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12 breathless algorithm
 

12 breathless algorithm

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Breathless Algorithm

Breathless Algorithm

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    12 breathless algorithm 12 breathless algorithm Presentation Transcript

    • The breathless patientAdapted from Lichtensteins BLUE protocol (with permission) 1
    • Summary1 (Ongoing resus) Clinical assessment: formulate the question2 Rapid screen3 Form a working diagnosis4 Continue resuscitation5 Re-scan / monitor progress / further investigations 2
    • 1. Formulate the question
    • 1. Formulate the question Why is the patient breathless? 4
    • Why is the patient breathless?• Pneumothorax (PTX)• Pneumonia• Acute cardiogenic pulmonary oedema (APO)• Pulmonary embolism (PE)• Asthma / COPD• (Other: rare) 5
    • 2. The BLUE protocol
    • Curved probe, abdominal preset• Machine settings: as for arrest screen 7
    • A 3-step scan1. Anterior lung fields: 2 points2. If A profile: scan the upper & lower limb veins for DVT3. If no DVT: PLAPS points 8
    • The BLUE protocol scan 9
    • The BLUE protocol scan 9
    • Step 1: anterior chest: upper & lower BLUE points 10
    • Step 1: anterior chest: upper & lower BLUE points• Probe sagittal, midclavicular line• 2 spots on each side• i.e. upper chest & lower chest 11
    • Recall: upper & lower BLUE points 1 1 2 2 12
    • Step 1 findings One lung not Both lungs sliding slidingA’ profile B’ profile A profile B profile A/B or C profile
    • Step 1 findings One lung not Both lungs slidng slidingA’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Treat. Oedema Pneumonialung point, Treat. Treat. consider DDX. Step 2 Treat
    • Step 2: the veins 15
    • Step 2 (if dry lungs) Compression scans UL & LL veins Upper limb: IJV, SCVLower limb: femoral confluence, lower SFV, calf veins!
    • Step 2: scan the veins Scan the veins DVT seen = PE Treat. DVT not seen: Proceed to step 3
    • Step 2 noteThis is rule-in, not rule-out. Even with 81% sensitivity in the hands of an expert, you’ll still miss 19% of patients with PE.
    • Step 3: the PLAPS points 19
    • What are the PLAPS points?= the most dependent part of the lungsAs far behind & as low as you can scan without hitting the diaphragm‘The Morison’s Pouch of the lung’ [thanks Dr Chris Wong]
    • Recall: PLAPSPosterolateral alveolar &/or pleural syndrome Not as bad as it sounds!
    • Posterolateral alveolar &/or pleural syndromeIf you see effusion or If you see anything consolidation at else (A lines, B PLAPS points its lines), its PLAPS- PLAPS positive’ negative
    • PLAPS-positive?
    • PLAPS-positive?
    • PLAPS-positive?
    • PLAPS-positive?
    • PLAPS-positive?
    • Step 3: the PLAPS points PLAPS points PLAPS seen: Pneumonia (PE still possible but much less likely) PLAPS not seen: Treat. COPD Asthma PE is still possible Reassess patient; consider other tests.
    • Now what? You’ve reached the end of the scan Patient still breathless You’ve ruled out APO, PTX, pneumonia …but not PE.If it’s still on your list, you need a different test. 27
    • The BLUE protocol One lung not sliding Both lungs slidng A’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Oedema Pneumonia lung point, Step 2consider DDX. Scan the Veins DVT not seen DVT seen: PE PLAPS seen: Step 3 PLAPS not seen: Pneumonia PLAPS points COPD / asthma / PE
    • BLUE protocol: important notes 29
    • BLUE protocol: notes• Controversial eg for DVT: • Scans below the knee • Scans the upper limbs (increases sensitivity for PE by 4%)• Does not make use of cardiac / IVC windows (and misses 19% PE in the hands of an expert)• Accurate in hands of expert lung sonologist. Not yet validated in multicentre trials of all comers with breathlessness, by non-experts 30
    • Suggestions1. Add cardiac/IVC scan to the protocol to increase sensitivity for PE (Rule-in, not rule –out: if cardiac/ IVC scan negative, could still be PE)• E.G. as step 4 (PTO)• Or as step 3 (before veins)2. Include upper limb & below knee in your DVT scan? Leave to operator discretion3. Perform validation studies & review this advice 31
    • Step 4: heart / IVC Dry lungs, no DVT, no PLAPS:High pressure RV Heart / IVC Grossly normal:+ distended IVC: COPD Massive PE Asthma PE is still possible Inadequate view: Reassess patient; Get help, or finish consider other the scan & tests. arrange other tests
    • Modified BLUE protocol Step 1 One lung not sliding The lungs Both lungs sliding A’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Oedema Pneumonia lung point, Step 2consider DDX. The veins DVT not seen DVT seen: PE PLAPS seen: Step 3 PLAPS not seen: Pneumonia PLAPS points Step 4 heart /IVC Grossly normal: COPD / Asthma High pressure RV PE is still possible + distended IVC: Reassess patient; consider other tests. Massive PE
    • Modified BLUE protocol scan 34
    • Modified BLUE protocol scan 34
    • Oustanding issues• Does RV/IVC distension occur in status asthmaticus / severe COPD? If so, this could limit its use as a discriminator for massive PE (and is the reason Lichtenstein does not include it on the BLUE protocol)• BUT realistically a sensible dr can pick asthma/COPD clinically, so this should not be an issue• Scanning for DVT • Include upper limb? Only adds 4% sensitivity • Include below knee? This will be controversial for many • Details less important than the understanding that this is ‘rule- in’, not ‘rule-out’• Validation studies by non-experts are needed 35
    • Summary: the modified BLUE protocol Step 1: anterior lungs Step 2: the veins Step 3: the PLAPS points Step 4: heart & IVC 36