Slides to accompany talk on breathlessness in the ED

1. BREATHING PROBLEMS

2. ASSESSMENT
 Clinical features – history, end-of-the-bed, focused exam
 Bedside investigations – pulse oximetry, blood gases
 Pathology
 Imaging

3. HISTORY
 Chronic lung disease
 Exposures
 Baseline function
 Condition specific symptoms

4. END-OF-THE-BED

5. PULSE OXIMETRY
 Fancy algorithm
 Beware dyshaemoglins
 If in doubt get blood gas

6. BLOOD GASES
 Ventilation and oxygenation
 Determines acid-base balance
 Degree of compensation
 Acute and chronic components
 KISS

7. 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

8. 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

9. BLOOD GASES
 78 male drowsy with #NOF
 FiO2 50%
 PaO2 180
 pH 7.12
 PaCO2 70
 HCO3 24

10. BLOOD GASES
 65 female with myasthenia gravis presents with severe cellulitis
 FiO2 28%
 O2 140
 pH 7.30
 PaCO2 70
 HCO3 26.5

11. BLOOD GASES
 62 male with exacerbation of COAD
 FiO2 35%
 PaO2 100
 pH 7.34
 PaCO2 65
 HCO3 34

12. BLOOD GASES
 93 female with COAD presents with leg cellulitis
 FiO2 25%
 PaO2 72
 pH 7.40
 PaCO2 59
 HCO3 36

13. BLOOD GASES
 62 male with exacerbation of COAD
 FiO2 35%
 PaO2 100
 pH 7.18
 PaCO2 85
 HCO3 36

14. BLOOD GASES
 74 male with vomiting for 3 days
 FiO2 50%
 PaO2 234
 pH 7.62
 PaCO2 30
 HCO3 30

15. 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

16. PATHOLOGY INVESTIGATIONS
 Anaemia
 Infection/inflammatory markers
 Cardiac markers
 Renal function
 Electrolyte disturbances

17. CXR
 Portable vs in radiology
 Need for lateral
 Gives lots of information

32. 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

33. COULD IT BE A PE?
 Scoring systems – PERC, Wells, Geneva, Charlotte
 D-dimer use
 Best imaging choice – CT, nuclear med, ultrasound, echo
 Best treatment

34. 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

36. IMAGING CONSIDERATIONS
 How much radiation (if any)?
 Test quality
 Accessibility

37. IMAGING CHOICE
 CTPA - sensitivity 83%, specificity 96%
 V/Q - sensitivity 80.5%, specificity 96.6%
 TTE - severity stratification
 U/S - look for the DVT

38. IMAGING CHOICE
 Up to 5x radiation with CTPA compared to VQ
 Foetus gets less radiation with CTPA
 Contrast reactions
 Renal impairment

39. TREATMENT
 Anticoagulation
 Thrombolysis
 Clot retrieval

40. 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

41. ASTHMA SEVERITY
 Previous episode severity
 Current markers in present episode
 Treatment already given

42. ASTHMA TREATMENT
 Depends of severity and response
 Bronchodilators - spacer, neb, IV
 Steroids
 Magnesium
 Oxygen
 Ventilation
 Education

43. 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?

44. PNEUMONIA
 PSI, CURB-65, SMARTCOP
 Oxygen supplementation
 Antibiotics
 Special groups - immunosuppressed, traveller

45. 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

46. EXACERBATION COAD
 Treat like asthma
 Likely less reversible than asthma with more comorbidities
 Use NIV early - prevent intubation
 End-of-life decision making

47. CASE
 23 male referred from radiology with CXR-confirmed pneumothorax
 He has had 3 days of chest pain which has been controlled with ibuprofen

49. PNEUMOTHORAX TREATMENT
 Presence of chronic lung disease
 Degree of breathlessness
 Size

50. 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

51. OTHERS
 Kussmaul breathing
 Anxiety
 Stimulants – sympathomimetics, salicylates
 Cerebral oedema