute dyspneic spells
▪ asthma exacerbation;
▪ infection;
▪ pulmonary embolus;
▪ intermittent cardiac dysfunction;
▪ psychogenic causes; or
▪ inhalation of irritants, allergens, or foreign bodies.
Hx
▪  Onset of Dyspnea.
– Sudden onset
▪ pulmonary embolism (PE) or
▪ spontaneous pneumothorax.
– Dyspnea that builds slowly over hours or days
▪ flare of asthma or COPD;
▪ pneumonia;
▪ recurrent, small pulmonary emboli;
▪ congestive heart failure; or
▪ malignancy.
5 30.11.14 Hx
▪  Positional Changes.
– Orthopnea
▪  left-sided heart failure,
– Paroxysmal nocturnal dyspnea is most common in pts
w left-sided HF but also in COPD.
▪  COPD,
– Exertional dyspnea commonly is associated with
COPD but also seen w poor cardiac reserve and
abdominal loading
▪  (caused by ascites, obesity, or pregnancy, leads to
elevation of the diaphragm, resulting in less effective
ventilation and dyspnea).
▪  Neuromuscular disorders.
– One of the earliest symptoms seen in pts w
diaphragmatic weakness from neuromuscular disease
is orthopnea.
Hx
▪  Trauma.
– fractured ribs,
– flail chest,
– hemothorax,
– pneumothorax,
– diaphragmatic rupture,
– pericardial effusion,
– cardiac tamponade, or
– neurologic injury
6 30.11.14 Sx
▪  Fever
– infectious cause.
▪  Anxiety or overwhelming fear, particularly if it precedes the
onset of dyspnea,
– panic attack or psychogenic dyspnea, if no organic cause
can be isolated.
▪  Isolated dyspnea ± chest pain, particularly if the pain is
constant, dull, or visceral.
– PE or AMI
▪  Sharp pain, worsened by deep breathing but not by
movement
– pleural effusion, pleurisy, or pleural irritation from
pneumonia or PE are possible.
– Spontaneous pneumothorax
Signs – Class’d acc/to PEx
7 30.11.14 Signs – Class’d acc/to PEx
Signs – Class’d acc/to Dis
8 30.11.14 Signs – Class’d acc/to Dis
Ancillary Studies
▪  Bedside SO2, or ABGs, are useful in determining the
degree of hypoxia and the need for supplemental oxygen
or assisted ventilation.
▪  An additional resource for quickly assessing ventilatory
status is noninvasive waveform capnography.
– End-tidal carbon dioxide (ETCO2) values correlate well
with PaCO2, and together with the shape of the
capnogram can be helpful in assessing the adequacy of
ventilations as well as underlying causes of the dyspnea.
▪  An EKG may be useful if hx or Pex findings suggest heart
failure, ischemic cardiac disease, dysrhythmia, or
pulmonary hypertension.
▪  Bedside USG is useful to rapidly dx pulmonary edema,
pneumothorax, and COPD, as well as deep venous
thrombosis.
9 30.11.14 Ancillary Studies
▪  Serum electrolytes may confirm metabolic acidosis or
a less common cause, such as hypokalemia,
hypophosphatemia, or hypocalcemia.
▪  A complete blood count may identify severe anemia or
thrombocytopenia associated with sepsis.
▪  The white blood cell count is not sufficiently sensitive
or specific to be of discriminatory value
Ancillary Studies
– Markers of Dyspnea
▪  Cardiac markers (hsTnTI, CK-MB, H-FABP)
– Cardiac ischemia
▪  D-dimer assay
– venous thromboembolic disease
▪  Amino-terminal pro-B–type natriuretic peptide (NTproBNP)
– DDx of heart failure, PE, and ischemic cardiac
disease.
10 30.11.14 Ancillary Studies
▪  Venous thromboembolism
– D-dimer testing, with or without chest CT
angiography,
– duplex venous USG,
– ventilation-perfusion scanning, rarely.
▪  Upper airway in origin (obstruction)
– direct or fiberoptic laryngoscopy or
– soft tissue lateral radiography of the neck
Tests – Class’d acc/to Dis
11 30.11.14 Tests – Class’d acc/to Dis
Ancillary Studies to Consider
12 30.11.14 Ancillary Studies to Consider
DDx
▪  After initial stabilization and assessment, findings from
the history, physical examination, and ancillary testing
are collated to match patterns of disease that produce
dyspnea. This process is updated periodically as new
information becomes available.
▪  The primary branch point is the determination of
whether the dyspnea primarily is cardiopulmonary
or toxic-metabolic in origin.
13 30.11.14 Critical Diagnosis to Consider
▪  Tension pneumothorax
– Should be dx’d by hx and PEx.
– Diminished breath sounds on one side, ipsilateral hyperresonance, severe respiratory distress, hypotension, and
oxygen desaturation, prompt decompression of
presumptive tension pneumothorax is indicated.
– Bedside USG
▪  Airway Obstruction
– Ddyspnea and stridor
– Early, definitive assessment and intervention in the ED.
– Complete obstruction by a foreign body = Heimlich
maneuver until the obstruction is relieved or the patient is
unconscious, followed rapidly by direct laryngoscopy for
foreign body removal.
Critical Diagnosis to Consider
▪  Anaphylaxis
– Significant dyspnea and wheezing = parenteral
epinephrine + supportive measures.
▪  Asthma
– Severe bronchospastic exacerbations of asthma at any
age may lead rapidly to respiratory failure and arrest and
should receive vigorous attention, including continuous or
frequent administration of a beta-agonist aerosol and
steroid therapy.
▪  USG may also be of benefit in rapidly distinguishing
between COPD and heart failure.
▪  Waveform capnography is a valuable adjunct for assessing
the severity and determining the cause of respiratory
distress.
14 30.11.14 Emergent Diagnosis to
Consider
▪  Asthma and COPD
▪  PE
– Sudden onset of dyspnea with a decreased oxygen
saturation on room air accompanied by sharp chest pain
▪  Spontaneous Pneumothorax
– Dyspnea accompanied by decreased breath sounds and
tympany on percussion on one side
▪  Multiple sclerosis, Guillain-Barré syndrome, myasthenia
gravis
– Dyspnea associated with decreased respiratory effort
may represent a neuromuscular process
▪  Pnuemonia
– Unilateral rales, cough, fever, and dyspnea.
Approach to a Pt w Dyspnea
-Emergent Diagnosis
All patients experiencing dyspnea, regardless of
possible cause, should be promptly evaluated in the
treatment area.
▪  Bedside pulse oximetry
– <95% = supp O2
▪  Secure the airway
▪  Cardiac monitor
▪  Rapid assessment of the pt’s appearance and vitals
15 30.11.14 Empirical Management and
Disposition
▪  Unstable or Critical diagnoses = stabilize, admit to ICU.
▪  Emergent, improved in ED = admit to intermediate care unit.
▪  Urgent cause Dx’d, danger of deterioration w/o proper tx =
admit for observation and tx.
▪  Pts w severe comorbidities, (DM, immunosuppression, or
Ca) = admit for observation and tx.
▪  Nonurgent cause Dx’d = Tx out-patients + follow-up
▪  Dyspnea despite Tx + no definitive cause = Admit for
observation and ongoing evaluation.
▪  No definitive Dx + Sx resolved = discharge w follow-up and
instructions to return if symptoms recur
Rapid assessment and stabilization of a dyspneic patient
16 30.11.14 Rapid assessment and stabilization of a dyspneic patient
Approach to a Pt w Dyspnea
Emergency Management Algorithm
17 30.11.14 Clinical guidelines for emergency department management of dyspnea
Clinical guidelines for emergency department management of dyspnea
18 30.11.14 Q & A?
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