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The patient with shortness of breath

The patient with shortness of breath. Differential diagnosis. Asthma COPD Pneumonia Heart failure PE Other. Asthma assessment. Asthma… pertinent negatives and positives. Fever, green sputum, pleuritic pain (?CXR?antibiotics)? On oral steroids already? ICU admissions in the past?

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The patient with shortness of breath

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  1. The patient with shortness of breath

  2. Differential diagnosis • Asthma • COPD • Pneumonia • Heart failure • PE • Other

  3. Asthma assessment

  4. Asthma…pertinent negatives and positives • Fever, green sputum, pleuritic pain (?CXR?antibiotics)? • On oral steroids already? • ICU admissions in the past? • Social situation, time of day? • (Is this asthma)? • (smoking)?

  5. Asthma management • Steroids • Beta agonist (+ipratropium bromide (atrovent)) • Oxygen • The kitchen sink • Review frequently (at least hourly)

  6. Asthma management • Prednisone 40 mg 5 days PO • (Hydrocortisone 200mg iv if unable to tolerate PO)

  7. Asthma management • Salbutamol • Nebs 5mg • Inhaler (100µg) via spacer 8 puffs • A suggested approach for moderate severity • 5mg salbutamol neb q 20mins x3. • Then, if required, 5mg q30mins x2 • Then, if required, 5mg q60mins x1 • R/V hourly (pre neb) • PEFR, RR, Sats, breath sounds • @ 3 hours from start…decide…admit / discharge / a bit longer…

  8. Asthma management • Ipratropium bromide • O.5mg nebs, q 20 mins x3 • Oxygen to get sats >93%

  9. Asthma management • The kitchen sink includes, in Resus • continuous neb salbutamol • magnesium iv, • salbutamol iv bolus+infusion, • iv aminophylline, • NIV/intubation

  10. Asthma • Who can go home? • Well patients • those with mild severity a reasonable time after last treatment • Varies between patients, eg initial severity and response to therapy • Those who require less than 2/24 salbutamol • PEFR >75% of best/predicted 2 hours after initial Rx • BUT!!!! • Social situation, time of day, prior asthma history, etc • ASK for a senior opinion

  11. Asthma discharge • Instructions • Meds • prednisone, • salbutamol (technique) • when to return • increasing severity • Increasing salbutamol use • “More concerned” • follow up with GP • depends on the patient • Not improving >24 hours

  12. Pneumonia • Assessment (diagnosis and severity) • Hx • Exam (OBS!!!) • Ancillary (CXR, Bloods, ECG) • CURB65 • Sick, not sick? • Based on patient factors, obs, clinical findings, results of investigations, gestalt

  13. Pneumonia • Management • General • iv fluids, • oxygen, • antipyretics • Specific • antibiotics • Disposition • sick/not sick? • CURB65

  14. PneumoniaAntibiotics (RMO handbook) • Outpatient • “risk factors” • Yes : augmentin + macrolide/doxycycline • No : macrolide or doxycycline • Inpatient • Iv augmentin/cefuroxime + macrolide/doxycycline

  15. PE • Should be considered when it is either • very obvious, or • nothing else fits • Wells criteria … • Do not order a d-dimer until you have thought long and hard about it! You must have other investigations back first. • Discuss with your senior before the d-dimer

  16. PE PERC Rule for Pulmonary Embolism According to the PERC Study, there is less than 2% risk of PE in this patient. The PERC rule only applies if all 8 criteria are met.

  17. COPD management…oxygen • “CO2 retainer”…use hypoxia for respiratory drive • Not common, not rare • Assess… • old notes/gas results/patient LOC/VBG/ABG • If there is respiratory acidosis, there is some degree of acute respiratory failure. • If there is elevated CO2 but no/minimal acidosis, there is a degree of chronic compensation (HCO3 elevated) • Acute on chronic respiratory failure is often found • Use venturi mask to titrate oxygen to maintain sats >88%

  18. COPD exacerbation • Management • General : oxygen, iv fluids, antipyretics • Specific : • salbutamol, • ipratropium, • antibiotics, • steroids, • NIV • Disposition : usually admit

  19. Heart failure • Assessment • Hx • Exam • Ancillary : CXR, ECG, BNP (last resort when, despite thorough assessment, cause of SOB uncertain. Used to EXCLUDE CCF) • Management • General : oxygen • Specific : diuretics • Disposition : usually admit

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