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Shortness of Breath

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by

Lukas Brown

on 14 July 2016

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Transcript of Shortness of Breath

Develop a clinical approach
Let's start with a Case
38M who is PostOp day#1 laparotomy develops acute SOB.
Interventions
Pulmonary
Shortness of Breath
Dr. L Brown, Dr. N Arora, Dr. M Gupta, Dr. E Khemani
Objective
Develop a clinical approach to assessing and managing acute shortness of breath
Keep your patient alive!
Recognize respiratory distress
Collaborate
Concurrently manage and investigate
Reassess soon and often
Asthma Exacerbation and COPD
Pneumonia
Pneumothorax & Pleural Effusions
Cardiac
Acute Coronary Syndromes
Arrhythmias
Cardiac Tamponade
Other
HEENT
Neuro
Metabolic
Other
Deciding disposition: CURB-65
Physical exam
Imaging
Reassess soon and often
frequent vitals and Px
Arterial vs. venous blood gas
trend vs. diagnosis
Recognize Respiratory Distress
Pulmonary Embolism
You then decide to do an arterial blood gas...
Collaborate
Ventilation and oxygenation
Not an exhaustive list!
Recognize when you need help
Permission to CUS
C - Concerned
U - Understand
S - Safety
Cancer
Subglottic stenosis
Vocal cord dysfunction
Laryngeal edema
Epiglottitis
ALS
GBS
MS
Myasthenia Gravis
Hypothyroidism
Myxedema coma
Adrenal insufficiency
Adrenal crisis
Acidosis
Anemia
Sepsis
Anxiety
Pregnancy
Trauma
,
Pain
Positioning
Escalation of
FiO2
Case Summary
Acutely:
Monitored setting
SpO2 >92%
Ventolin
Atrovent
Systemic corticosteroids
Frequent Reassessment
Acutely:
SpO2 >92% (88-92% in known CO2 retainer)
Ventolin
Atrovent
Systemic corticosteroids
Antibiotics if indicated
Frequent Reassessment
C
onfusion
U
remia (>7 mmol/L)
R
espiratory Rate (>30)
Low
B
P (<90mmHg)
age ≥
65
2+ = admit
4+ = consider ICU
Imaging
Leukocytosis
Cough, sputum
Dyspnea, CP
Fever, exam
Wells, Geneva, PESI
D-dimer vs. CTPA vs. V/Q
Unstable - Heparin vs. tPA vs. surgery
Stable - Heparin/LMWH
Auscultation
Percussion
Symmetry
Ventilation/pressures
Essential skill
Need to look for it
Stable Tachycardia
Narrow (Adenosine)
Sinus (HR 100-140)
*A Flutter (~150)
AFib (80-160)
AVNRT/AVRT
(HR ~160-220)
WIDE (synchronized cardiovert)
VT
SVT + BBB
Accessory Pathway
Bradycardia
Unstable/High Degree Block =
Pacing
Mobitz Type II, 3rd Degree
Management
1) Stop offending medications
2) Temporary pacing pads +/- Atropine
3) Call Senior or CCU

pH= 7.25
PO2= 185
PCO2= 60
HCO3= 25
Urgent
ABC's and vitals
Call for help early
Assess and manage
Re-evaluate
Tachypnea
Accessory muscles
pursed-lipped breathing
anxiety
or
obtunded
few words
tripod
stridor, wheezes, poor airflow
Aspiration and Mucous Plugging
Low LOC
Poor dentition
Dysphagia
Elderly
Alcoholic
Poor cough, post-surgical
Can be catastrophic
Protect the airway, treat like bad pneumonia
CHF
Volume Overload
Pulmonary Edema
Management (LMNOP)
Lasix + Foley
Morphine
Nitroglycerin
Oxygen
Position
FIND & TREAT PRECIPITANT!!

Manage
Investigate
Keep DDx in mind
Treat on spec
Refine DDx and Treatment
Recognize Ischemia on ECG




Management Overnight
1) Recognize
ISCHEMIA

2) Old & new ECGs
3) CK/Trops
4)
ASA 160mg chewed
5) Call SENIOR/CCU - Don't Wait!
ST Elevation

ST Depression

V1-V3 - Get 15 Lead
T Wave Changes
Hyperacute
Inversion
Flattening
Biphasic (V1-V3)
ECG Findings of Ischemia
Four Questions...
1) What is the HR?
2) Wide or Narrow?
3) Regular or Irregular?
4) Patient
Unstable

Decreased LOC
Chest Pain
SOB
Hypotension
DIAGNOSIS
SHOCK
(No pulmonary edema)
Elevated JVP, dull HS
Pulsus paradoxus
ECG - low voltage
CXR - NEW cardiomegaly
Management
1) CALL CCU
2) Unstable - CCOT
3) Volume (
carefully
)
Auscultates "Crackles and wheezes bilaterally"
150/90
(106)

140/90
(103)
go to slido.com
enter# T2R

And now for something completely different...
NPPV
Repeat analysis...
pH= 7.25
PO2= 185
PCO2= 60
HCO3= 25
Original
45 min later
pH= 7.15
PO2= 185
PCO2= 70
HCO3= 26
What about?
pH= 7.35
PO2= 185
PCO2= 45
HCO3= 24
2011 Resuscitation Bleyer et al.
*Non-invasive Positive Pressure Ventillation
CPAP and BiPAP
BiPAP
Mod/severe dyspnea
RR > 24/min
Increased WOB
Hypoxemia
Respiratory acidosis
FiO2
NP
2L = 28%
Each L increase by 4%
Venturi Mask
NRB

Special thanks to
Joan Binnendyk
Dave Creces
Janet Hong
Dr's Khemani, Reddy, and Meiwald
John Seitz
Barry Zhang "Mr. Lam"

And for your attention!
FAST= CARDIOVERT
SLOW = PACE
What about my patient whose SOB comes on gradually?
Approach to acid-base disorders
Differential Diagnosis for acid-base disorders
Most Common
Asthma
COPD
Interstitial Lung Disease
Heart Failure
Coronary Artery Disease
Obesity/Deconditioning

Exercise Stress Test
When to Order
Criteria:
1. Substernal chest pain discomfort,
characteristic quality and duration
2. Provoked by exercise or emotional stress
3. Relief with rest or nitro
At least 2/3
At least 1/3 AND
male >40
female >60
multiple risk factors
single severe risk factor
ACS (unstable angina, recent acute MI)
Uncontrolled arrhythmia, HTN (>220/120)
Severe CHF
3rd degree heart block
Acute myocarditis, pericarditis, endocarditis
Acute VTE
Dissecting aneurysm
Severe aortic stenosis, HOCM
Contraindications
Bruce Protocol
How Does it Work?
Max Heart Rate
Goal to at least attain 85% of max:
Men: 220 - age
Women: 210 - age
Interpretation
High Probability of CAD
Horizontal ST depression < 2 mm
Downsloping ST depression
Early positive response within 6 mins
ST depression >6mins into recovery
ST depression in ≥5 leads
Exertional hypotension
But Don't Be Fooled!
Sharp upsloping ST segments is normal with exercise...This is not ST elevation.

Pulmonary Function Tests
What do PFTs include?
Spirometry
DLCO
Diffusing capacity of carbon monoxide
Spirometry alone can't determine residual capacity (and therefore total lung volume).
Lung Volumes
COPD
Approach to Interpretation
Canadian Lung Health Test
1. Do you
cough
regularly?
2. Do you cough up
phlegm
regularly?
3. Do even
simple chores
make you SoB?
4. Do you
wheeze
when you exert yourself (exercise, go up stairs?)
5. Do you get many
colds
and do your colds usually last longer than your friends colds?
If >40, ever smoker, with Yes to any:
SEND FOR SPIROMETRY
Asthma
“Don’t diagnose or manage asthma without spirometry.”
Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.
Exception: <6yo
Symptoms ≥8 days/month or ≥2 exacerbations
and
Directly observed improvement with SABA
or
Parental report of improvement with 3 month trial of SABA prn +/- ICS

CPS Guideline Oct 2015
Restrictive Lung Disease
ILD (sarcoidosis, pulmonary fibrosis)
Obesity
NMS
Chest wall (kyphosis, scoliosis)
NOT
volumes
helium
Good quality study?
FEV1/FVC ratio?
FVC low
FEV1 low/normal
FEV1/FVC >0.7
FVC low/normal
FEV1 low
FEV1/FVC < 0.7
FVC normal
FEV1 normal
FEV1/FVC >0.7
Normal study!

Consider Methacholine challenge if strong clinical suspicion of asthma
(FEV1 falls >20% with bronchoprovocation;
hyperresponsive)
Restrictive Pattern
order full PFTs
Obstructive Pattern
Perform bronchodilator challenge
>12% increase in FEV1?
NO
YES
Reversible Airway Disease

(e.g. Asthma)
Assess Severity
Asthma:
Obstructive Ventilatory Impairment

(e.g. COPD)
COPD GOLD Staging Criteria
Repeat spirometry to r/a severity
DLCO low
TLC low
but in proportion
(DLCO/TLC ~ 1)
Obesity?
DLCO ++ low
TLC low
DLCO/TLC low
Interstitial Lung Disease?
Assess Severity
American Thoracic Society Criteria
When Might You Order?
Examples...
normal flow rates, but smaller volume
decreased flow rate
either same volume or smaller if severe
Peter Sloane MD
PFT Interpretation Tutorial on Youtube
Handovers
"SBAR"
Situation
Background
Assesment
Recommendations
Who you gunna call?
Your Sr Resident/Fellow/Staff
CCOT
RT
Anesthesia/ICU

When in doubt, Call Early

Q
Q
Q
Q
Q
Q
Practice!
60M with increasing SOB-E. 40 pack year. Retired building contractor. 80kg, 164cm.
Q
Q
Q
Q
Q
Full transcript