ED Approach to the Dyspneic Patient

University of Utah Medical Center

Division of Emergency Medicine

Medical Student Orientation

Dyspnea

• Subjective feeling of shortness of breath– Difficult– Labored– Uncomfortable

• Ventilatory demands exceed respiratory function– Alterations in:

• Gas exchange• Pulmonary circulation• Respiratory mechanics• O2-carrying capacity of

blood• Cardiovascular function

Differential Diagnosis

Upper Airway Obstruction•Angioedema•Epiglottitis•Foreign Body•Vocal cord paralysis/spasm

Pulmonary•Aspiration•Asthma•COPD exacerbation•Pneumonia•Pneumothorax•Pleural Effusion•ARDS•Toxic Inhalation

Metabolic/Systemic•Anaphylaxis•Anemia•Hyperthyroidism•Sepsis•Acidosis•Salicylate intoxication•Obesity

Cardiovascular•CHF•Pulmonary edema•Cardiac tamponade•Acute MI•Dysrhythmia•Pulmonary Embolus

Neuromuscular•Guillain-Barre Syndrome•Myasthenia gravis

Psychogenic•Hyperventilation syndrome

Cases…

Case 1

• 59 yo female• CC:

– left upper chest pain– shortness of breath

• HPI– Sudden onset while watching

television– Increased pain with inspiration– Non productive cough– No fevers or chills– Tried acetaminophen without relief

• PMHx– Hypertension– hypercholesterolemia

Case 1

• Surgical Hx– 2 wks s/p partial colectomy for diverticulitis

• Social Hx– No tobacco, EtOH or drug use– Married– Works in the food industries

• Family Hx– hypertension

Case 1

• ROS: negative

• Vitals: T:37 HR: 62 RR: 20 BP: 120/64 SpO2: 98% room air

• Physical Exam: essentially normal

• Assessment?? Plan?

Pulmonary Embolism

• Occurs a lot more than we think it does!– 1.5 million DVT

• 30% symptomatic PE, 30% asymptomatic PE

– 50k deaths/year– 2.5% mortality if dx’d– 30% mortality if not

dx’d

• High index of suspicion

Symptoms of Acute Pulmonary Embolism

Symptoms Massive Emboli Submassive Emboli

(n=197) (n=130)

Chest Pain 85% 82%

Pleuritic 64% 85%

Non Pleuritic 6% 8%

Dyspnea 85% 82%

Apprehension 65% 50%

Cough 53% 52%

Hemoptysis 23% 40%

Sweats 29% 23%

Syncope 20% 4%

Pulmonary Embolism

• Risk factors– Post-op– Inactivity

• casts

– Chronic disease– Hypercoagulable

states• Malignancies• Protein C&S deficiency• Lupus anticoagulants• Estrogen therapy• Factor V Leiden

Signs of Acute Pulmonary EmbolismSigns Massive PE Submassive PE

RR > 16/min 95% 87%

Rales 57% 60%

Increased S2 58% 45%

HR >100/min 48% 38%

Temp > 37.8 43% 42%

Phlebitis 36% 26%

Gallop 39% 25%

Diaphoresis 42% 27%

Edema 23% 25%

Murmur 27% 16%

Cyanosis 25% 9%

Pulmonary Embolism

• ECG findings– S1Q3T3

• 25 % of the time• RV strain

– Tachycardia• Most common

When to test?!?

• Everyone?

• High risk only?

• Who is safe to clinically rule out PE?

PERC/Well’s Criteria

• Clinical rules to limit testing

• Low risk pts have false positive rates and morbidity/mortality with treatment

• Directs when to work-up

Pulmonary Embolus

• Wells Criteria – What is the pre-test probability?– 3.0 Signs/Symptoms of DVT– 1.5 HR>100– 1.5 Immobilization >3d or surgery in past 4 wks.– 1.5 Prior DVT or PE– 1.0 Hemoptysis– 1.0 Malignancy– 2.0 PE as likely or more likely than alternative

diagnosis

High Probability > 6.0

Moderate Probability 2.0 – 6.0

Low Probability < 2.0

Wells et al. Ann Int Med 2001; 135:98-107

PERC Rule

• Age <50• HR <100• RA SpO2 >94%• No prior PE/DVT• No recent surgery• No estrogen• No DVT findings• No hemoptysis

Will have a PTP <2% and therefore will not

benefit from an evaluation for PE

Kline JA et al. J. Thrombosis Haemostasis 2004; 2:1247-1255

Imaging

• CXR

• V/Q Scan

• CT chest

• Angiography

CXR

VQ Scan

Normal excludes PE, otherwise in context of patient

90% sensitive, 95% specific

Pulmonary Embolism

• Treatment– High suspicion prior to imaging = heparin– Proven with imaging = heparin (LMW or UFH)– Thrombolytics in select cases

• Perimortem• RV dysfunction on echo• Pulmonary HTN on echo• Pulmonary HTN on R heart cath• New ECG signs of RV strain

Konstantinides et al NEJM 2002;347(15):1143-1150

Case 1 Summary

• Risk: age, post-op

• Pleuritic chest pain

• Mild tachypnea but vital signs otherwise normal = don’t be fooled!

• High index of suspicion!

Case 2

• 85 yo male

• CC: Cough, fever

• HPI: – 3 days of progressive cough with green

sputum production. – Fevers and chills– Pleuritic R sided chest pain

• PMHx: CAD, HTN, hypercholesterolemia

Case 2

• Surg Hx: TURP, Coronary stent x 2, appy

• Soc Hx: remote tobacco, occasional EtOH, no drug use. Widowed. Retired fisherman.

• FHx: Coronary disease

• ROS: no HA, abdominal pain, N/V/D, urinary symptoms

Case 2

• Vitals: T 38.5 HR 95 RR 20 BP 105/62 SpO2 94% room air

• Physical: – HEENT: dry mucous membranes– Cor: RRR no murmurs– Lungs: LLL crackles & occ wheeze– Abd: soft NT/ND

• Assessment?? Plan?

Pneumonia

• #1 infectious mortality– #6 overall– 1% as outpt, 25% when needing admission

• #1 cause nosocomial infectious mortality– Up to 50% mortality– 25-50% of all ICU pts get pneumonia

Pathogens

• Typical S pneumoniae, H Flu, Staphylococcus• AtypicalLegionella, Mycoplasma, Chlamydia• EtohKlebsiella pneumoniae• DM/DKAS pneumoniae/S aureus• HIVbased on CD4 count• COPDHaemophilus influenzae/Moraxella

catarrhalis• Sickle CellS pneumoniae/H influenzae

Diagnosis

• History/Physical

• CXR

• CBC

• Blood Cx

• Urine Cx

Treatment

• Ceftriaxone + Macrolide or Fluroquinolone (moxi/levo)– Typical and Atypical coverage– May to Cefepime for better G-

• Hospital/Nursing Home– Health care associated (includes dialysis pts)– Add Vanco

• Admit or outpt therapy?

PNA Severity Score

• Age:– Males: Age – Females: Age -10

• Nursing home : +10• Comorbid illnesses

– Neoplastic disease: +30– Liver disease: +20– CHF: +10– CVA disease: +10– Renal disease: +10

• Physical examination– AMS: +20– RR >30/minute: +20– SBP <90mmHg: +20– Temp <35, >40C: +15– Pulse >125/minute: +10

• Laboratory findings – pH <7.35: +30– BUN >30: +20– Sodium <130 mEq/L: +20– Glucose >250: +10– Hct <30%t: +10– PO2 <60 mmHg: +10– Pleural effusion: +10

PSS30d Mortality Prediciton

Total Score Rank Site or Rx Mortality (%)

None I Outpt 0.1

<70 II Outpt 0.6

71-90 III Outpt 0.9-2.8

90-130 IV Inpt 8.2-9.3

>130 V Inpt 27-29

CURB-65

• Confusion?

• BUN > 19 mg/dL (7 mmol/L)?

• Respiratory Rate ≥ 30?

• Systolic BP < 90 mmHg orDiastolic BP ≤ 60 mmHg?

• Age ≥ 65?

• For each yes answer pt gets 1 point

CURB-65 Score 30 day mortality

• 1 = 2.7%, outpt treatment

• 2 = 6.8%, consider inpt vs close outpt tx

• 3 = 14%, inpt tx, poss ICU

• 4 = 27.8%, inpt, prob ICU

• 5 = 27.8%, prob ICU tx

• CAVEAT: notice the score does not take into account hypoxia.

Atypical Pneumonia

RLL Pneumonia

RUL Pneumonia

LUL Pneumonia

Case 3

• 24 yo female• CC: Shortness of breath, wheezing• HPI:

– 2 days of gradual increased shortness of breath

– Worse today without relief with albuterol MDI– Non productive cough– No fevers– Recently got a new kitten

Case 3

• PMHx: asthma – No prior hospitalizations

• All/Meds: none/albuterol MDI

• Surgical Hx: none

• Social Hx: ½ ppd tobacco, no EtOH or drugs. Single. Waitress

• FHx: COPD

• ROS: negative

Case 3

• Vitals: T 37.8 HR 105 RR 22 BP 140/90 SpO2 91% RA

• Exam: +accessory muscle use, decreased air movement and very little wheezing

• Assessment?? Plan?

Asthma

• chronic, nonprogressive lung disorder characterized by:– Increased airway

responsiveness– Airway inflammation– Reversible airway obstruction

Physical Exam

• Tachypnea• Tachycardia• Cough• Prolonged expiratory phase• Wheezing

– NOT an accurate indicator of the severity of an attack

• BEWARE of the silent chest!!!– Wheezing may be ABSENT or only barely

audible in patients with severe obstruction

Physical Examination

Severe obstruction:– Inability to speak– Use of accessory muscles– Altered mental status– Diaphoresis– The ‘silent chest’

Can we accurately risk stratifyasthma patients with our exam alone?

No… clinicians & patients are notoriouslyinaccurate when assessing severity.

Checking an objective measure of lung function is considered the standard.

Assessment Tools

• Clinical scoring systems

• Peak expiratory flow rates

• Pulse oximetry

• Arterial blood gases

• Chest radiography

• CBC

Peak Expiratory Flow Rates

• Should be measured before and after each treatment

• Easiest test to perform in the ED

Peak Expiratory Flow Rates

• Provides an objective measure– Based on height, age, gender

• Is effort-dependent

• Useful to assess the response to Rx

<25% Severe25%-50% Moderate50%-70% Mild>70% Discharge Goal

Pulse Oximetry

• Used to assess and follow oxygenation

• O2 sats < 90% indicate a severe asthma attack and significant hypoxemia

• May have near-normal pulse-ox with impending hypercapneic respiratory failure

Arterial Blood Gases

• Respiratory alkalosis typical

• Inaccurate predictor of outcome

• Will seldom alter your treatment plan

• Painful and not free

Chest Radiography

• Adds little to decision making in most patients

• The presence of ‘abnormal’ findings on CXR seldom alters management

• Should not be ordered routinely

Indications for CXR

• First episode of wheezing

• Unclear diagnosis

• Patients refractory to therapy

• Respiratory failure

• Clinical evidence of infection, pneumothorax, or pneumomediastinum

Complete Blood Count

• Often elevated from stress of acute asthma attack or chronic steroid use

• Mild eosinophilia is common

• NOT routinely ordered

• Indications: infectious work-up

Pharmacotherapy

• Beta-agonists• Corticosteroids• Anticholinergics

Beta Agonists

• Mainstay of acute therapy

• Promote bronchodilation by increasing cAMP

• Primary effect is small airways

• Onset of action < 5 min

β-Agonists: MDI vs. Nebulizer?

• Both are equally effective, even in severe asthma

• MDI is substantially cheaper

• 6 puffs = 2.5 mg via a holding chamber nebulizer

Anticholinergic Agents

• Produce bronchodilation by inhibition of vagally-mediated bronchoconstriction

• Decrease cGMP

• Primarily affect large, central airways

• Onset of action up to 30 min and peak in 1-2 hrs

• Use in combination with beta-agonists as first-line therapy

Steroids

• Administer early• Used to treat the

inflammatory component of asthma

• Reduce the rate of relapse and the rate of hospital admission

Oral Versus IV?

• Both routes equally effective– Methylprednisolone 60-125mg IV– Prednisone 1-2mg/kg PO

• Oral route preferred– Easier and faster– Decreases pain/anxiety of IV– Cheaper

Inhaled Steroids

In chronic asthma the regular use of inhaled steroids has been shown to:– Suppress airway inflammation– Decrease beta-agonists use– Decrease the frequency of acute exacerbations– Decrease mortality related to acute asthma

The emergency physician can use the “rule of two” to determine if a patient’s asthma is well controlled:– Use of a rescue inhaler >2 times a week– Awakening with an asthma attack > 2 times a

month– Use of >2 quick-relief β-agonist canisters/year

Evidence Supporting the Role of Inhaled Corticosteroids In Controlling Asthma

Singer A. Acad Emerg Med 2005; 45:295-298.

Inhaled Steroids After Discharge?

• Use BID• Always use a spacer• Rinse mouth after use to

reduce complications (dysphonia, S/T, oropharyngeal candidiasis)

Case 4

• 69 yo male• CC: difficulty breathing• HPI

– Recent cold symptoms x 4 days– Now with cough, increased shortness of

breath– Poor exercise tolerance– Cough is productive with yellow sputum– No fevers, N/V/D, or other complaints

Case 4

• PMHx: HTN, COPD, hypercholesterolemia

• All: PCN• Meds: combivent, lipitor, HCTZ• Surgical Hx: cholecystectomy• Social Hx: 70 pk-yr tobacco, +EtOH, no

drug use; married, retired ship builder• FHx: emphysema• ROS: negative

Case 4

• Vitals: T 37.6 HR 100 RR 20 BP 150/94 SpO2 89% room air

• Physical: pursed-lip breathing, barrel chest, using accessory muscles. Distant heart and lung sounds, occasional wheeze. +clubbing

• Assessment?? Plan?

COPD

• Definition– Chronic bronchitis: Chronic, productive cough

x 3 months in each of 2 successive years in which other causes of chronic cough have been eliminated (Blue bloaters)

– Emphysema: abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of bronchiolar walls but without obvious fibrosis (Pink puffers)

COPD

• Exacerbations– Worsening airflow

obstruction due to• Bronchospasm• Sputum production

(infectious, environmental irritants)

• Cardiovascular deterioration

COPD

• History– Progressive shortness of breath– Increased sputum production– Audible wheezing

• Physical exam– Tachypnea– Hypoxemia– Cyanosis– Agitation – Hypercarbia (confusion, stupor, inadequate respiratory effort)– Sitting up, pursed-lip breathing (PEEP)– Diminished breath sounds, prolonged expiratory phase,

wheezing

COPD Work-up

• CBC (r/o anemia)• CXR (r/o infection, ptx, CHF)• ECG• Other labs

– Lytes– Cardiac enzymes– BNP– Theophylline level (if on med, uncommon these

days)

COPD Treatment

• Oxygen– Most have baseline sats of 88-91% with mod/severe disease– Hypoxic drive

• Bronchodilation– Beta-agonists i.e. albuterol

• Decrease mucous production– Anticholinergic i.e. atrovent

• Decrease inflammation– Steroid therapy

• Treat infection or underlying cause• Similar to asthma treatment

Combivent or Duoneb

Summary

• Dyspnea = Subjective

• Large differential to consider…– Pulmonary Embolus– Pneumonia– Asthma– COPD– AMI, CHF, Anemia, Tox, pneumothorax,

airway obstruction etc.