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Approach to the Dyspneic Patient

Approach to the Dyspneic Patient. Dan Crouch Kristi Kuhn Kate Lindley Ben Voss. First and Foremost…. Identify the correct patient Obtain the most recent vitals Ask the nurse about the acuity of the episode Does an ACT Now or CODE need to be called?.

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Approach to the Dyspneic Patient

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  1. Approach to the Dyspneic Patient Dan Crouch Kristi Kuhn Kate Lindley Ben Voss

  2. First and Foremost… • Identify the correct patient • Obtain the most recent vitals • Ask the nurse about the acuity of the episode • Does an ACT Now or CODE need to be called?

  3. Requiring Quick Diagnosis and Intervention • Pulmonary Embolism • Acute Coronary Syndromes • Aortic Dissection • Pneumothorax

  4. Things You Have A Little Time For • The Exacerbations: • Asthma/Reactive Airway Disease • COPD • CHF/Tamponade • Pneumonia (CAP vs HAP) • ARDS • Less Common Causes: • Anxiety • Anemia

  5. Armed with this knowledge… • You walk into the patient’s room - 02 sat=80% • Start supplemental oxygen ASAP! • Get an idea of all the vitals (BP, HR, RR, Temp) • Look at the patient: • Is he/she markedly tachypneic? • Is he/she hypotensive? • Is he/she mentating well? • Is he/she cyanotic? • While you quickly peruse the chart, obtain an ABG, ECG and order a STAT portable CXR • Unlike your usual admission, the history comes second here

  6. Key is to be FOCUSED General Appearance - how distressed do they look Vitals - Repeat Vitals, q 10 min Assess for pulsus paradox and BP in both arms Cardiac - Rhythm, JVP, capillary refill, new gallops, murmurs or rubs Pulmonary - air movement, crackles, wheezes, breath sounds Extremity - presence of edema, cyanosis Do I Have Time for a Physical Exam?

  7. Therapy - Oxygen • Oxygen • Relieves pulmonary vasoconstriction • Increases myocardial reserve • Start with high-flow NC, then proceed to non-rebreather facemask delivering 100% • If oxygen saturation does not improve, plan NPPV or intubation

  8. Therapy - Diuretics • Can decrease preload and also reduce cardiac filling pressures • Dosing regimen: • Lasix 40-80mg IVP (may need more if in renal failure) • Bumetanide 1-2 mg IVP • Torsemide 10-20 mg IVP • If a patient is on chronic diuretics, simply change the PO to a IV regimen • Continuous infusion leads to modest improvement in urine output but no change in mortality

  9. Therapy - Vasodilators • Nitrates work well by decreasing both afterload and preload • Nitroglycerin - develop tolerance • Nitroprusside - develop cyanide toxicity • Hydralazine acts as a direct arteriolar vasodilator • Watch out for reflex sympathetic tachycardia

  10. Other Pharmacologic Options • Steroids are useful in COPD and Asthma exacerbations • Start with methylprednisolone 60 mg IV q6h • Bronchodilators are also useful • Start with nebulized albuterol (2.5mg q1-2h) • Add on Atrovent (2 puffs q 2-4h or 0.5mg q 2-4 h) • Opioid antagonists - narcan 0.4 mg IVP • Benzo reversal – flumazenil 0.2 mg IVP • Antibiotics for Pneumonia

  11. Other options before intubation • Aggressive chest physical therapy • Useful for mucus plugs, cystic fibrosis patients, and excessive secretions • BiPAP • Remember, it should be used primarily for hypercarbic respiratory failure secondary to COPD or hypoxemic respiratroy failure secondary to cardiogenic pulmonary edema • Situations to avoid BiPAP; • Somnolent, lethargic mental status • Hemodynamic instability • Profounnd acidemia (pH < 7.1)

  12. Make sure you have the following ready: Suction catheter Oxygen monitor Crash Cart and Airway Box ET Tube with Stylet OP Airway 10ml Syringe CO2 Detector IV Access Sedative support (Fentanyl, Versed) Paralytic support Anesthesia Start with preoxygenation Administer sedative/paralytic Intubate Observe for color change and bilateral breath sounds Recheck vitals Obtain CXR Mechanical Ventilation

  13. Case 1 • R.D. is a 32 y.o male with PMHx of asthma admitted for asthma exacerbation within the past 12 hours. • Vitals stable, O2 = 93%RA • Less than 12 hours into admission, nurse calls you stating “His oxygen sat is 81% on 4L NC”

  14. What do you do? • Examine the patient • His vitals are BP 140/75, HR 113, RR 38, O2 = 86% on 6L NC • Exam: mentating well, bilateral faint expiratory wheezing, using accessory muscles • Obtain a portable CXR and ABG

  15. What is the likely diagnosis?Asthma Exacerbation

  16. What else? • Supplemental oxygen to 8 L NC • His oxygen sat increases to 90% • Call RT to administer: • Albuterol 2.5 mg nebulizer • Atrovent 0.5 mg nebulizer • Steroids • Methylprednisolone 60 mg IV q6h if not previously started • No need for antibiotics in asthma exacerbation

  17. Asthma Management - Summary • Nebulizers • Supplemental Oxygen • Steroids • Magnesium (minimal benefit) • No Antibiotics • Close monitoring - q4h vitals/peak flows

  18. Case 2 • G.B. is a 56 y.o AAF with PMHx of CRI (Cr 3.3 at baseline), HTN, DM2, admitted for cellulitis • On HD#2, during morning rounds, you find the patient markedly tachypneic and unable to speak in full sentences…

  19. What do you want to do? • Get a set of vitals • BP 200/115, HR 105, RR 32, O2=89% 2L NC • Exam: JVP 11 cm, bilateral rales, S3 gallop, no LE edema, 2/6 SEM at apex  radiating to axilla • Supplemental oxygen, ABG • Order an ECG • Stat pCXR

  20. While you await the CXR… • Hypertension Control: • IV Metoprolol/Diltiazem • IV Nitroglycerin gtt • IV Labetalol gtt • PO Clonidine • Diuresis: • Lasix 40 mg IV x 1

  21. What is the likely diagnosis? Pulmonary Edema

  22. Acute Cardiogenic Pulmonary Edema • Ischemia • Valvular – MR/AR/AS • Renovascular hypertension • Dysrythmias: AVB, Afib, V-tach, SVT • Overhydration with crystalloid or colloid

  23. What is the next step? • Assess response to diuresis within 30 min to 1 hour • Assess response to afterload reduction within 15 min • If no response to either, tx to ICU for closer monitoring and likely BiPAP or mechanical ventilation

  24. Case 3 • N.M is a 28 yo WM with hx of Marfan’s syndrome who p/w sudden onset chest pain and SOB. • You are called to see him in the ER • He is afebrile, but tachycardic (HR 120). BP 110/65, 0x Sat 90 % RA, RR 28

  25. CXR

  26. What is the diagnosis? Pneumothorax

  27. What is your approach? • Assess oxygenation • Is current oxygen requirement stable • Assess size of PTX • Call Thoracic Surgery consult • Are there signs of tension: • hyperlucent, overly expanded hemithorax • mediastinal shift to the opposite side • radiographic signs of pneumothorax - heart elevated from the sternum, lung lobes retracted from the thoracic wall

  28. Summary Points • Always recheck vitals immediately • Close monitoring is essential • Assess ability to oxygenate • Try oxygen, diuretics, nitrates, bronchodilators, steroid, afterload reduction • Have an end-point ready • Evaluate probability of requiring mechanical ventilation • Have an ICU bed available • Coordinate with nursing supervisor

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