Approach to the Dyspneic Patient
Dan Crouch
Kristi Kuhn
Kate Lindley
Ben Voss
First and Foremost…
Identify the correct patient
Obtain the most recent vitals
Ask the nurse about the acuity of the episode
Does an ACT Now or CODE need to be called?
Requiring Quick Diagnosis and Intervention
Pulmonary Embolism
Acute Coronary Syndromes
Aortic Dissection
Pneumothorax
Things You Have A Little Time For
The Exacerbations: Asthma/Reactive Airway Disease COPD CHF/Tamponade
Pneumonia (CAP vs HAP) ARDS Less Common Causes:
Anxiety
Anemia
Armed with this knowledge…
You walk into the patient’s room - 02 sat=80%
Start supplemental oxygen ASAP! Get an idea of all the vitals (BP, HR, RR, Temp) Look at the patient:
Is he/she markedly tachypneic? Is he/she hypotensive? Is he/she mentating well? Is he/she cyanotic?
While you quickly peruse the chart, obtain an ABG, ECG and order a STAT portable CXR
Unlike your usual admission, the history comes second here
Do I Have Time for a Physical Exam? Key is to be FOCUSED
General Appearance - how distressed do they lookVitals - Repeat Vitals, q
10 minAssess for pulsus
paradox and BP in both arms
Cardiac - Rhythm, JVP, capillary refill, new gallops, murmurs or rubsPulmonary - air
movement, crackles, wheezes, breath soundsExtremity - presence of
edema, cyanosis
Therapy - Oxygen
Oxygen Relieves pulmonary vasoconstriction Increases myocardial reserveStart with high-flow NC, then proceed to
non-rebreather facemask delivering 100% If oxygen saturation does not improve, plan
NPPV or intubation
Therapy - Diuretics
Can decrease preload and also reduce cardiac filling pressures
Dosing regimen: Lasix 40-80mg IVP (may need more if in renal failure) Bumetanide 1-2 mg IVP Torsemide 10-20 mg IVP
If a patient is on chronic diuretics, simply change the PO to a IV regimen
Continuous infusion leads to modest improvement in urine output but no change in mortality
Therapy - Vasodilators
Nitrates work well by decreasing both afterload and preload Nitroglycerin - develop tolerance Nitroprusside - develop cyanide toxicity
Hydralazine acts as a direct arteriolar vasodilator Watch out for reflex sympathetic tachycardia
Other Pharmacologic Options
Steroids are useful in COPD and Asthma exacerbations Start with methylprednisolone 60 mg IV q6h
Bronchodilators are also useful Start with nebulized albuterol (2.5mg q1-2h) Add on Atrovent (2 puffs q 2-4h or 0.5mg q 2-4 h)
Opioid antagonists - narcan 0.4 mg IVP
Benzo reversal – flumazenil 0.2 mg IVP
Antibiotics for Pneumonia
Other options before intubation
Aggressive chest physical therapy Useful for mucus plugs, cystic fibrosis patients, and
excessive secretions
BiPAP Remember, it should be used primarily for
hypercarbic respiratory failure secondary to COPD or hypoxemic respiratroy failure secondary to cardiogenic pulmonary edema
Situations to avoid BiPAP; Somnolent, lethargic mental status Hemodynamic instability Profounnd acidemia (pH < 7.1)
Mechanical Ventilation Make sure you have the
following ready:Suction catheterOxygen monitorCrash Cart and Airway Box
ET Tube with StyletOP Airway10ml SyringeCO2 Detector
IV AccessSedative support (Fentanyl,
Versed)Paralytic supportAnesthesia
Start with preoxygenation Administer
sedative/paralytic Intubate Observe for color change
and bilateral breath sounds Recheck vitals Obtain CXR
Case 1
R.D. is a 32 y.o male with PMHx of asthma admitted for asthma exacerbation within the past 12 hours.
Vitals stable, O2 = 93%RALess than 12 hours into admission,
nurse calls you stating “His oxygen sat is 81% on 4L NC”
What do you do?
Examine the patientHis vitals are BP 140/75, HR 113, RR 38,
O2 = 86% on 6L NCExam: mentating well, bilateral faint
expiratory wheezing, using accessory muscles
Obtain a portable CXR and ABG
What is the likely diagnosis?Asthma Exacerbation
What else?
Supplemental oxygen to 8 L NC His oxygen sat increases to 90%
Call RT to administer: Albuterol 2.5 mg nebulizer Atrovent 0.5 mg nebulizer
Steroids Methylprednisolone 60 mg IV q6h if not previously
started No need for antibiotics in asthma exacerbation
Asthma Management - Summary
Nebulizers
Supplemental Oxygen
Steroids
Magnesium (minimal benefit)
No Antibiotics
Close monitoring - q4h vitals/peak flows
Case 2
G.B. is a 56 y.o AAF with PMHx of CRI (Cr 3.3 at baseline), HTN, DM2, admitted for cellulitis
On HD#2, during morning rounds, you find the patient markedly tachypneic and unable to speak in full sentences…
What do you want to do?
Get a set of vitals BP 200/115, HR 105, RR 32, O2=89% 2L NC Exam: JVP 11 cm, bilateral rales, S3 gallop, no LE
edema, 2/6 SEM at apex radiating to axilla
Supplemental oxygen, ABG
Order an ECG
Stat pCXR
While you await the CXR…
Hypertension Control: IV Metoprolol/Diltiazem IV Nitroglycerin gtt IV Labetalol gttPO Clonidine
Diuresis:Lasix 40 mg IV x 1
What is the likely diagnosis? Pulmonary Edema
Acute Cardiogenic Pulmonary Edema
Ischemia
Valvular – MR/AR/AS
Renovascular hypertension
Dysrythmias: AVB, Afib, V-tach, SVT
Overhydration with crystalloid or colloid
What is the next step?
Assess response to diuresis within 30 min to 1 hour
Assess response to afterload reduction within 15 min
If no response to either, tx to ICU for closer monitoring and likely BiPAP or mechanical ventilation
Case 3
N.M is a 28 yo WM with hx of Marfan’s syndrome who p/w sudden onset chest pain and SOB.
You are called to see him in the ER
He is afebrile, but tachycardic (HR 120). BP 110/65, 0x Sat 90 % RA, RR 28
CXR
What is the diagnosis?
Pneumothorax
What is your approach?
Assess oxygenation Is current oxygen requirement stable
Assess size of PTX Call Thoracic Surgery consult
Are there signs of tension: hyperlucent, overly expanded hemithorax mediastinal shift to the opposite side radiographic signs of pneumothorax - heart elevated from the
sternum, lung lobes retracted from the thoracic wall
Summary Points
Always recheck vitals immediately Close monitoring is essential
Assess ability to oxygenate Try oxygen, diuretics, nitrates, bronchodilators,
steroid, afterload reduction Have an end-point ready Evaluate probability of requiring mechanical ventilation
Have an ICU bed available Coordinate with nursing supervisor