This document discusses the case of a 62-year-old man presenting with acute dyspnea. On examination, the patient is pale, sweaty, coughing pink sputum, and in respiratory distress. His pulse is 140 BPM, respiratory rate is 30, and oxygen saturation is 85%. The document outlines potential causes of acute dyspnea including pulmonary edema and provides guidance on evaluating, diagnosing, and initially managing such a patient. Key factors to consider include the patient's medical history, signs of heart failure on examination, and portable chest x-ray findings suggestive of pulmonary edema. The goals of treatment are to place the patient in a sitting position, provide high-flow oxygen, administer diuretics and opioids,

2. Drowning !!
Imagine yourself sinking deep into the sea ,
ALONE , surrounded by darkness
Your heart beating fast ,
Laborious breathing ,
effortlessly and with pain
Feeling the end is near ,
Your hands looking pale
Trembling from fear
You are too breathless to speak or to shout for
help
When suddenly ………

3. When suddenly
The rotator comes and seeks a complete 30
minute history from you !!
Including social history thinking that water
sanitation is relevant to the case

4. Please note
ACUTE
DYSPNEA
IS EMERGENCY

5. Throwing a life jacket to the drowning patient

6. Case
You were called in the ER for managing a 62 year
old man , brought for sudden severe shortness
of breath , you found the patient sitting , leaning
forward and supporting his arms on a chairback
, looking distressed , pale , sweaty and coughing
productively of pink tinged frothy sputum . You
asked him some questions , but he was too
dyspneic and distressed to answer . But you
found past history of MI 6 months ago .

7. Case

8. Further examination
• Xanthelasma
• Pulse rate was 140 BPM
• RR : 30 cycles /min
• Spo2 was 85 %
• Blood pressure : 180 / 90 mmHg
• Basal crepitation
• Gallop rhythm
• Ankle edema bilaterally

9. Ask yourself
• Is the patient in respiratory distress ?
• Do you think additional investigations will do
any good ?
• Is the dyspnea cardiac or respiratory in origin
• What are your hints toward the cause ?

10. DDX of acute dyspnea
• Airway obstruction
• Tension PNX
• Anaphylaxis
• Arrhythmia with cardiac compromise
• Acute pulmonary edema
• Acute coronary syndrome
• Asthma exacerbation
• Respiratory tract infection
• Acute dyspnea in patient with COPD
NEED
IMMEDIATE
CORRECTION

11. Goals
• Main pathologies of pulmonary edema
• Causes of pulmonary edema
• What's important in history ?
• What to find in examination ?
• X-ray findings
• Other investigations
• Proper management

12. Being able to approach to such a case
You have to know the
basics

13. 3 factors important
• capillary hydrostatic pressure
• capillary oncotic pressure
• capillary – alveolar permeability

14. Pulmonary edema will develop if
• Increased capillary hydrostatic pressure
• Decreased capillary oncotic pressure
• Increased capillary – alveolar permeability
Usually the heart will act on the first factor
Oncotic pressure depends on albumin
3rd factor is influenced by lung causes

15. ...So
Pulmonary edema
Is either
cardiogenic
or
non cardiogenic

16. Cardiogenic edema
• Acute complication of MI and IHD
• Exacerbation of heart failure
• Arrhythmias
• Failure of prosthetic heart valve
• VSD
• Cardiomyopathy
• B-blockers
• Acute myocarditis
• Pericardial diseases

17. Non cardiogenic edema
• ARDS
• Intracranial
• Fluid overload
• Hypoalbuminemia (liver , renal , …)
• Drugs / poisons / chemical inhalation
• Lymphangitis carcinomatosis
• Smoke inhalation
• Near drowning incidents
• High altitude mountain sickness

18. What to get from history
Little but important
its good to search for :
Main symptoms: acute dyspnea , anxiety , pallor ,
sweating , orthopnea , productive cough .
Medical history: Previous heart diseases
(IHD , Failure …..) Respiratory illnesses
Surgical Hx: recent surgery (fluid overload) or valve
replacement surgeries
Drug Hx: -ve inotropics

19. Examination
• Tachypnea
• Tachycardia
• Anxiety
• Cyanosis ( if severe )
• coughing up frothy pink sputum
• Unable to talk
• Listen to the chest : murmurs , S3 /S4 , crackles (
either basal or widespread )
• JVP , ankle edema … signs of heart failure
• Sweating , pallor

20. Investigations
start treatment based on clinical suspicion before
completing all Ix .
• Attach cardiac monitor and check SpO2
• Obtain CXR
• Obtain ECG
• Send blood for U & E , glucose , CBC , troponins
• If severely ill or SpO2 < 94% get ABG
• Request previous notes on medical Hx

21. What to find in CXR
• Upper lobe diversion
• Cardiomegaly
• Kerley A or B lines
• Fluid in interlobar fissures
• Pleural effusions
• Bat wing hilar shadows

22. CXR mnemonic

23. CXR

24. Treatment

25. Treatment
• Nurse in sitting position
• High flow high concentration O2
• Give furosemide I/V 50-100 mg
• Give small doses of opioids I/V
(don’t give opioids to pt who are drowsy , confused
or exhausted as this may ppt. respiratory arrest )
• Give GTN iv 10-200 microgram/min or buccal
GTN 2-5 mg
• Dopamine may be needed to augment cardiac
function.

26. Treatment
• consider Foley , and monitor urine output
• treat underlying cause and associated
problems ( arrhythmia , MI , cardiogenic shock
, acute prosthetic valve failure )
• No response : ICU

27. Treating non-cardiogenic edema
Resuscitate with ABC
THEN
According to the underlying cause

28. Some cases
• 53 years old heavy alcoholic man ( with known
liver disease) developed sudden onset
shortness of breath , clinically and with
investigations the patient was found to have
acute pulmonary edema .
Whats the likely cause? Why ? And how to
manage ?

29. Case 2
• 49 years old man heavy smoker on his 2nd
post op day in the general surgery ward ,
developed sudden onset of shortness of
breath , on examination you found unilateral
leg swelling ?
What your suspicion ? Why ?

30. Case 3
• 55 years old man , hypertensive and PMHx of
IHD before 3 months now presented with
acute onset of SOB , on examination you
found bilateral leg swelling
What's your suspicion ?

31. Case 4
• 35 years old female with past history of
gallstones , presented with central abdominal
pain radiated to the back , with bluish
discoloration of skin around the umbilicus .
Patient later developed acute SOB which was
found to be from acute pulmonary edema
How to link gallstones with pulmonary edema?

32. Take home message
• Acute dyspnea is an emergency case
• Exclude causes that require immediate
correction (?)
• 3 main factors determine the cause of p. edema
• Differentiating cardiogenic from non-cardiogenic
is usually by history and its imp. In management
• Treatment should start before completing IX

33. Thank you 
Rushd J. Sadiq