Download Management of Dyspnea

Hendarsyah Suryadinata, dr., SpPD
Tempat/Tanggal Lahir
Email
Pekerjaan
Jabatan
Bandung Integrated Respiratory Care IV | 16–18 September 2016
: Bandung, 24 November 1977
: [email protected]
: Departemen Ilmu Penyakit Dalam Divisi
Respirologi dan Respirasi Kritis
: Staff Departemen Ilmu Penyakit
Dalam RSHS Bandung
LOGO
Management of Dyspnea
Hendarsyah Suryadinata
Divisi Repirologi dan Kritis Respirasi
Departemen/SMF Ilmu Penyakit Dalam
FK Unpad/RSUP Dr Hasan Sadikin
Bandung
Dyspnea
Dyspnea on Effort (DOE)
Exertion-induced SOB
Orthopnea
Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND)
Sudden SOB after recumbent
Sever breathness at night relieved when
patient sits up
Dyspnea
Rapid Assessment
ABC’s
Mental status
Presence of cyanosis
Dyspnea
Initial Interventions
IV assess
Pulse oximetry; supplemental O2
Cardiac monitor
What Are the Indications for Airway
Management?
Secure & maintain patency
Protection
Oxygenation
Ventilation
Treatment – Suction, medications
Dyspnea : History
 Prolonged questioning can be counterproductive
 Yes/No questions if significantly dyspneic
 Unlike pain, severity of dyspnea = severity of disease
 What does patient mean by SOB?
 How long has SOB been present?
 Is it sudden or gradual
 Does anything make it better or worse?
Dyspnea : History
Has there been similar episodes?
Are there associated symptoms?
What is the past medical Hx?
Smoking Hx?
Medications?
Cause : Acute
Bronchial asthma
Pneumonitis
Pneumonia
Pneumothorax
Thromboembolic disease
Cardiac
Pulmonary Edema
Non Cardiac Pulmonary Edema
Psychogenic
Cause : Chronic
Pulmonary Cause
COPD
Bronchial Asthma
Emphysema Chronic Bronchitis
Restrictive Lung Disease
Sarcoidosis
Rheumatoid lung
fibrosing alveolitis
Pneumoconosis
Dyspnea : Etiologies
80%
75%
70%
60%
50%
40%
30%
20%
10%
15%
10%
0%
Respiratory
Cardiac
Other
Dyspnea
Etiologies: Pulmonary Causes
Dyspnea
Common Pulmonary Causes
Obstructive lung disease
Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax
Dyspnea
Etiologies: Nonpulmonary Causes
Dyspnea
Common Cardiac Causes
Acute coronary syndromes
CHF
Dysrhythmias
Valvular heart disease
Dyspnea
Common Miscellaneous Causes
Metabolic acidemias
Severe Anemia
Pregnancy
Hyperventilation Syndrome
Pulmonary Diseases & Disorders
Pulmonary Disease & Conditions may result from:
Infectious causes
Non-Infectious causes
Adversely affect one or more of the following
Ventilation
Diffusion
Perfusion
Pulmonary Diseases & Disorders
The Respiratory Emergency may stem from
dysfunction or disease of (examples only):
Control System
Hyperventilation
Central Respiratory Depression
CVA
Thoracic Bellows
Chest/Diaphragm Trauma
Pickwickian Syndrome
Guillian-Barre Syndrome
Myasthenia Gravis
COPD
Pulmonary Diseases & Disorders
The Respiratory Emergency may affect the
upper or lower airways
Upper Airway Obstruction






Tongue
Foreign Body Aspiration
Angioneurotic Edema
Maxillofacial, Larnygotracheal Trauma
Croup
Epiglottitis
Pulmonary Diseases & Disorders
Lower Airway Obstruction




Emphysema
Chronic Bronchitis
Asthma
Cystic Fibrosis
Pulmonary Diseases & Disorders
The Respiratory Emergency may stem from
Gas Exchange Surface Abnormalities






Cardiogenic Pulmonary Edema
Non-cardiogenic Pulmonary Edema
Pneumonia
Toxic Gas Inhalation
Pulmonary Embolism
Drowning
Dyspnea
Physical Examination: Vital Signs
BP
  if dyspnea significant
  = life-threatening problem
Pulse
 Usually 
 Bradycardia - severe hypoxemia
Respiratory rate
 Sensitive indicator of respiratory distress
 DANGER = > 35-40 bpm or < 10-12 bpm
Dyspnea
Physical Examination: Observation
Ability to speak
Patient position
Cyanosis
Central vs. peripheral (Acrocyanosis)
Mental status
Altered MS - Hypoxemia/Hypercapnia
Dyspnea
Physical Examination
Pulmonary
Use of accessory muscles
Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor
Cardiac
Check neck for presence of JVD
Signs of severe
respiratory
distress
Dyspnea
Physical Examination: Pulmonary
Inspection
 Use of accessory muscles
 Splinting
 Intercostal retractions
Percussion
 Hyper-resonance vs. dullness
 Unilateral vs. bilateral
Dyspnea
Physical Examination: Pulmonary
Auscultation
Air Entry
Stridor = Upper Airway Obstruction
Breath sounds
Normal
Abnormal
Wheezing, Rales, Rhonchi, etc.
Unilateral vs Bilateral
Dyspnea
Physical Examination: Cardiac
Neck
JVP ?
Auscultation
Abnormal S2 splitting
Present of S3 and/or S4
Rubs
Murmurs
What does
clubbing suggest?
Chronic Hypoxemia
Pneumonia
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fever with Chill
Pleuratic Chest Pain
Purulent Sputum
History of Upper Respiratory Symptoms
Signs of Consolidation
CXR
CBC
Blood Culture
BGA
Pneumonia
Inflammation of the bronchioles and alveoli
Products of inflammation (secretions, pus) add to
respiration difficulty
Gas exchange is impaired
Work of breathing increases
May lead to
Atelectasis
Sepsis
V/Q Mismatch
Hypoxemia
Pneumonia: Etiology
Viral
Bacterial
Fungi
Protozoa (pneumocystis)
Aspiration
Management of Pneumonia
Treatment mostly based upon symptoms






Oxygen
Rarely is intubation required
IV Access & Rehydration
B2 agonists may be useful
Antibiotics
Antipyretics
Pneumonia: Management
MD follow-up for labs, cultures & Rx
Transport considerations




Elderly have significant co-morbidity
Young have difficulty with oral medications
ED vs PMD office/clinic
Transport in position of comfort
Acute Bronchial Asthma
1.
2.
3.
4.
5.
6.
7.
Age Start in Young Age
Family History
H/O Allergic Rhinitis
Physical Examination
Barrel Shape
CXR
BGA
Asthma: Signs and Symptoms
Onset of attacks associated with “triggers”
Dyspnea
Non-productive cough
Tachypnea
Expiratory wheezing
Accessory muscle use
Retractions
LOGO
Asthma : Signs and
Symptoms
Absence of wheezing
IMPENDING
RESPIRATORY ARREST!
LOGO
Asthma : Signs and
Symptoms
Lethargy, confusion,
suprasternal retractions
RESPIRATORY FAILURE
Asthma : Signs and Symptoms
Early Blood Gas Changes
 Decreased PaO2
 Decreased PaCO2
WHY?
Asthma : Signs and Symptoms
Later Blood Gases
 Decreased PaO2
 Normal PaCO2
IMPENDING
RESPIRATORY
FAILURE
Asthma : Signs and Symptoms
Still Later Blood Gases
 Decreased PaO2
 Increased PaCO2
RESPIRATORY
FAILURE
Asthma : Management
Airway
Breathing
Sitting position or position of comfort
Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs
Encourage coughing
Consider intubation, assisted ventilation
Impending respiratory failure
Avoid if at all possible
Asthma : Management
Circulation
IV TKO
Assess for dehydration
Titrate fluid administration to severity of dehydration
Trial bolus of 250 cc
Monitor ECG, Pulse Oximetry
Obtain medication history
Consider
Overdose
Dysrhythmias
Asthma : Management
Nebulized Beta-2 agents
Salbutamol
Nebulized anticholinergics
Ipratropium
Atropine
IV Corticosteroid
Methylprednisolone
Combination
Asthma : Management
Rarely used
Questionable efficacy, Potential Complications
Magnesium Sulfate (IV)
Methylxanthines
Aminophylline (IV)
COPD : Management
Causes of Decompensation
Respiratory infection (increased mucus
production)
Chest trauma (pain discourages coughing or deep
breathing)
Sedation (depression of respirations and
coughing)
Spontaneous Pneumothorax
Dehydration (causes mucus to dry out)
COPD: Management
Airway and Breathing
Sitting position or position of comfort
Calm & Reassure
Encourage cough
Avoid exertion
Oxygen
Don’t withhold
Maintain O2 saturation above 90 %
TRUE HYPOXIC DRIVE IS VERY RARE
COPD: Management
Ventilation
Avoid intubation unless absolutely necessary
Near respiratory failure
Exhaustion
Circulation
IV TKO
Titrate fluid to degree of dehydration
250 cc trial bolus
Excessive fluid may precipitate CHF
Monitor ECG
COPD : Management
Drug Therapy
Obtain thorough medication history
Nebulized Beta 2 agonists
Albuterol
Terbutaline
Metaproterenol
Isoetharine
COPD : Management
Drug Therapy
Ipratropium (anticholinergic) by SVN
(Beta-2 agonist) by MDI, SQ or IV
Corticosteroids (Anti-inflammatory agent) by IV
Pneumothorax
1.
2.
3.
4.
5.
Suden Chest Pain
Dyspnea, Cough
H/O Asthma
COPD
Examination  Trachea, Shifted to
Opposite side, Absent Breath Sound
6. CXR
Acute Pulmonary edema
1. Previous H/O Heart Disease
2. Hyperthyroidism
3. Rheumatic Heart Disease  MS
4. Sign of LVF
5. Tachycardia
6. Pulses alternant
7. Basal Criptation/Fine Crackles
8. ECG Change
9. CXR ( cardiomegaly)
10.Echo
Pulmonary Edema
High Pressure (Cardiogenic)
AMI
Chronic HTN
Myocarditis
High Permeability (Non-Cardiogenic)
Poor perfusion, Shock, Hypoxemia
High Altitude, Drowning
Inhalation of pulmonary irritants
Cardiogenic Pulmonary Edema: Etiology
Left ventricular failure
Valvular heart disease
Stenosis
Insufficiency
Hypertensive crisis (high afterload)
Volume overload
Increased Pressure in Pulmonary Vascular Bed
Non-Cardiogenic Pulmonary Edema: Etiology
Toxic Inhalation
Near Drowning
Liver Disease
Nutritional Deficiencies
Lymphomas
High Altitude Pulmonary Edema
Acute Respiratory Distress Syndrome
Increased Permeability of Alveolar-Capillary Walls
Pulmonary Edema: Signs &Symptoms
Dyspnea on Exertion
Paroxysmal Nocturnal Dyspnea
Orthopnea
Noisy, Labored Breathing
Restlessness, Anxiety
Productive Cough (Frothy Sputum)
Rales, Wheezing
Tachypnea
Tachycardia
Management of Non-Cardiogenic Pulmonary Edema
Position
Oxygen
PPV / Intubation
CPAP
PEEP
IV Access; Minimal fluid administration
Treat the underlying cause
Diuretics usually not helpful; May be harmful
Transport
Acute Respiratory Distress Syndrome
AKA: Non-Cardiogenic Pulmonary Edema
A complication of :
Severe Trauma / Shock
Severe infection / Sepsis
Bypass Surgery
Multiple Blood Transfusions
Drug Overdose
Aspiration
Decreased Compliance
Hypoxemia
Pulmonary Embolism
1.
2.
3.
4.
5.
6.
7.
8.
9.
History of Prolonged Imobilization
Pelvic Surgery
Contraceptive Pills
Cyanosis
ECG
CXR
BGA
Echo
V/Q Study
Pulmonary Embolism
A disorder of perfusion
Combination of factors increase probability of
occurrence
Hypercoagulability
Platelet aggregation
Deep vein stasis
Embolus usually originates in lower
extremities or pelvis
Pulmonary Embolism
Risk factors
Venostasis or DVT
Recent surgery or trauma
Long bone fractures (lower)
Oral contraceptives
Pregnancy
Smoking
Cancer
Pulmonary Embolism: Management
Management Based on Severity of Sx/Sx
Airway & Breathing
High Concentration O2
Consider Assisting Ventilations
Early Intubation
Circulation
IV, 2 Large Bore Sites
Fluid Bolus then TKO; Titrate to BP ~ 90 mm Hg
Monitor ECG
Rapid transport
Pulmonary Embolism: Management
Thrombolytics
Aspirin & Heparin
Rapid transport to appropriate facility
Embolectomy or thrombolytics at hospital (rarely
effective in severe cases due to time delay)
Poor prognosis when cardiac arrest follows
Pulmonary Embolism: Management
 IV Heparin vs Low Molecular Weight Heparin
(LMWH)
 IV Un-fractionated (UF) Heparin:
Hypotension, massive PE, RF




75-100 units/kg bolus over 10 minutes
Infusion 20 units/kg/h
Maintain Prothrombin time (PTT) 60-85 seconds
Oral or LMWH follow up to Heparin
 LMWH Dosing: For hemodyanamically stable
pts

Enoxaparin
 > 2mo/age: 1mg/kg SQ BID
 < 2mo/age: 1.5 mg/kg SQ daily

Reviparin
 > 5kg: 100 U/kg SQ BID
Pleurisy
Inflammation of pleura caused by a friction
rub
Layers of pleura rubbing together
Commonly associated with other respiratory
disease
Presentation of Pleurisy
Sharp, sudden and intermittent chest pain
with related dyspnea
Possibly referred to shoulder
May  or  with respiration
Pleural “friction rub” may be audible”
May have effusion or be dry
Pleurisy
Management
Based upon severity of presentation
Mostly supportive
Laryngotracheobronchitis (Croup)
 Common syndrome of
infectious upper airway
obstruction
 Viral Infection
Parainfluenza Virus
 Subglottic Edema
Larynx, Trachea,
mainstem bronchi
 Usually 3 months to 4
years of age
Croup: Management
Usually requires little out of home
treatment
Calm & Prevent agitation
Moist cool air - mist
Humidified O2 by mask or blowby
Do Not Examine Upper Airways
Croup: Management
If in respiratory distress:
Racemic epinephrine via nebulizer
Decreases subglottic edema (temporarily)
Necessitates transport for observation for rebound
IV TKO - ONLY if severe respiratory distress
Transport
Epiglottitis
 Bacterial infection
(Hemophilus
influenza )
 Edema of epiglottis
(supraglottic)
partial upper
airway obstruction
 Typically affects 3-7
year olds
Epiglottitis: Management
Immediate life threat (8-12% die
from airway obstruction)
Do NOT attempt to visualize airway
Allow child to assume position of comfort
 AVOID agitation of the child
 AVOID anxiety of the healthcare providers
O2 by high concentration mask
Epiglottitis: Management
If respiratory failure is eminent:
IV TKO ONLY if eminent or respiratory arrest
Be prepared to take control of airway
Intubation equipment with smaller sized tubes
Needle cricothyrotomy & jet ventilation equipment
Rapid but calm transport
Appropriate facility
Upper Respiratory Infection
Common illness
Rarely life-threatening
Often exacerbates underlying pulmonary
conditions
May become more significant in some
patients
Immunosuppressed
Elderly
Chronic pulmonary disease
Management of URI
Usually requires no intervention
Oxygen if underlying condition has been
exacerbated
Rarely, pharmacologic interventions are
required
Bronchodilators
Corticosteroid
LOGO
Hyperventilation Syndrome
Hyperventilation Syndrome
A diagnosis of EXCLUSION!!!
An increased ventilatory rate that
DOES NOT have a pathologic origin
Results from anxiety
Remains a real problem for the patient
Hyperventilation Syndrome: Pathophysiology
Tachypnea or Hyperpnea
secondary to anxiety
Decreased PaCO2
Respiratory alkalosis
Vasoconstriction
Hypocalcemia
Decreased O2
Release to
Tissues
Hyperventilation Syndrome : Signs & Symptoms
Symptoms
Light-headedness, giddiness, anxiety
Numbness, paresthesias of:
Hands
Feet
Circumoral area
Cold hands, feet
Carpopedal spasms
Dyspnea
Chest pain
Hyperventilation Syndrome : Signs & Symptoms
Signs
Rapid breathing
Cool & possibly pale skin
Carpopedal spasm
Dysrhythmias
Sinus Tachycardia
SVT
Sinus arrhythmia
Loss of consciousness and seizures (late &
rare)
Hyperventilation Syndrome : Management
Educate patient & family
Consider possible psychopathology especially
in “repeat customers”
Transport occasionally required
If loss of consciousness, carpopedal spasm,
muscle twitching, or seizures occur:
Monitor EKG
IV TKO
Transport
LOGO
Hyperventilation
Syndrome
Serious diseases can
mimic hyperventilation
Hyperventilation itself can
be serious
LOGO
Central Respiratory
Depression
Respiratory Depression : Causes
Head trauma
CVA
Depressant drug toxicity
Narcotics
Barbiturates
Benzodiazepines
ETOH
Respiratory Depression : Recognition
Decreased respiratory rate (< 12/min)
Decreased tidal volume
Decreased LOC
Look, Listen, Feel
If you can’t tell
whether a patient
is breathing
adequately...
Use Your
Stethoscope
THEY PROBABLY
AREN’T
Respiratory Depression : Management
Airway
Open, clear, maintain
Consider endotracheal intubation
The need to VENTILATE is not the
same as the need to INTUBATE
Respiratory Depression: Management
Breathing
 Oxygenate, ventilate
 Restore normal rate, tidal volume
Oxygen alone is INSUFFICIENT if
Ventilation is INADEQUATE
Respiratory Depression: Management
Circulation
Obtain vascular access
Monitor EKG (Silent MI may present as CVA)
Manage Cause
Check Blood Sugar
Consider Narcan 2mg IV push if S/S suggest
narcotic overdose
Intubate if can not find or treat cause
Guillian-Barre´ Syndrome
Autoimmune disease
Leads to inflammation and degeneration of
sensory and motor nerve roots (demyelination)
Progressive ascending paralysis
Progressive tingling and weakness
Moves from extremities then proximally
May lead to respiratory paralysis (25%)
Guillian-Barre´ Syndrome Management
Treatment based on severity of symptoms
Control airway
Support ventilation
Oxygen
Transport in cases of respiratory depression,
distress or arrest
Myasthenia Gravis
Autoimmune disease
Causes loss of ACh receptors at
neuromuscular junction
Attacks the ACh transport mechanism at the
NMJ
Episodes of extreme skeletal muscle
weakness
Can cause loss of control of airway,
respiratory paralysis
Myasthenia Gravis Presentation
Gradual onset of muscle weakness
Face and throat
Extreme muscle weakness
Respiratory weakness -> paralysis
Inability to process mucus
Myasthenia Gravis Management
Treat symptomatically
Watch for aspiration
May require assisted ventilations
Assess for Pulmonary infection
Transport based upon severity of
presentation
Plasmapharesis
LOGO