approach to dyspnea

1. APPROACH TO DYSPNEA
DR AMINA MUNIR

2. GENERAL APPROACH
ASSESS SEVERITY
IMMEDIATE
INTERVENTIONS
FURTHER
HISTORY
ADDITIONAL
TREATMENT

3. ASSESSING THE SEVERITY
• WHA ARE THE SIGNS OF RESPIRSORY DISTRESS?

4. ASSESSING THE SEVERITY
• VITALS (Tachypnea, Abnormal heart rate)
• SATURATION
• POSITION ( SUPINE REASSURING, TRIPOD WORRISOME)
• SPEECH (WORDS PER SENTENCE)
• RETRACTIONS
• ACCESSORY MUSCLE USE
• ALTERED CONSCIOUS LOC
• DIAPHORESIS

5. RESPIRATORY
DISTRESS
IMMEDIATE
INTERVENTION

6. INTERVENTION
• Following intervention maybe needed immediately before evaluation is complete
 Intubation
 CPAP/BIPAP
 Nebulization
 Chest tube
 Tracheostomy

7. INDICATIONS OF ETT AND VENTILATION
• Slowing of respiratory rate
• Depressed mental status
• Inability to maintain respiratory effort
• Severe hypoxemia

8. HISTORY
 SUDDEN ONSET
 Pulmonary Embolism
 Pneumothorax
 Anxiety
 Heart Failure

9. HISTORY
 Orthopnea or PND
 consider congestive heart failure

10. HISTORY
 ASSOCIATED CHEST PAIN
 MI
 PULMONARY EMBOLISM
 TENSION PNEUMOHORAX
PNEUMONIA

11. HISTORY
 ASSOCIATED SYSTEMIC SMPTOMS
 FEVER
 WEIGHT LOSS
 NIGHT SWEATS
 ANXIETY

12. HISTORY
 Past medical history
• COPD
• CHF
• ASTHMA
• PULMONARY EMBOLISM RISK FACTORS

13. PHYSICAL EXAMINATION
• RESPIRATORY RATE
• SIGNS OF RESPIRATOR DISTRESS
• AUSCULATION

14. CASE SCENARIO
• A 15 Yr. old male patient presents in emergency department with severe shortness
of breath gradually worsening all day. SOB is associated with cough that is non
productive. Past medical history= Asthma On examination patient is visibly
dyspneic,diaphoretic
• Vitals are PR 110, RR 24, BP140/80, Temp 100F, Sats 95% on room air
• Normal mental status
• Chest retractions +
• Diffuse wheezing

15. WHAT IS YOUR PROVISIONAL
DIAGNOSIS

16. CASE SCENARIO
• WHAT TREATMENT DO YOU WANT TO START?

17. ACUTE EXACERBATION OF ASTHMA
• Beta agonists are cornerstone (ventolin 2. 5 to 5mg by nebulization every 20 min
for 3 doses then 2.5 to 5mg every 1 to 4 hrs as needed.)
• Steroids treat underlying inflammation. (hydrocortisone 150 to 200mg, dexa 6mg
to10mg, methylprednisolone 60 to120mg iv)
• Ipraatropium bromide 500mcg by nebulization every20 min for 3 doses.
• Magnesium sulfate 2g over 20 min.

18. WHAT IS SILENT CHEST?

19. CASE SCENARIO
• A 71 yr. old female presents to emergency department with severe shortness of
breath that progressed gradually over period of 4 days and was much worse this
morning. Patient has mild non productive cough. No chest pain and fever. According
to attendant patient was not able to lie flat last night and slept on chair. Past
medical history DM,CAD,GERD. On echocardiography ejection fraction is 25 percent.
• Vitals PR 106, RR 32, BP 200/110, SATS 87 on RA.
• Patient is dyspneic, sweaty, anxious but awake and alert.
• ON auscultation diffuse rales

21. CASE SCENARIO
• What is your provisional diagnosis

22. ACUTE DECOMPENSATED HEART FAILURE
• WHAT TREATMENT DO U WANT TO BEGIN?

23. ACUTE DECOMPENSATED HEART FAILURE
• Place the patient in upright position
• Provide supplemental oxygen if sats <90%
• Provide NIV as needed or mechanical ventilation if required
• Initiate loop diuretics without delay furosemide 40mg iv
• if response to iv diuretics is inadequate start isoket infusion @ 2 to 10 mg/min
titrate according to response
• if pt is in cardiogenic shock give an iv inotrope dobutamine
• Look for etiology of heart failure like Acute MI / Arrythmia and manage accordingly

24. CASE SCENARIO
• A 55 yr. old male chronic smoker k/c of COPD presented to us in ER department
with complain of gradually worsening SOB cough and altered conscious level for
past 3 days associated with fever that was low grade and continuous. on
examination
• vitals PR 92, RR 25, BP 140/90, SATS 85% on RA.
• Chest bilateral decreased air entry.

26. CASE SCENARIO
• what is your provisional diagnosis
• what other important blood test u want to order

27. CASE SCENARIO
• oxygen inhalation ( Titrate to the target saturation of 88 to 92)
• Plan for BiPAP / mechanical ventilation if type 2 respiratory failure
• Bronchodilators
• systemic steroids
• Antibiotics

28. ACUTE INFECTIVE EXACERBATION OF
COPD
• Send ABGS to rule out type 2 respiratory failure.
• in case of type 2 respiratory failure give trial of BiPAP if pt is conscious and able o
clear secretions. Reassess ABGs after 2hrs and if there is no resolution of
hypercapnia intubate the pt and start mechanical ventilation.

29. WHAT IS HYPOXIA WITH CLEAR
LUNGS?

30. CASE SCENARIO
• A 35 yr. old female pt with no previous premorbids presented to us in ER
department with complain of sudden onset severe shortness of breath on rest.
patient is visibly dyspneic, diaphoretic and can speak few words per sentence only.
There is no medication history except for oral contraceptive pills for past 10 months.
On examination
• vitals are PR 110, RR 28, BP 100/60
• SATS 80 on RA
• chest bilateral clear with no added sounds

31. CASE SCENARIO
• what is your provisional diagnosis based on history and examination

32. PULMONARY EMBOLISM
• Respiratory support
• Hemodynamic support
• Empiric anticoagulation
• thrombolectomy / embolectomy

33. CASE SCENARIO
• A 16 year old boy is brought to emergency department with sudden onset severe
shortness of breath. He has history of stung by a bee 30 minutes ago. Initially
patient complained of localized pain and swelling that progressed to shortness of
breath in 15 mins. On examination
• Vitals PR 120/min, RR39/min, BP 70/40
• There is generalized urticaria.
• Lips and tongue are not swollen
• On auscultation of chest there is bilateral wheeze.

34. WHAT IS YOUR DIAGNOSIS

35. ANAPHYLAXIS
• Give IM epinephrine 0.3 to 0.5mg into outer mid thigh. Can repeat every 5 to 15
minutes
• If patient symptoms are not improving prepare iv epinephrine for infusion @ 0.1
ug/kg/minute
• Give iv fluids
• Give iv steroids
• nebulization with Albuterol
• continuous monitoring.

36. CASE SCENARIO
• A 15 year old female student with no previous premorbids presented to emergency
department with complain of sudden onset severe shortness of breath. Patient has
no history of any respiratory illness before. Her final exams of fsc are going to be
started soon. On examination
• vitals PR 110, RR 18, BP 110/70 Afebrile.
• saturation 100%
• Chest bilateral clear

37. WHAT IS UR DIAGNOSIS BASED ON
HISTORY AND EXAMINATION?

38. ANXIETY

39. SUMMARY
• Many patients with dyspnea will require immediate intervention based On minimal
information.
• Don’t forget foreign bodies in the differential of acute dyspnea.
• All that wheezes are not asthma
• Always think of pulmonary embolism in hypoxia with clear lungs.
• History and physical examination are cornerstone in beginning the empirical
treatment of acute Dyspnea