BREATHING PROBLEMS

ASSESSMENT

Clinical features – history, end-of-the-bed, focused exam Bedside investigations – pulse oximetry, blood gases Pathology Imaging

HISTORY

Chronic lung disease Exposures Baseline function Condition specific symptoms

END-OF-THE-BED

PULSE OXIMETRY

Fancy algorithm Beware dyshaemoglins If in doubt get blood gas

BLOOD GASES

Ventilation and oxygenation Determines acid-base balance Degree of compensation Acute and chronic components KISS

BLOOD GASES

Is PaO2 adequate for the FiO2? Is the patient acidaemic or alkalaemic? How does the CO2 contribute to the pH?

How does the HCO3 contribute to the pH? What compensation has occurred? Rules of thumb

BLOOD GASES – COMPENSATION RULES

Acute CO2 retention – for every 10 the CO2 goes up, the HCO3 will go up by 1

Chronic CO2 retention – for every 10 the CO2 goes up, the HCO3 goes up by 4

Acute CO2 loss – for every 10 the CO2 goes down, the HCO3 goes down by 2

Chronic CO2 loss – for every 10 the CO2 goes down, the HCO3 does down by 5

BLOOD GASES

78 male drowsy with #NOF FiO2 50%

PaO2 180 pH 7.12 PaCO2 70

HCO3 24

BLOOD GASES

65 female with myasthenia gravis presents with severe cellulitis

FiO2 28%

O2 140 pH 7.30 PaCO2 70

HCO3 26.5

BLOOD GASES

62 male with exacerbation of COAD FiO2 35%

PaO2 100 pH 7.34 PaCO2 65

HCO3 34

BLOOD GASES

93 female with COAD presents with leg cellulitis FiO2 25%

PaO2 72 pH 7.40 PaCO2 59

HCO3 36

BLOOD GASES

62 male with exacerbation of COAD FiO2 35%

PaO2 100 pH 7.18 PaCO2 85

HCO3 36

BLOOD GASES

74 male with vomiting for 3 days FiO2 50%

PaO2 234 pH 7.62 PaCO2 30

HCO3 30

BLOOD GASES

43 female 3 days post-TKR transferred from rehab with new-onset breathlessness

FiO2 50%

PaO2 170 pH 7.62 PaCO2 25

HCO3 24

PATHOLOGY INVESTIGATIONS

Anaemia Infection/inflammatory markers Cardiac markers Renal function Electrolyte disturbances

CXR

Portable vs in radiology Need for lateral Gives lots of information

CASE

31 female sudden onset breathlessness 3 hours ago Usually fit and well OCP Speaking in sentences 37.2C, RR 26, SaO2 98%, HR 102, 105/60 Normal CXR

COULD IT BE A PE?

Scoring systems – PERC, Wells, Geneva, Charlotte D-dimer use Best imaging choice – CT, nuclear med, ultrasound, echo Best treatment

SCORING

PERC - 8 criteria, 1.8% miss rate, gestalt, use it to stop workup Well’s - 8 criteria variably weighted, use it to decide on D-dimer, 3 risk

groups

IMAGING CONSIDERATIONS

How much radiation (if any)? Test quality Accessibility

IMAGING CHOICE

CTPA - sensitivity 83%, specificity 96% V/Q - sensitivity 80.5%, specificity 96.6% TTE - severity stratification U/S - look for the DVT

IMAGING CHOICE

Up to 5x radiation with CTPA compared to VQ Foetus gets less radiation with CTPA Contrast reactions Renal impairment

TREATMENT

Anticoagulation Thrombolysis Clot retrieval

CASE

34 male arrives to ED via ambulance with wheeze and breathless. He has a history of asthma with 3 previous ICU admissions.

RR 33, SaO2 95% on salbutamol neb, HR 107, BP 134/70, sitting upright, words only

ASTHMA SEVERITY

Previous episode severity Current markers in present episode Treatment already given

ASTHMA TREATMENT

Depends of severity and response Bronchodilators - spacer, neb, IV Steroids Magnesium Oxygen Ventilation Education

CASE

64 female usually well referred by GP with multi-lobar pneumonia referred by GP

39C, RR 30, SaO2 95%, 95/59, HR 90, GCS 15 Elevated WCC and CRP, low albumin, normal renal function Admit or home?

PNEUMONIA

PSI, CURB-65, SMARTCOP Oxygen supplementation Antibiotics Special groups - immunosuppressed, traveller

CASE

85 male BIBA respiratory distress with previous admissions for management of infective exacerbations of COAD

37C, RR 45, SaO2 85% NRB, HR 115, BP 146/98, GCS 15, words only

EXACERBATION COAD

Treat like asthma Likely less reversible than asthma with more comorbidities Use NIV early - prevent intubation End-of-life decision making

CASE

23 male referred from radiology with CXR-confirmed pneumothorax He has had 3 days of chest pain which has been controlled with

ibuprofen

PNEUMOTHORAX TREATMENT

Presence of chronic lung disease Degree of breathlessness Size

CASE

11 year old girl referred by GP with lethargy and breathlessness

35.8C, RR 26, SaO2 100% R/A, HR 148, BP 90/60, responds to voice

https://emetdotme.files.wordpress.com/2015/06/1.pdf

OTHERS

Kussmaul breathing Anxiety Stimulants – sympathomimetics, salicylates Cerebral oedema