Emergency Evaluation of the Dyspneic Patient

1. EmergencyEvaluation of the Dyspneic Patient Dr. Didem Ay EmergencyMedicine

2. Goals • Definitions • Emergency Department Evaluation • RespiratoryAssessment • Treatment • Etiology

3. Dyspnea: • Sensation of breathlessness or inadequate breathing • Most common complaint of patients with cardiopulmonary diseases.

4. Dyspnea - common complaint/symptom • Defined as“shortness of breath” or “breathlessness” • “abnormal/uncomfortable breathing” • “not getting enough air” • Multiple etiologies - • 2/3 of cases - cardiac or pulmonary etiology

5. Terms • Tachypnea: Rapidbreathing • Ortopnea: Dyspnea in the recumbent position • Paroxysmal nocturnal dyspnea:Orthopnea that awakens the patientfromsleep

6. Terms • Trepopnea: Dyspnea associated with only one of severalrecumbentpositions • Platypnea: The opposite of orthopnea (dyspnea in theuprightposition) • Hyperpnea: Hyperventilation and is defined as minute ventilation in excess of metabolicdemand

9. Hypoxia:Insufficient delivery of oxygen to the tissues Hypoxemia: Abnormallylowarterialoxygentension. (PaO2) < 60mmHgorarterieloxygensaturation(SaO2) < 90%

10. OxyhemoglobinDissociationCurve

11. Attention • Psychogenic dyspnea should be diagnosed after exclusion of organic causes

12. Emergency Department Evaluation • There is no one specific cause of dyspnea and no single specific treatment • Treatment varies according to patient’s condition • chief complaint • history • exam • laboratory & study results

13. Respiration: Inspirationandexpirationtoprovidesufficienttissueoxygenation Respiratorydistress:Unnatural, uncomfortable, distressinginspirationandexpirationcausingtissuehypoxia Clinicallyhypoxia, cyanosis, hypercapniaoccur

14. RespiratoryAssesment • Primaryevaluation: Goal is toeliminate life threateningcauses • Secondaryevaluation: Detailed

15. RespiratoryAssesment • Primary • Normal: Spontaneous, comfortable, painless, regularrespiration: 12-20/min (in adults) • Look, listen andfeelforbreathing • Wheezing, stridor? • Consciousness? • Talking? • Paradoxalchestmovement?(flailchest)

16. Look, Listen, Feel

17. RespiratoryAssesment • Primary • Respiratorydistress • Head-tilt, chin lift orjawtrust • Openairway • Reassesbreathing • Ifbreathingpresent, start oxygen • Ifbreathing is not present start artificialventilation

18. Baş geriye, alt çene öne yukarıya

22. Aspiration

23. Airways

35. RespiratoryAssesment • Secondary • History • Physicalexamination • Chest film

36. History • Age,past medical condition • Associated symptoms (Fever, cough, sputum, angina, pretibialoedema) • Timing: acuity and duration (Spontaneous/suddenonset, dyspnea on effort, orthopnea, PND) • Severity • Past medical history • Smoking, drugs (OKS, HRT), trauma, immobilization, malignancy

37. SignsandSymptoms Seriousrespiratorydistress : • Clinical: • Tachypnea (RR> 35/min), apnea • Cyanosis • Retractions • Agitation, inabilityto talk, unconscioussness, coma • Rales, wheezes • SO2< %90, PaO2<60 mmHg, PCO2>45 mmHg

38. Physical Examination • Headtotoe • Vital signs • Consciousness • Skin color (paleness, diaphoresis, cyanosis, erythema, urticaria) • Retractions (intercostal, suprasternal, abdominal) • Clubbing • Auscultation • Signs of heartfailure

39. Laboratory • Pulseoxymetry, arterialbloodgases • Completebloodcount • Chest X-ray, lateralneck X-ray • ECG monitorization • Echocardiography • Biochemicalparameters • Ifneeded: CT, ventilation-perfusionscintigraphy

40. PulseOxymetry • Rapid, widely available, noninvasive means of assessment in most clinical situations- • insensitive (may be normal in acute dyspnea) • The % of Oxygen saturation does not always correspond to PaO2 • The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels

41. ArterialBloodGases • Commonly used to evaluate acute dyspnea • Can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia • Normal ABGs do not exclude cardiac/pulmonary diseases as cause of dyspnea • Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing

42. ArterialBloodGases Normal values • PO275-100 mmHg • PCO235-45 mmHg • Sat O295-100 % • pH 7.35-7.45 • P(A-a) O212-20 mmHg • HCO322-26 mEg/l • Base Excess+or-2

43. Alveolar-ArterialOxygenPartialPressureGradient • A-a O2gradientmeasures how well alveolar oxygen is transferred from the lungs to thecirculation • P(A-a) O2 = 149 – PaCO2 / 0.8 - PaO2 • N = 2.5 + age X 0.21 (+/-11) • Anyparenchymaldisease in lungs? • Followingmeasure

44. RespiratoryArrest • Acutemyocardialinfarction • Stroke • Foreign body obstruction • Drowning • Electricalinjury • Intoxication • Excessnarcotics • Trauma (Tensionpneumotorax) • Suffocation • Severe metabolicacidosis

45. Differential Diagnosis • Four general categories • Cardiac • Pulmonary • Mixed cardiac or pulmonary • Non-cardiac or non-pulmonary

46. Pulmonary Etiology • COPD • Asthma • Pulmonarythromboembolism • Restrictive Lung Disorders • Hereditary Lung Disorders • Pneumonia • Pneumothorax

47. Cardiac Etiology • CHF • CAD • MI (recent or past history) • Cardiomyopathy • Valvular dysfunction • Left ventricular hypertrophy • Pericarditis • Arrhythmias

48. Mixed Cardiac/Pulmonary Etiology • COPD with pulmonary HTN and/or corpulmonale • Chronic pulmonary emboli • Pleural effusion

49. Noncardiac or Nonpulmonary Etiology • Metabolic conditions (e.g. acidosis) • Pain • Trauma • Neuromuscular disorders • Functional (anxiety,panic disorders, hyperventilation) • Chemical exposure