1 / 25

Evaluation of the adult with dyspnea in the emergency department Dr. Ali S Dauod MD, MBchB, MPH, JBFM Family Medicin

Dyspnea is the perception of an inability to breathe comfortably. Objectives:will provide a differential diagnosis of the life-threatening and common causes of dyspnea in the adultdescribe important historical and clinical findings that can help to narrow the differential diagnosisdiscuss the u

shen
Download Presentation

Evaluation of the adult with dyspnea in the emergency department Dr. Ali S Dauod MD, MBchB, MPH, JBFM Family Medicin

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Evaluation of the adult with dyspnea in the emergency department Dr. Ali S Dauod MD, MBchB, MPH, JBFM Family Medicine Consultant University Teaching Center Jordan University of Science and technology

    2. Dyspnea is the perception of an inability to breathe comfortably

    3. Objectives: will provide a differential diagnosis of the life-threatening and common causes of dyspnea in the adult describe important historical and clinical findings that can help to narrow the differential diagnosis discuss the use of common diagnostic studies, and provide recommendations for initial management and disposition

    4. According to one prospective observational study, the most common diagnoses among patients presenting to an ED with a complaint of acute shortness of breath and manifesting signs of respiratory distress (eg, respiratory rate >25, SaO2 <93 percent) are: decompensated heart failure, pneumonia chronic obstructive pulmonary disease, pulmonary embolism, and asthma

    5. DIFFERENTIAL DIAGNOSIS: Life-threatening upper airway causes 2. Life-threatening pulmonary causes 3. Life-threatening cardiac causes 4. Life-threatening neurologic causes 5. Life-threatening toxic and metabolic causes 6. Miscellaneous causes

    6. DIFFERENTIAL DIAGNOSIS: Life-threatening upper airway causes Tracheal foreign objects Angioedema Angioedema can cause swelling of the lips, tongue, posterior pharynx, and most dangerously the larynx over minutes to hours, and may progress to severe dyspnea. The skin may be not pruritic erythematous, The various types include allergic, NSAID-induced, ACE-inhibitor induced, and complement-related (C1-esterase inhibitor deficiency or a nonfunctional allele).

    7. Anaphylaxis Often triggered by foods, insect bites, and various medications, anaphylaxis may cause severe swelling of the upper airway and tongue, and possibly airway occlusion. Symptoms and signs develop over minutes to hours and may include skin and mucosal findings (eg, hives, flushing, oropharyngeal swelling), respiratory compromise (eg, wheezing, stridor, hypoxia), cardiovascular compromise (eg, hypotension, tachycardia, syncope), and gastrointestinal complaints (eg, abdominal pain, vomiting).

    8. Infections of the pharynx and neck: A number of oropharyngeal infections can cause acute dyspnea. Epiglottitis, Pertussis, Deep space infections of the neck, (Ludwig's angina, severe tonsillitis, peritonsillar abscess, and retropharyngeal abscess)

    9. 2. Life-threatening pulmonary causes

    10. 1.Pulmonary embolism Risk factors include a history of deep venous thrombosis or pulmonary embolism, prolonged immobilization, recent trauma or surgery (particularly orthopedic), pregnancy, malignancy, stroke or paresis, and a personal or family history of hypercoagulability. Presentation varies widely, but dyspnea at rest, tachycardia and tachypnea are the most common signs. A sizable minority of patients have no known risk factor at the time of diagnosis. Other embolic phenomenon include fat embolism, especially after a long bone fracture, and amniotic fluid embolism.

    11. 2.COPD Exacerbations of chronic obstructive pulmonary disease (COPD) can present with acute shortness of breath. Most often, a viral or bacterial respiratory infection exacerbates the patient's underlying illness. Pulmonary emboli may be responsible for up to 25 percent of apparent "COPD exacerbations" and should be suspected when the patient fails to improve with standard COPD treatment measures.

    12. 3.Asthma Asthma exacerbations generally present with dyspnea and wheezing. Signs of severe disease include the use of accessory muscles, brief fragmented speech, profound diaphoresis, agitation, and failure to respond to aggressive treatment. Extreme fatigue, cyanosis, and depressed mental status portend imminent respiratory arrest.

    13. 4.Pneumothorax and pneumomediastinum Any simple pneumothorax can develop into a life-threatening tension pneumothorax. In addition to trauma and medical procedures (eg, central venous catheter placement), a number of medical conditions increase the risk for developing a pneumothorax Risk factors for primary spontaneous pneumothorax include smoking, a family history, and Marfan syndrome. Patients are generally in their 20s and complain of sudden onset dyspnea and pleuritic chest pain that began at rest secondary spontaneous pneumothorax (including COPD, cystic fibrosis, tuberculosis, and AIDS patients with pneumocystis pneumonia)

    14. 5.Pulmonary infection: Lung infections such as severe bronchitis or pneumonia

    15. 7.Pulmonary hemorrhage Hemorrhage from an injury or an underlying disease (eg, malignancy, tuberculosis) can cause acute dyspnea

    16. Life-threatening cardiac causes

    17. 1. Acute coronary syndrome (ACS) 2. Acute decompensated heart failure (ADHF) Symptomatic ADHF can be caused by: volume overload, systolic or diastolic dysfunction, or outflow obstruction (eg, aortic stenosis, hypertrophic cardiomyopathy, severe systemic hypertension). Myocardial ischemia and arrhythmia are common precipitants. Symptoms range from mild dyspnea on exertion to severe pulmonary edema requiring emergent airway management. Common findings include tachypnea, pulmonary crackles, jugular venous distension, S3 gallop, and peripheral edema. ADHF is among the most common causes of acute respiratory failure among patients over 65 years.

    18. 3.High output heart failure High output heart failure may be precipitated by a number of conditions, including severe anemia, pregnancy, Beriberi (thiamine deficiency), and thyrotoxicosis. Signs may include tachycardia, bounding pulses, a venous hum heard over the internal jugular veins, and carotid bruits. 4.Cardiomyopathy may result in pulmonary edema and manifest as dyspnea. Potential causes include cardiac ischemia, hypertension, alcohol abuse, cocaine abuse, and a number of systemic diseases (eg, sarcoidosis, systemic lupus erymatosus).

    19. 6.Cardiac arrhythmia Cardiac conduction abnormalities, such as atrial flutter, atrial fibrillation, second and third degree heart block, and tachyarrhythmias (eg, SVT and ventricular tachycardia) can result in dyspnea. Such abnormalities may stem from underlying disease, including myocardial ischemia. 7.Valvular dysfunction Aortic stenosis, mitral regurgitation, or ruptured chordae tendinae can present with acute dyspnea. A murmur may be appreciable, but the absence of an audible murmur does not exclude the diagnosis. 8.Cardiac tamponade Whether due to trauma, malignancy, uremia, drugs, or infection, cardiac tamponade can present with acute dyspnea. The classically described findings of hypotension, distended neck veins, and muffled heart tones suggest the diagnosis, but are often absent. The electrocardiogram generally shows sinus tachycardia and low voltage

    20. Life-threatening neurologic causes 1.Stroke aspiration pneumonia, neurogenic pulmonary edema, and a number of abnormal respiratory patterns, including apnea 2.Neuromuscular disease A number of neuromuscular diseases, including multiple sclerosis, Guillain-Barr syndrome, myasthenia gravis, and amyotrophic lateral sclerosis, can cause weakness of the respiratory muscles, leading to acute respiratory failure

    21. Life-threatening toxic and metabolic causes

    22. Poisoning A number of toxins can cause derangements in respiratory function, leading to dyspnea. Organophosphate poisoning causes an increase in airway sections and bronchospasm. Petroleum distillates and paraquat can cause respiratory difficulty. Salicylate poisoning Salicylate overdose leads to stimulation of the medullary respiratory center, causing hyperventilation and respiratory alkalosis initially, followed by metabolic acidosis. In some cases, pulmonary edema may occur with severe poisoning. Prominent extrapulmonary signs include fever, tinnitus, vertigo, vomiting, diarrhea, and in more severe cases mental status changes Carbon monoxide poisoning Carbon monoxide is a potentially lethal toxin that impairs oxygen metabolism. Carbon monoxide poisoning may present with tachypnea and acute dyspnea in moderate cases, and pulmonary edema in severe cases. Extrapulmonary signs are generally more prominent and often nonspecific. They can include headache, malaise, chest discomfort, and altered mental status

    23. Diabetic ketoacidosis Diabetic ketoacidosis can cause tachypnea and dyspnea largely from the body's attempt to correct the metabolic acidosis. Patients with diabetic ketoacidosis give a history of polyuria, polydipsia, polyphagia, and progressive weakness; signs of severe disease include hyperventilation, altered mental status, and abdominal pain. Sepsis Severe sepsis often causes respiratory compromise secondary to tachypnea and respiratory fatigue, which may stem from underlying pneumonia, compensation for lactic acidosis, or some other process. Acute chest syndrome Chest pain syndrome is a potentially life-threatening complication of sickle cell disease. In the United States, it is seen predominantly in the African American population. Patients generally complain of severe chest pain and acute dyspnea and have a fever, while chest x-ray reveals a new pulmonary infiltrate.

    24. Miscellaneous causes Lung cancer Shortness of breath is a common symptom in patients with lung cancer at the time of diagnosis, occurring in approximately 25 percent of cases. Dyspnea may be due to extrinsic or intraluminal airway obstruction, obstructive pneumonitis or atelectasis, lymphangitic tumor spread, tumor emboli, pneumothorax, pleural effusion, or pericardial effusion with tamponade. Pleural effusion A pleural effusion, secondary to infection, ascites, pancreatitis, cancer, heart failure, or trauma, can cause severe acute dyspnea. Analysis of the pleural fluid is often necessary to determine the source. Intraabdominal processes A number of conditions such as peritonitis, ruptured viscous, or bowel obstruction Ascites Ascites secondary to malignancy or liver disease Pregnancy A number of physiologic changes occur during pregnancy that effect respiratory function, including an increase in minute ventilation, a decrease in functional residual capacity, a decrease in hematocrit, and elevation of the diaphragm. Approximately two-thirds of women experience dyspnea during the course of normal pregnancy. However, pregnancy increases the risk for several potentially life-threatening conditions that may manifest with dyspnea, notably pulmonary embolism. Pulmonary edema may be identified in the setting of a number of diseases associated with pregnancy, including preeclampsia, amniotic fluid embolism, and cardiomyopathy. Massive obesity Hyperventilation and anxiety Hyperventilation from anxiety is a diagnosis of exclusion in the emergency departmentt

    25. Thank YOU

More Related