Breathing problems
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Transcript of Breathing problems
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