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Home , Acute chest syndrome, Hyperpnea, Orthopnea, Tachypnea, Westermark sign

Chapter 17 Dyspnea Sabina Braithwaite and Debra Perina

■ PERSPECTIVE Pathophysiology Dyspnea is the term applied to the sensation of breathlessness The actual mechanisms responsible for dyspnea are unknown. and the patient’s reaction to that sensation. It is an uncomfort- Normal is controlled both centrally by the respira- able awareness of breathing difficulties that in the extreme tory control center in the medulla oblongata, as well as periph- manifests as “air hunger.” Dyspnea is often ill defined by erally by chemoreceptors located near the carotid bodies, and patients, who may describe the feeling as , mechanoreceptors in the diaphragm and skeletal muscles.3 chest tightness, or difficulty breathing. Dyspnea results Any imbalance between these sites is perceived as dyspnea. from a variety of conditions, ranging from nonurgent to life- This imbalance generally results from ventilatory demand threatening. Neither the clinical severity nor the patient’s per- being greater than capacity.4 ception correlates well with the seriousness of underlying The perception and sensation of dyspnea are believed to pathology and may be affected by emotions, behavioral and occur by one or more of the following mechanisms: increased cultural influences, and external stimuli.1,2 work of breathing, such as the increased resistance or The following terms may be used in the assessment of the decreased compliance that occurs with or chronic dyspneic patient: obstructive pulmonary disease (COPD), or increased respira- tory drive, such as results from severe , acidosis, or : A greater than normal. Normal rates centrally acting stimuli (toxins, central nervous system events). range from 44 cycles/min in a newborn to 14 to 18 cycles/ Pulmonary stretch receptors also are thought to play a role. min in adults. : Greater than normal to meet metabolic requirements. ■ DIAGNOSTIC APPROACH : A minute ventilation (determined by respira- Differential Considerations tory rate and tidal volume) that exceeds metabolic demand. Arterial blood gases (ABG) characteristically show a normal Dyspnea is subjective and has many different potential causes.5 partial pressure of oxygen (Po2) with an uncompensated The list can be divided into acute and respiratory alkalosis (low partial pressure of carbon dioxide chronic causes, of which many are pulmonary. Other etiologies [Pco2] and elevated pH). include cardiac, metabolic, infectious, neuromuscular, trau- Dyspnea on exertion: Dyspnea provoked by physical effort or matic, and hematologic (Table 17-1). exertion. It often is quantified in simple terms, such as the number of stairs or number of blocks a patient can manage before the onset of dyspnea. Pivotal Findings : Dyspnea in a recumbent position. It usually is mea- History sured in number of pillows the patient must use to lie in bed (e.g., two-pillow orthopnea). Duration of Dyspnea. Chronic or progressive dyspnea usually Paroxysmal nocturnal dyspnea: Sudden onset of dyspnea occur- denotes primary cardiac or pulmonary disease.6 Acute dys- ring while reclining at night, usually related to the presence pneic spells may result from asthma exacerbation; infection; of congestive . pulmonary embolus; intermittent cardiac dysfunction; psycho- genic causes; or inhalation of irritants, allergens, or foreign Epidemiology bodies. Onset of Dyspnea. Sudden onset of dyspnea should lead to Dyspnea is a common presenting complaint among emergency consideration of (PE) or spontaneous department patients of all ages. Causes vary widely and may . Dyspnea that builds slowly over hours or be due to a benign, self-limited condition or significant pathol- days may represent a flare of asthma or COPD; ; ogy that can produce long-term morbidity and premature recurrent, small pulmonary emboli; congestive heart failure; or mortality. malignancy.

124 Chapter 17 / Dyspnea

125 2 - - - - = 70) = 70) DIAGNOSES

Polymyositis Porphyria ALS Rib fractures Pneumonia (CAP score < Thyroid disease Fever Congenital heart disease heart Valvular disease Cardiomyopathy Pregnancy Ascites Obesity Hyperventilation syndrome Somatization disorder Panic attack COPD Pneumonia Pneumonia (CAP score < Neoplasm Pleural effusion NONEMERGENT Table Table 17-2). Physical findings found in = 70) Serum electrolytes may suggest less common possible Signs Physical signs in dyspneic patients may specific be consistent illnesses with ( specific diseases also can be grouped 17-3). as presenting(Table patterns Ancillary Studies exam physical and history the from obtained findings Specific ination should be used to determine which ancillary studies are needed 17-4 ). (Table Bedside oxygen saturation determi nations, or selective use of ABGs when oximetry is not able, are useful reli in determining the degree of and the addi An ventilation. assisted or oxygen supplemental for need tional resource for quickly assessing ventilatory status is non- CO end-tidal the both Using capnography. waveform invasive value and the shape of the waveform itself can be helpful in assessing the adequacy of ventilations causes of as the dyspnea (See Chapter well 3). An electrocardiogram as potential may be useful if the etiology is cardiac or suggests acute pul- monary hypertension. causes, such as hypokalemia, ketoacidosis, or hypocalcemia. hypophosphatemia, A complete diabetic blood count may identify severe or thrombocytopenia associated with . The white blood cell count is not sufficiently sensitive or specific to be of discriminatory value. Cardiac markers and D-dimer assay may be useful in pursuing etiologies such as - - - - DIAGNOSES

obstruction, inflammatory/infectious process spnea Guillain-Barré syndrome paralysis Tick Anemia Multiple sclerosis Simple pneumothorax, Pneumonia (CAP score < Electrolyte abnormalities Metabolic acidosis Renal failure Mechanical interference Pericarditis Hypotension, sepsis from ruptured viscus, bowel Pneumonia Aspiration Cor pulmonale Asthma Spontaneous Spontaneous pneumothorax EMERGENT Dy

e Acut

Paroxysmal nocturnal 7 for

result from left-sided heart DIAGNOSES

Diagnoses

Organophosphate Organophosphate poisoning Cardiac tamponade Flail chest Carbon monoxide poisoning Acute chest syndrome intracranial CVA, insult Tension pneumothorax Tension DKA Myocardial infarction Cardiac tamponade ingestion Toxic Pulmonary Ventilatory failure Ventilatory Anaphylaxis Noncardiogenic Noncardiogenic edema Pulmonary Pulmonary embolus Airway obstruction CRITICAL Orthopnea can

Differential

Dyspnea can result from trauma, causing fractured If the pain is sharp and worsened by deep breathing deep by worsened and sharp is pain the If

SYSTEM

8,9 but also can be found in COPD. Exertional dyspnea 6 Positional Changes. Trauma. ketoacidosis. Hematologic Primarily Associated with Decreased Respiratory Effort Neuromuscular Traumatic Infectious Primarily Associated with Normal or Increased Respiratory Effort Abdominal Psychogenic Metabolic/endocrine Cardiac ORGAN Pulmonary Table Table 17-1 ally correlate poorly with severity. Fever suggests an infectious an suggests Fever severity. with poorly correlate ally cause. may point dyspnea, if no cause organic can be isolated. PE or myocardial to panic attack infarction or may present psychogenic with isolated dyspnea or with associ ated , particularly if the pain visceral. is constant, dull, or Symptoms Patient descriptions of dyspnea vary significantly and gener ribs, flail chest, hemothorax,neurologic or tamponade, cardiac effusion, pericardial rupture, pneumothorax, diaphragmatic injury. failure, COPD, or neuromuscular disorders. One of the earliest the of One disorders. neuromuscular or COPD, failure, symptoms seen in patients with diaphragmatic weakness from neuromuscular disease is orthopnea. ALS, amyotrophic lateral sclerosis; CAP, community-acquired pneumonia; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DKA, diabetic chronic DKA, cerebrovascular accident; obstructive community-acquired pulmonary COPD, pneumonia; CVA, disease; amyotrophic lateral CAP, ALS, sclerosis; vation of the diaphragm, resulting in less effective ventilation and dyspnea. commonly is associated with COPD, but also can be seen with seen be can also but COPD, with associated is commonly poor cardiac reserve loading, caused by ascites, or leads obesity, pregnancy, to ele and abdominal loading. Abdominal but not by movement, pleural and effusion or pleural irritation from pneumonia or PE are pneumothorax also may produce sharp pain with deep breath possible. Spontaneous ing that is not worsened by movement. dyspnea is most common in failure, patients with left-sided heart 126 Table 17-2 Pivotal Findings in Physical Examination

SIGN PHYSICAL FINDING DIAGNOSES TO CONSIDER

Vital signs Tachypnea Pneumonia, pneumothorax Intracranial insult, drug/toxin ingestion Tachycardia PE, traumatic chest injury Hypotension Tension pneumothorax Fever Pneumonia, PE General appearance Cachexia, weight loss Malignancy, acquired immune disorder, mycobacterial infection • Cardinal Presentations

Obesity , sleep , PE

wo Pregnancy PE T Barrel chest COPD “Sniffing” position Epiglottitis e c tion “Tripoding” position COPD/asthma with severe distress S

/ Traumatic injury Pneumothorax (simple, tension), rib fractures, flail chest, hemothorax, Skin/nails Tobacco stains/odor COPD, malignancy, infection Clubbing Chronic hypoxia, intracardiac shunts or pulmonary vascular anomalies Pallid skin/conjunctivae Anemia Muscle wasting Neuromuscular disease Bruising Chest wall: rib fractures, pneumothorax Diffuse: thrombocytopenia, chronic steroid use, anticoagulation Subcutaneous emphysema Rib fractures, pneumothorax, tracheobronchial disruption Hives, rash Allergic reaction, infection, tick-borne illness

Fundamental Clinical Concepts Upper airway edema/infection, foreign body, traumatic injury,

■ anaphylaxis

I JVD Tension pneumothorax, COPD or asthma exacerbation, fluid overload/CHF, PE

PART Lung examination CHF, anaphylaxis Bronchospasm Rales CHF, pneumonia, PE Unilateral decrease Pneumothorax, , consolidation, rib fractures/ contusion, pulmonary contusion Malignancy, infection, disorder, CHF production Infection (viral, bacterial) Friction rub Pleurisy Abnormal respiratory pattern (e.g., Intracranial insult Cheyne-Stokes) Chest examination Crepitance or pain on palpation Rib or sternal fractures Subcutaneous emphysema Pneumothorax, tracheobronchial rupture Thoracoabdominal desynchrony Diaphragmatic injury with herniation; cervical spinal cord trauma Flail segment Flail chest, pulmonary contusion Cardiac examination Murmur PE S3 or S4 gallop PE S2 accentuation PE Muffled heart sounds Cardiac tamponade Extremities Calf tenderness, Homans’ sign PE Edema CHF Neurologic examination Focal deficits (motor, sensory, Stroke, intracranial hemorrhage causing central abnormal respiratory cognitive) drive; if long-standing, risk of Symmetrical deficits Neuromuscular disease Diffuse weakness Metabolic or electrolyte abnormality (hypocalcemia, hypomagnesemia, hypophosphatemia), anemia Hyporeflexia Hypermagnesemia Ascending weakness Guillain-Barré syndrome

CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; JVD, jugular venous distention; PE, pulmonary embolism.

cardiac ischemia or PE. Amino-terminal pro-B-type natriuretic ■ DIFFERENTIAL DIAGNOSIS peptide (NT-proBNP) analysis adds both diagnostic and prog- nostic value for several causes of dyspnea, including heart The range and diversity of pathophysiologic states that produce failure, PE, and ischemic cardiac disease.9-11 Combinations of dyspnea make a simple algorithmic approach difficult.16 After specific serum markers can also help define pathology.12-14 initial stabilization and assessment, findings from the history, Specialized tests, such as ventilation-perfusion scans, chest physical examination, and ancillary testing are collated to computed tomography, pulmonary angiography, or, rarely, match patterns of disease that produce dyspnea. This process conventional pulmonary angiography, may confirm the diag- is updated periodically as new information becomes available. nosis of PE.15 If dyspnea is believed to be upper airway in Table 17-3 presents recognizable patterns of disease for origin, direct or fiberoptic laryngoscopy or a soft tissue lateral common dyspnea-producing conditions, along with specific radiograph of the neck may be useful. associated symptoms. Chapter 17 / Dyspnea

127

dyspnea; SH, social history; URI, upper respiratory infection. respiratory upper URI, history; social SH, dyspnea;

JVD, jugular venous distention; MI, myocardial infarction; MRV, magnetic resonance venography; NT-proBNP, amino-terminal pro-brain natriuretic peptide; PE, pulmonary embolism; PMH, past medical history; PND, paroxysmal nocturnal nocturnal paroxysmal PND, history; medical past PMH, embolism; pulmonary PE, peptide; natriuretic pro-brain amino-terminal NT-proBNP, venography; resonance magnetic MRV, infarction; myocardial MI, distention; venous jugular JVD,

ABG, arterial blood gas; CBC, complete blood count; CHF, congestive heart failure; CT, computed tomography; CXR, chest x-ray; DVT, deep vein thrombosis; ECG, electrocardiogram; FH, family history; HPI, history of present illness; illness; present of history HPI, history; family FH, electrocardiogram; ECG, thrombosis; vein deep DVT, x-ray; chest CXR, tomography; computed CT, failure; heart congestive CHF, count; blood complete CBC, gas; blood arterial ABG,

hives

Abrupt onset, exposure to allergen to exposure onset, Abrupt Anaphylaxis Oral swelling, stridor, wheezing, wheezing, stridor, swelling, Oral Dysphagia

PMH: recent MI, , CHF diabetes, MI, recent PMH: NT-proBNP reflux

pain ECG: ischemia, dysrhythmia ischemia, ECG: dysrhythmia, hepatojugular hepatojugular dysrhythmia,

medication noncompliance, chest chest noncompliance, medication Kerley B lines, cardiomegaly lines, B Kerley gallop, new cardiac cardiac new gallop,

4 3 JVD, peripheral edema, S edema, peripheral JVD, PND orthopnea, Worsening Gradual onset, dietary indiscretion or or indiscretion dietary onset, Gradual overload Fluid CXR: pleural effusion, interstitial edema, interstitial effusion, pleural CXR: S or

occupational exposure occupational focal focal

Weight loss, tobacco or other other or tobacco loss, Weight Malignancy CXR, chest CT: mass, hilar adenopathy, adenopathy, hilar mass, CT: chest CXR, Hemoptysis Dysphagia

FH: asthma FH:

PMH: environmental environmental PMH: Waveform capnography Waveform

sudden weather change weather sudden

tripoding, tripoding, atelectasis (mucus plug) (mucus atelectasis noncompliance, URI symptoms, symptoms, URI noncompliance,

Retractions, accessory muscle use, use, muscle accessory Retractions, diaphoresis hunger, Air CXR: rule out infiltrate, pneumothorax, pneumothorax, infiltrate, out rule CXR: Tobacco use, medication medication use, Tobacco COPD/asthma

ultrasound cardiovascular collapse cardiovascular

decompression. May verify using bedside bedside using verify May decompression. pneumothorax muffled heart sounds, sounds, heart muffled

Clinical diagnosis: requires immediate immediate requires diagnosis: Clinical Decompensation of simple simple of Decompensation Tension Above JVD, tracheal deviation, deviation, tracheal JVD, Above Diaphoresis

Simple Ultrasound positive for pneumothorax for positive Ultrasound

chest wall wounds or instability or wounds wall chest spontaneous pneumothorax spontaneous

hemothorax subcutaneous emphysema, emphysema, subcutaneous males more likely to have have to likely more males

± CXR: pneumothorax, rib fractures, fractures, rib pneumothorax, CXR: Decreased breath sounds, sounds, breath Decreased pain chest Localized trauma, chest pain, thin thin pain, chest trauma, onset Abrupt Pneumothorax

Exposure (e.g., birds), indolent onset indolent birds), (e.g., Exposure Fungal/parasitic Episodic fever, nonproductive nonproductive fever, Episodic

Immune disorder, chemotherapy disorder, Immune Opportunistic

Exposure (e.g., , varicella) influenza, (e.g., Exposure Viral

status

Waveform capnography if altered mental mental altered if capnography Waveform

Bacterial SH: tobacco use tobacco SH: ABG if hypoxia suspected hypoxia if ABG

sounds

exertional dyspnea, cough dyspnea, exertional rales or decreased breath breath decreased or rales

CXR, CBC, sputum and blood cultures blood and sputum CBC, CXR, Pneumonia Fever, productive cough, chest pain chest cough, productive Fever, Anorexia, chills, nausea, vomiting, vomiting, nausea, chills, Anorexia, Fever, tachycardia, tachypnea, tachypnea, tachycardia, Fever,

Ultrasound positive for DVT for positive Ultrasound

contraception, obesity contraception, Pulmonary angiogram Pulmonary

hypercoagulability, oral oral hypercoagulability, , spiral CT, MRV CT, spiral , Q V

CXR (, Hampton’s hump) Hampton’s sign, (Westermark CXR PMH: malignancy, DVT, PE, PE, DVT, malignancy, PMH:

ECG (dysrhythmia, right heart strain) heart right (dysrhythmia, ECG fever embolism immobility (travel, recent surgery) recent (travel, immobility

Diaphoresis, exertional dyspnea exertional Diaphoresis, Tachycardia, tachypnea, low-grade low-grade tachypnea, Tachycardia, ABG (A-a gradient), D-dimer gradient), (A-a ABG Pulmonary Pulmonary HPI: abrupt onset, pleuritic pain, pain, pleuritic onset, abrupt HPI:

DISEASE SPNEA) (DY HISTORY: SYMPTOMS ASSOCIATED FINDINGS AL PHYSIC AND SIGNS TESTS

Table 17-3 Table Diagnostic tterns Pa Table: ten Of Diseases of spnea Dy in Resulting 128 Table 17-4 Ancillary Testing in the Dyspneic Patient

CATEGORY TEST FINDINGS/POTENTIAL DIAGNOSES

Laboratory Pulse oximetry, selective ABG use Hypoxia, hyperventilation (muscular weakness, intracranial event)

Waveform capnography CO2 retention (COPD, ), obstructive or restrictive pulmonary pattern Metabolic versus respiratory acidosis (DKA, ingestions) A-a gradient (PE) Elevated carboxyhemoglobin (inhalation injury or CO poisoning) Complete blood count WBC • Cardinal Presentations Increase: infection, stress demargination, hematologic malignancy wo Decrease: neutropenia, sepsis T Hgb/Hct: anemia, polycythemia Smear: abnormal Hgb (i.e., sickling), inclusions e c tion

S Platelets: thrombocytopenia (marrow toxicity) / Chemistry BUN/Cr: acute/chronic renal failure K/Mg/Phos: low levels resulting in muscular weakness Glucose: DKA D-dimer: abnormal clotting activity NT-proBNP: heart failure, PE Troponin: cardiac ischemia or infarct

Cardiac ECG Ischemia, dysrhythmia, S1Q3T3 (PE), right heart strain Echocardiogram , valvular disorders Wall motion abnormalities related to ischemia, intracardiac shunts Radiologic Bony structures: fractures, lytic lesions, pectus, kyphoscoliosis Mass: malignancy, cavitary lesion, infiltrate, foreign body Fundamental Clinical Concepts

Diaphragm: eventration, elevation of hemidiaphragm, bowel herniation ■

Mediastinum: adenopathy (infection, sarcoid), air I Cardiac silhouette: enlarged (cardiomyopathy, fluid overload) Soft tissue: subcutaneous air PART Lung parenchyma: blebs, pneumothorax, effusions (blood, infectious), interstitial edema, local consolidation, air bronchograms, Hampton’s hump, Westermark’s sign VQ scan PE Pulmonary angiogram PE, intervention (thrombolysis) CT Mass lesion, adenopathy, trauma, PE MRI PE, bony and soft tissue lesions, vascular abnormality Soft tissue neck radiograph Epiglottitis, foreign body Ultrasound Pneumothorax, pleural effusion, impaired cardiac function or Fiberoptic Bronchoscopy Mass lesion, foreign body Intervention (stenting, biopsy) Laryngoscopy Mass lesion, edema, epiglottitis, foreign body

A-a, alveolar-arterial; ABG, arterial blood gas; BUN, blood urea nitrogen; CHF, congestive heart failure; CO, carbon monoxide; COPD, chronic obstructive pulmonary disease; Cr, creatinine; CT, computed tomography; DKA, ; ECG, electrocardiogram; MRI, magnetic resonance imaging; NT-proBNP, amino-terminal pro-brain natriuretic peptide; PE, pulmonary embolism; V/Q , ventilation-perfusion; WBC, white blood cell.

Critical Diagnoses should receive vigorous attention, including continuous or fre- quent administration of a beta-agonist aerosol.18 As mentioned Several critical diagnoses should be promptly considered to earlier, waveform capnography is a valuable tool for assessing determine the best treatment options to stabilize the patient. the severity and determining the cause of respiratory Tension pneumothorax is such a critical diagnosis. If a distress. dyspneic patient has diminished breath sounds on one side, ipsilateral hyper-resonance, severe respiratory distress, hypo- Emergent Diagnoses tension, and oxygen desaturation, prompt decompression of presumptive tension pneumothorax is necessary. Bedside Asthma and COPD exacerbations can result in marked dyspnea ultrasonography may assist in confirming pneumothorax. If with bronchospasm and decreased ventilatory volumes.19 obstruction of the upper airway is evidenced by dyspnea and Sudden onset of dyspnea with a decreased oxygen saturation stridor, early, definitive assessment and intervention must on room air accompanied by sharp chest pain may represent occur in the emergency department or operating room. Com- PE.15 Dyspnea accompanied by decreased breath sounds and plete obstruction by a foreign body warrants the Heimlich tympany to on one side is seen with spontaneous maneuver until the obstruction is relieved or the patient is pneumothorax. Dyspnea associated with decreased respiratory unconscious, followed rapidly by direct laryngoscopy. Conges- effort may represent a neuromuscular process, such as multiple tive heart failure and can produce dyspnea sclerosis, Guillain-Barré syndrome, or myasthenia gravis.14 and and should be treated as soon as possi- Unilateral rales, cough, fever, and dyspnea usually indicate ble if severe.17 Significant dyspnea and wheezing can be seen pneumonia. in anaphylaxis and must be treated promptly to prevent further Figure 17-1 provides an algorithm for assessment and stabi- deterioration. Severe bronchospastic exacerbations of asthma lization of a dyspneic patient. The initial division is based on at any age may lead rapidly to respiratory failure and arrest and the degree of breathing effort associated with the symptoms. Chapter 17 / Dyspnea 129 Thoracostomy Yes ABG Unequal, trauma: decompression No Immediate chest large pneumothorax Pulse oximetry Pulse Abnormal or hemothorax on U/S A-a gradient Hypotension, shock, Directed evaluation History and physical History and tracheal deviation, JVD? Oxygen supplementation Oxygen Anticoagulate, V/Q scan, pulmonary angiogram, spiral CT cardiac Ischemic: evaluation and treatment chest trauma Bedside U/S with Unequal, cardiac collapse, ptx D-dimer , right-sided 3 T anginal equivalent, NSSTWC: Clear, ± chest pain: Clear, 3 heart strain, consider PE Q 1 central neurogenic cause sinus tachycardia Troponin neuromuscular disorder or S consider pulmonary embolism, ECG No When the airway has been secured, rapid assessment of the ventilation intubation or Endotracheal mask depending on the degree of desaturation necessary, detected. the If patient should be should be assisted with manual intubated, or . and breathing patient’s appearance and vital signs can help determine need the for further stabilization. inability Decreased to speak in more mental than one-word syllables, alertness, or certain types of body positioning, signal the presence of significant cricothyrotomy breath and mechanical Assess sounds , ventilation-perfusion ratio; U/S, ultrasound. ventilation-perfusion U/S, , ratio; VQ Rhonchi, Antibiotics diminished infiltrate on pneumonia, blood cultures CXR: consider breath sounds, pleural effusion CXR Assist ventilation 2 , end-tidal carbon dioxide; IV, intravenous; JVD, jugular venous NSSTWC, nonspecificJVD, distention; ST intravenous; wave end-tidal , carbon IV, dioxide; 2 No steroids, waveform epinephrine, anaphylaxis, antihistamines CXR: consider sharkfin EtCO bronchospasm, Wheezes, clear , CXR Yes Yes evidence of capnography own airway or Able to maintain chest movement pulse oximetry, IV pulse oximetry, respiratory failure? Supplement oxygen, Supplement Respiratory distress? Respiratory continuous waveform Assess breath sounds, access, cardiac monitor, (RR >24 or <8), tripoding, (RR >24 obtain history and physical Rapid assessment and stabilization of a dyspneic patient. ABG, arterial blood gas; ACE, angiotensin-converting enzyme; BiPAP, Rapid biphasic assessment and stabilization of a arterial ABG, dyspneic angiotensin-converting enzyme; blood patient. BiPAP, ACE, gas; altered mental status, abnormal altered mental

ECG accessory muscle use, retractions, accessory muscle edema ACE inhibitors, CPAP or BiPAP CPAP pattern on CXR: +BNP, interstitial +BNP, Diuretics, nitrates, morphine, consider All patients experiencing dyspnea, regardless of possible consider pulmonary cause, should be promptly transported to the treatment area. Bedside pulse oximetry should be obtained, and the patient should be placed on a cardiac monitor. If the pulse oximetry is less than 98% saturated on room air, the patient should be placed on supplemental oxygen either by nasal cannula or The most critical diagnoses appropriate intervention taken must as necessary. be considered first and positive airway pressure; BNP, B-type natriuretic peptide; CO, carbon monoxide; CPAP, continuous positive airway pressure; CT, computed continuous tomography; positive airway CT, pressure; carbon CPAP, B-type monoxide; natriuretic CO, peptide; positive airway BNP, pressure; EtCO electrocardiogram; chest CXR, ECG, x-ray; Figure 17-1. changes (on ECG); PE, changes pulmonary respiratory PE, (on RR, rate; embolism; ECG); 130 Asthma or COPD exacerbation if appropriate • Cardinal Presentations

1. Inhaled beta-agonist 2. Steroids IV 3. Consider other adrenergics concurrent infection Treat 4. 5. Counsel smoking cessation wo T e c tion S / D-dimer Pulmonary embolism IV heparin or subcutaneous low-molecular-weight heparin if unstable with pulmonary angiography or cardioversion 1. Initiate anticoagulation with 2. Consider systemic thrombolysis 3. Consider interventional clot lysis beta-blockade or PCA Heart failure: diuretics, nitrates, morphine, ACE nitrates, morphine, Fundamental Clinical Concepts management, thrombolysis,

Ischemia: nitrates, ASA, pain Ischemia: nitrates, Dysrhythmia: antiarrhythmics ■

I

PART BNP 2 O Cardiac obtain ECG capnography and vital signs Respiratory failure vital signs with Sa Continuous waveform Supplemental oxygen endotracheal intubation, and mechanical ventilation Cardiac monitor IV access Complete initial evaluation, Differential diagnosis based 1. CPAP/BiPAP (short term) or 1. CPAP/BiPAP underlying cause Treat 2. on history, physical examination, on history, Pneumonia, infectious cause 1. Initiate appropriate empirical antibiotic, antifungal, or antiviral medication promptly 2. Isolation if needed 3. Blood, sputum cultures Anaphylaxis blocker IV Tension pneumothorax: Tension Inhalation injury: 2 Pain management multiple rib fractures: /H Pulmonary contusion, 1 by needle or tube thoracostomy Immediate chest decompression endotracheal intubation, cricothyrotomy epinephrine, heliox Early endotracheal intubation 1. Secure airway when needed: 2. Epinephrine IV (extreme), SQ 3. Steroids IV 4. Diphenhydramine IV 5. Inhaled beta-agonist 6. Consider inhaled racemic 7. H Clinical Clinical guidelines for emergency department chronic obstructive angiotensin-converting acetylsalicylic management enzyme; ASA, pulmonary of COPD, ACE, acid; dyspnea. disease;

FAST Trauma Figure 17-2. subcutaneous. SQ, patient-controlled analgesia; PCA, continuous intravenous; positive airway pressure/biphasic IV, positive electrocardiogram; airway ECG, pressure; CPAP/BiPAP, Chapter 17 / Dyspnea 131 - Most patients in the nonurgent category can be treated as rioration rioration without proper cancer, or immunosuppression, treatment diabetes, as such or comorbidities, patients with severe may also require admission for observation and treatment. outpatients if good medical dyspnea follow-up persists despite can therapy and no be definitive cause has arranged. for hospitalization is action of course best the delineated, been If observation and ongoing evaluation. If no definitive diagnosis can be obtained and the symptoms have abated, the patient may be discharged with good medical follow-up and instruc tions to return if symptoms recur. The references for this chapter can be found online by accessing the accompanying Expert Consult website. Fig. 17-2) outlines

MANAGEMENT

DISPOSITION

EMPIRICAL the approach to treatment Unstable patients or patients for with critical diagnoses must most be unit. care intensive an identifiableto admission require may and stabilized diseases. Emergent patients who have department improved may in be admitted the to emergency an Patients diagnosed intermediate with urgent conditions care in danger unit. of dete- The management algorithm for dyspnea ( ■ AND respiratory respiratory distress and the need for rapid intervention. After stabilization has occurred, the cause of the further investigated. dyspnea can be