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Shortness of Breath
Transcript of Shortness of Breath
Let's start with a Case
38M who is PostOp day#1 laparotomy develops acute SOB.
Shortness of Breath
Dr. L Brown, Dr. N Arora, Dr. M Gupta, Dr. E Khemani
Develop a clinical approach to assessing and managing acute shortness of breath
Keep your patient alive!
Recognize respiratory distress
Concurrently manage and investigate
Reassess soon and often
Asthma Exacerbation and COPD
Pneumothorax & Pleural Effusions
Acute Coronary Syndromes
Deciding disposition: CURB-65
Reassess soon and often
frequent vitals and Px
Arterial vs. venous blood gas
trend vs. diagnosis
Recognize Respiratory Distress
You then decide to do an arterial blood gas...
Ventilation and oxygenation
Not an exhaustive list!
Recognize when you need help
Permission to CUS
C - Concerned
U - Understand
S - Safety
Vocal cord dysfunction
SpO2 >92% (88-92% in known CO2 retainer)
Antibiotics if indicated
remia (>7 mmol/L)
espiratory Rate (>30)
2+ = admit
4+ = consider ICU
Wells, Geneva, PESI
D-dimer vs. CTPA vs. V/Q
Unstable - Heparin vs. tPA vs. surgery
Stable - Heparin/LMWH
Need to look for it
Sinus (HR 100-140)
*A Flutter (~150)
WIDE (synchronized cardiovert)
SVT + BBB
Unstable/High Degree Block =
Mobitz Type II, 3rd Degree
1) Stop offending medications
2) Temporary pacing pads +/- Atropine
3) Call Senior or CCU
ABC's and vitals
Call for help early
Assess and manage
stridor, wheezes, poor airflow
Aspiration and Mucous Plugging
Poor cough, post-surgical
Can be catastrophic
Protect the airway, treat like bad pneumonia
Lasix + Foley
FIND & TREAT PRECIPITANT!!
Keep DDx in mind
Treat on spec
Refine DDx and Treatment
Recognize Ischemia on ECG
2) Old & new ECGs
ASA 160mg chewed
5) Call SENIOR/CCU - Don't Wait!
V1-V3 - Get 15 Lead
T Wave Changes
ECG Findings of Ischemia
1) What is the HR?
2) Wide or Narrow?
3) Regular or Irregular?
(No pulmonary edema)
Elevated JVP, dull HS
ECG - low voltage
CXR - NEW cardiomegaly
1) CALL CCU
2) Unstable - CCOT
3) Volume (
Auscultates "Crackles and wheezes bilaterally"
go to slido.com
And now for something completely different...
45 min later
2011 Resuscitation Bleyer et al.
*Non-invasive Positive Pressure Ventillation
CPAP and BiPAP
RR > 24/min
2L = 28%
Each L increase by 4%
Special thanks to
Dr's Khemani, Reddy, and Meiwald
Barry Zhang "Mr. Lam"
And for your attention!
SLOW = PACE
What about my patient whose SOB comes on gradually?
Approach to acid-base disorders
Differential Diagnosis for acid-base disorders
Interstitial Lung Disease
Coronary Artery Disease
Exercise Stress Test
When to Order
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
multiple risk factors
single severe risk factor
ACS (unstable angina, recent acute MI)
Uncontrolled arrhythmia, HTN (>220/120)
3rd degree heart block
Acute myocarditis, pericarditis, endocarditis
Severe aortic stenosis, HOCM
How Does it Work?
Max Heart Rate
Goal to at least attain 85% of max:
Men: 220 - age
Women: 210 - age
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
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?
Diffusing capacity of carbon monoxide
Spirometry alone can't determine residual capacity (and therefore total lung volume).
Approach to Interpretation
Canadian Lung Health Test
1. Do you
2. Do you cough up
3. Do even
make you SoB?
4. Do you
when you exert yourself (exercise, go up stairs?)
5. Do you get many
and do your colds usually last longer than your friends colds?
If >40, ever smoker, with Yes to any:
SEND FOR SPIROMETRY
“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.
Symptoms ≥8 days/month or ≥2 exacerbations
Directly observed improvement with SABA
Parental report of improvement with 3 month trial of SABA prn +/- ICS
CPS Guideline Oct 2015
Restrictive Lung Disease
ILD (sarcoidosis, pulmonary fibrosis)
Chest wall (kyphosis, scoliosis)
Good quality study?
FEV1/FVC < 0.7
Consider Methacholine challenge if strong clinical suspicion of asthma
(FEV1 falls >20% with bronchoprovocation;
order full PFTs
Perform bronchodilator challenge
>12% increase in FEV1?
Reversible Airway Disease
Obstructive Ventilatory Impairment
COPD GOLD Staging Criteria
Repeat spirometry to r/a severity
but in proportion
(DLCO/TLC ~ 1)
DLCO ++ low
Interstitial Lung Disease?
American Thoracic Society Criteria
When Might You Order?
normal flow rates, but smaller volume
decreased flow rate
either same volume or smaller if severe
Peter Sloane MD
PFT Interpretation Tutorial on Youtube
Who you gunna call?
Your Sr Resident/Fellow/Staff
When in doubt, Call Early
60M with increasing SOB-E. 40 pack year. Retired building contractor. 80kg, 164cm.