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The Short of Breath Patient Outline Differential Diagnosis Assessment Investigations Management Specific Treatments Summary Causes ? Differential Diagnosis Asthma / COAD Pulmonary oedema Pulmonary embolism Pneumonia / “chest infection” Pneumothorax Chest trauma NON-respiratory disease (DKA!!!) Assessment Look Resp Rate, effort and symmetry Colour Listen Breath Sounds Feel Trachea Pulse Assessment Past History Previous episodes, medications? Current Episode: Precipitants, rapidity of onset? Associated symptoms? Initial treatment and response? Examination Primary survey / ABCs Resuscitation Oxygen, oxygen, oxygen Secondary survey Definitive treatment Look at the Patient Look at the patient from a distance Posture, speech Air hunger Anxiety / conscious state Pain limiting movement Look at the chest from a distance Respiratory rate Even movement Flail segments Retractions or “tracheal tug” Listen to the Patient Speech Stridor or Wheeze Absent breath sounds? Crepitations or crackles Rubs Touch the Patient Trachea Midline? Fractured Ribs? Surgical Emphysema? Pulse rate, BP, paradox? Respiratory Distress How bad are they? How do you know? What do you look for? Respiratory Distress Mild Mod. Severe Mental No No Yes Speech Sentences Phrases Words-Nil Colour Normal Fatigue No Peripheral Cyanosis Mild Per. & Central Cyanosis Yes Chest Normal Accessories Movement Pulse <110 100-120 >120 Wheeze Moderate Loud Soft “Investigations” Peak Flow Monitor trends and response “Counting” test if no PEFR meter (20) Pulse oximetry ECG AMI PE “Investigations” Blood gases Oxygenation and ventilation Acid base status Chest x-ray Utilise early if available Often provides diagnosis Full blood Count Anaemia Infection “Investigations” U&E BNP Cardiac Markers CKMB Myoglobin Troponin 1 “Investigations” “Capnography” Look at the patient! The tiring patient has an increasing CO2 They develop: A far away look Eyes roll back Sweat Not answering questions any more Quicker than blood gases Respiratory Distress Mild Mod. Severe PEFR >60% 40-60% <40% Sats >94% 90-94% <90% pO2 Normal >8kpa <8kpa pCO2 Normal <5kpa >5kpa Beware the hypoxic patient with normal CO2!!! Treatment Non-Oxygen Therapy? Reassurance and explanation Better airway if required Better posture: On side, sitting up “Antidotes”...drug induced problem? Not loss of “Hypoxic drive”? Specific therapy for diagnosis Oxygen Hypoxia due to numerous causes Not all primarily lung related!! Impairs function of all organs Brain, heart, kidneys, lungs Hypoxia leads to restlessness!!!! (Sedation is not a Rx for hypoxia!) Oxygen can be life saving DON’T withhold if “hypoxic” Oxygen Toxicity Many “toxicities” Primary problem is “loss of hypoxic drive” Balance between hypoxia and hypercapnia!! Consider patient’s “normal hypoxia” Oxygen Therapy Intranasal O2 prongs Maximum 2 lit/min Provides about 24% O2 “Hudson” type mask Minimum 6 lit/min Prevents any CO2 retention Oxygen Therapy “Venturi”type mask More accurate O2 % delivered Respiratory Support CPAP Continuous Positive Airway Pressure Recruits collapsed alveoli Useful in pulmonary oedema especially “Pseudo-CPAP” with bag and mask Respiratory Support Intubation and Ventilation The “ultimate control” in respiratory failure Case 1. 70 year old male History of IHD Acute SOB, sweaty, chest pain Tachycardia, tachypnoea Difficulty talking, altered mentation Creps to midzones Pink frothy sputum What is wrong? Acute pulmonary oedema.. What’s the treatment? Acute Pulmonary Oedema Sit upright High flow Oxygen IV Frusemide 1mg/kg “Vasodilators” – GTN infusion CPAP Treat the precipitant M.I. Arrythmia Case 2. 45 year old female smoker Sharp left sided chest pain Fevers, sweats and rigors Yellow sputum Tachycardiac, tachypnoea Hypotensive Coarse creps and bronchial breathing What’s the likely diagnosis Infection, ?? pneumonia. What’s the treatment Pneumonia Oxygen IV antibiotics ASAP IV Augmentin 1.2gms IV Klacid 500mgs Cultures if possible But don’t allow to delay antibiotics! Physiotherapy Posture Bronchodilators (Salbutamol 5mgs Nebuliser) Case 3. 60 year old male smoker Increasing SOB 2 hours Tachycardia, tachypnoea Pale, sweaty No creps, no wheezes No air entry detectable!!!! What’s the diagnosis? COAD / asthma / emphysema… What’s the treatment? Asthma / COAD Reassurance Oxygen Continuous salbutamol nebs 5mgs +/500mcgs Atrovent IV steroids – Hydrocortisone 200mgs I.V. Aminophylline infusion (little/no data to support usage) Consider Magnesium infusion Cosider Salbutamol infusion? Case 4 26 year old man Sudden onset right sided chest pain Shortness of breath at rest Difficulty talking Tachycardia, Hypotensive, Hypoxic Pneumothorax Tension pneumothorax Respiratory distress Asymmetrical chest movement / sounds Tracheal deviation Mediastinal shift Distended neck veins Cardiovascular collapse Needle Thoracostomy Temporary measure Wide bore cannula 2nd interspace, MCL Remove sylet, leave cannula in Prepare for definitive ICC Case 5 53 year old woman Cigarette smoker Hx of Ovarian Carcinoma Sudden onset shortness of breath Asociated chest pain Palpitations What’s the diagnosis ? Pulmonary embolus Treatment High flow 02 Low Molecular weight Heparin (Clexane 1mg/kg) Warfarin 10 mgs Consider thrombolysis Consider embolectomy +/- inotropic support Questions ? Summary Past history helpful Severity can be assessed at the bedside Don’t forget to examine the chest Summary Therapy may have to start before the diagnosis is confirmed Give complete Rx: more than just oxygen Croup Steroids standard care Route of administration not Inhaled, oral or parenteral Adrenaline Neb (1:1000) 5mg in 5ml Intubation rarely Open Pneumothorax Sucking chest wound Close the wound!! Seal with opsite, dressing etc. Intercostal catheter Chest Trauma Penetrating trauma Lung, cardiac, vascular, GIT injuries Abdominal injuries too! Blunt trauma Don’t need to break ribs etc Pulmonary contusion Aspiration
