Download Dyspnea

EM Clerkship: Dyspnea
David Carlbom, MD
Martin Makela, MD
Objectives
• Discuss approach to patient with dyspnea
• Review differential diagnosis
• Develop an understanding of the diagnosis and
management of common and serious causes of
dyspnea
Background
• Dyspnea: An uncomfortable sensation of
breathlessness
• Among the most common complaints of patients
presenting to ED
• May indicate a variety of underlying diseases,
from non-urgent to life threatening
General Approach
• Approach all patients with dyspnea as having a serious
cause until proven otherwise
• H&P, diagnostic testing and treatment should proceed in
parallel given range of possible conditions
• Immediate visualization and rapid evaluation
• Stabilize and treat prior to full evaluation
Diag.
Treat
Primary Survey
Working Dx
Life-Saving
Therapy
Dx Plan
Definitive
Therapy
General Approach
• Primary Survey: ABCs & Vital Signs
– Correct & support life-threatening issues
• IV access, O2, Monitor
• ECG
• Lab
– Electrolytes, CBC, Cardiac enzymes
– Possibly D-dimer, BNP, ABG
• CXR
• Peak Flow if asthma or COPD
History
• Onset
• Associated symptoms
– Fever, cough, chest pain, edema, hives
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Aggravating/Alleviating factors
Similarity to prior episodes
PMH
Medications
Physical exam
• Vitals
• General appearance/color
• Assess for respiratory distress
– Accessory muscle use/retractions
– Ability to speak full sentences (or not)
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Lungs
Heart
Extremities
Abdomen
Differential Diagnosis
• What are serious causes of dyspnea?
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PE
PNA
CHF
ACS
Asthma/COPD
Anaphylaxis
Pneumothorax/hemothorax
Arrhythmia
Airway obstruction
Differential Diagnosis
• What are other causes of dyspnea?
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Anxiety
Anemia
URI
Pericarditis
Pleural effusion
Abdominal distention
• Ascites
• Pregnancy
– Aspiration/chemical exposure
– Acidosis
– Neuromuscular weakness
Case 1
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35yo F with h/o asthma c/o SOB
No relief from repeated albuterol use
VS 36.8 112 128/76 28 97%RA
Appears uncomfortable, speaking 3 word
sentences
• Lungs with diffuse expiratory wheeze
• Remainder of exam normal
ACTIONS?
Initial Management
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ABCs
IV, O2, monitor, full VS
CXR?
Medications
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Steroids (IV vs. PO)
Inhaled beta agonist and ipratropium
Magnesium if severe exacerbation
Antibiotics if infection
Case 1: Course
• CXR clear
• Patient receives steroids and 3 nebs
• On reexamination, patient still in moderate
distress, states “I am (gasp) getting a bit
(gasp) tired, Doc (gasp)!”
• PMH: 3 intubations for asthma
ACTIONS?
Acute Asthma/COPD Exacerbation
• Indications for Admission
– Incomplete response after initial ED therapy
– Failed road test (hypoxia with ambulation)
• Indications for Intubation
– Respiratory failure
– Altered mental status
– Patient fatigue after aggressive therapy
– Clinical decision more than a laboratory
decision
Case 2
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58yo F presents c/o sudden onset SOB
+lightheaded, denies CP, denies cough or fever
PMH: DM, depression/anxiety
Meds: Metformin, tylenol, zoloft, premarin
All: ASA
SH: +tob, -ETOH
FH: DM
ACTIONS?
Initial Management
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ABCs
IV, O2, monitor, full VS
EKG
pCXR
Labs:
CBC, M7, Coags, Cardiac enzymes
Case 2
• VS 37.6 112 128/76 28 94%RA
• Gen: Alert, obese female, slightly
uncomfortable
• Lungs: CTAB
• Heart: Tachy, regular, no murmur
• Legs: Trace edema bilaterally, L>R
• Remainder of exam normal
Case 2
Case 2
ACTIONS? What next?
There’s the answer
Pulmonary Embolism
• 650,000 cases/year in the U.S.
• Mortality
– 2-12% if diagnosed and treated
– 30% if undiagnosed
• LE DVT is source in 80-90% of cases
• Risk factors
– Hormone use, malignancy, immobilization, recent
surgery, smoking, peripartum/pregnancy
PE Diagnosis
• History:
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Pleuritic chest pain (49%)
Dyspnea (82%)
Tachypnea
Tachycardia (44%)
• Lab:
– A negative D-Dimer in a low risk patient may r/o PE
– D-dimer not helpful if pre-test probability moderate to
high (or if risk is very low per PERC rules)*
• Radiology:
– CXR often normal
– CTA Chest test of choice for diagnosis
McGee, S. Evidence Based Physical Diagnosis. 2001 WB Saunders Company. Philadelphia, PA.
PE Therapy
• Heparin (UF or LMWH), transition to warfarin
• Standard of care is hospitalization (for now…)
• Thrombolytics, acute surgical or interventional
radiologic intervention if in extremis (shock &
impending death).
Case 3
• 65yo M presents c/o progressive SOB
• +dyspnea on exertion, feeling fatigued,
abdominal distention
• PMH: HTN, CAD s/p stents x 2
• Meds: ASA, Atenolol
• All: latex
• SH: +tob, +ETOH (social), occ cocaine
• FH: CVA
ACTIONS?
Initial Management
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ABCs
IV, O2, monitor, full VS
EKG
pCXR
Labs:
CBC, M7, Coags, Cardiac enzymes, BNP
Case 3
• VS 37.0 118 166/98 28 92%RA
• Gen: Alert, obese male, sitting forward,
uncomfortable
• Lungs: symmetric crackles B, ½ way up
• Heart: Tachy, regular, no murmur, +S4
• Legs: 2+ edema bilaterally
• Abd: Obese, mild distention, nontender
Case 3
CHF: Diagnostics
• Labs
– CBC, C7, coags, troponin, BNP
• B-type natriuretic peptide
– <100 ng/dL Good NPV
– Most helpful relative to patient’s baseline
– Can be elevated in: PNA, PE, pulm HTN
• CXR*
• EKG*
CHF: Treatment
• Reduce Preload
– Venodilators (NTG): increase venous capacity
– Diuretics: eliminate excess plasma volume
• Reduce Afterload
– Control BP (NTG): lowers LV work
– Positive Pressure ventilation if in extremis
• Improve Contractility if in shock
– Dobutamine
Case 4
• 77yo M presents c/o progressive SOB
• +dyspnea on exertion, feeling fatigued.
Denies CP
• PMH: Denies any. No doctor for 20 years.
• Meds: ASA “my daughter makes me”
• All: NKDA
• SH: -tob, +ETOH (social)
• FH: parents lived to their 90s ACTIONS?
Initial Management
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ABCs
IV, O2, monitor, full VS
EKG
CXR
Labs:
CBC, M7, Coags, Cardiac enzymes, BNP
Case 4
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VS 36.8 118 106/68 96%RA
Gen: Alert, thin elderly gentleman, NAD
Lungs: CTAB
Heart: Tachy, regular, II/VI sys murmur
Legs: No edema
Abd: Soft, flat, mild epigastric TTP, no r/g
Case 4
Case 4
Case 4
• What is your differential diagnosis now?
Case 4
• Labs
– Troponin, C7, BNP all normal
– Charge nurse comes to inform you of a critical
value
• HCT=18
• Return to your patient
– Detailed ROS reveals dark tarry stools x 3 days
– Rectal exam reveals melena
– Aha! A non-lung cause of dyspnea
– You treat your patient for his GI bleeding
anemia
Dyspnea
• Approach all patients with dyspnea as
having a serious cause until proven
otherwise
• H&P, diagnostic testing and treatment
should proceed in parallel given range of
possible conditions