emergency evaluation of the dyspneic patient

Emergency Evaluation ofEmergency Evaluation of the the Dyspneic PatientDyspneic Patient

Dr. Didem AyDr. Didem AyEmergency MedicineEmergency Medicine

GoalsGoals

• DefinitionsDefinitions• Emergency Department EvaluationEmergency Department Evaluation• Respiratory AssessmentRespiratory Assessment• TreatmentTreatment• EtiologyEtiology

• DyspneaDyspnea::– SSensation of breathlessness or inadequate ensation of breathlessness or inadequate

breathingbreathing– MMost common complaint of patients with ost common complaint of patients with

cardiopulmonary diseases. cardiopulmonary diseases.

• Dyspnea - common complaint/symptomDyspnea - common complaint/symptom– Defined asDefined as“shortness of breath” or “shortness of breath” or

“breathlessness”“breathlessness”– ““abnormal/uncomfortable breathingabnormal/uncomfortable breathing””– ““not getting enough air”not getting enough air”

• Multiple etiologies - Multiple etiologies - – 2/3 of cases - cardiac or pulmonary etiology 2/3 of cases - cardiac or pulmonary etiology

TermsTerms

• Tachypnea: Rapid breathingTachypnea: Rapid breathing• Ortopnea: DOrtopnea: Dyspnea in the recumbent yspnea in the recumbent

positionposition• Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea:: OOrthopnea rthopnea

that awakens the patientthat awakens the patient from sleep from sleep

TermsTerms

• TrepopneaTrepopnea: D: Dyspnea associated with only yspnea associated with only one of severalone of several recumbent positions recumbent positions

• PlatypneaPlatypnea: T: The opposite of orthopneahe opposite of orthopnea (dyspnea in the upright position)(dyspnea in the upright position)

• Hyperpnea: HHyperpnea: Hyperventilation and is defined yperventilation and is defined as minute ventilation in excess of metabolicas minute ventilation in excess of metabolic demanddemand

• HypoxiaHypoxia:: IInsufficient delivery of oxygen nsufficient delivery of oxygen to the tissuesto the tissues

• Hypoxemia: Abnormally low arterial Hypoxemia: Abnormally low arterial oxygen tension.oxygen tension. (PaO (PaO22) < 60mmHg) < 60mmHg or or arterarteriel iel ooxygen xygen saturasaturation tion (SaO(SaO22) < 90%) < 90%

Oxyhemoglobin Dissociation Oxyhemoglobin Dissociation CurveCurve

AttentionAttention

• Psychogenic dyspnea should be diagnosed Psychogenic dyspnea should be diagnosed after exclusion of organic causesafter exclusion of organic causes

Emergency Department Emergency Department EvaluationEvaluation

• There is no one specific cause of dyspnea and no There is no one specific cause of dyspnea and no single specific treatmentsingle specific treatment

• Treatment varies according to patient’s conditionTreatment varies according to patient’s condition– chief complaintchief complaint– historyhistory– examexam– laboratory & study resultslaboratory & study results

RespirationRespiration: Inspiration and expiration to : Inspiration and expiration to

provide sufficient tissue oxygenationprovide sufficient tissue oxygenation

Respiratory distress:Respiratory distress: Unnatural, Unnatural, uncomfortable, distressing inspiration and uncomfortable, distressing inspiration and expiration causing tissue hypoxiaexpiration causing tissue hypoxia

Clinically hypoxia, cyanosis, hypercapnia Clinically hypoxia, cyanosis, hypercapnia occuroccur

Respiratory AssesmentRespiratory Assesment

• Primary evaluation: Goal is to eliminate life Primary evaluation: Goal is to eliminate life threatening causesthreatening causes

• Secondary evaluation: DetailedSecondary evaluation: Detailed

Respiratory AssesmentRespiratory Assesment

• PrimaryPrimary– Normal: Spontaneous, comfortable, painless, Normal: Spontaneous, comfortable, painless,

regular respiration: 12-20/min (in adults)regular respiration: 12-20/min (in adults)– Look, listen and feel for breathingLook, listen and feel for breathing– Wheezing, stridor?Wheezing, stridor?– Consciousness?Consciousness?– Talking?Talking?– Paradoxal chest movement?(flail chest)Paradoxal chest movement?(flail chest)

Look, Listen, FeelLook, Listen, Feel

Respiratory AssesmentRespiratory Assesment

• PrimaryPrimary– Respiratory distressRespiratory distress– Head-tilt, chin lift or jaw trustHead-tilt, chin lift or jaw trust– Open airwayOpen airway– Reasses breathingReasses breathing– If breathing present, start oxygen If breathing present, start oxygen – If breathing is not present start artificial If breathing is not present start artificial

ventilationventilation

Baş geriye,

alt çene öne yukarıya

AspirationAspiration

AirwaysAirways

28

33

34

35

Respiratory AssesmentRespiratory Assesment

• SecondarySecondary– HistoryHistory– Physical examinationPhysical examination– Chest filmChest film

HistoryHistory

• Age,Age, past medical condition past medical condition • AAssociated symptomsssociated symptoms (Fever (Fever, cough, sputum, , cough, sputum,

angina, pretibial oedema)angina, pretibial oedema)• Timing: acuity and durationTiming: acuity and duration

(Spontaneous/sudden onset, dyspnea on effort, (Spontaneous/sudden onset, dyspnea on effort, orthopnea, PND)orthopnea, PND)

• SeveritySeverity• Past medical historyPast medical history• Smoking, drugs (OKS, HRT), trauma, Smoking, drugs (OKS, HRT), trauma,

immobilization, malignancyimmobilization, malignancy

Signs and SymptomsSigns and Symptoms

Serious respiratory distress :Serious respiratory distress :1.1. Clinical:Clinical:

1.1. Tachypnea (RR> 35/min), apneaTachypnea (RR> 35/min), apnea2.2. CyanosisCyanosis3.3. RetractionsRetractions4.4. Agitation, inability to talk, unconscioussness, Agitation, inability to talk, unconscioussness,

comacoma5.5. Rales, wheezesRales, wheezes

2.2. SOSO22< %90, PaO< %90, PaO22<60 mmHg, PCO<60 mmHg, PCO22>45 mmHg>45 mmHg

Physical ExaminationPhysical Examination• Head to toeHead to toe• Vital signsVital signs• ConsciousnessConsciousness• Skin color (paleness, diaphoresis, cyanosis, Skin color (paleness, diaphoresis, cyanosis,

erythema, urticaria) erythema, urticaria) • Retractions (intercostal, suprasternal, Retractions (intercostal, suprasternal,

abdominal)abdominal)• ClubbingClubbing• AuscultationAuscultation• Signs of heart failureSigns of heart failure

LaboratoryLaboratory

• Pulse oxymetry, arterial blood gasesPulse oxymetry, arterial blood gases• Complete blood countComplete blood count• Chest X-ray, lateral neck X-rayChest X-ray, lateral neck X-ray• ECG monitorizationECG monitorization• EchocardiographyEchocardiography• Biochemical parametersBiochemical parameters• If needed: CT, ventilation-perfusion If needed: CT, ventilation-perfusion

scintigraphyscintigraphy

• Rapid, widely available, noninvasive means of Rapid, widely available, noninvasive means of assessment in most clinical situations-assessment in most clinical situations-– insensitive (may be normal in acute dyspnea)insensitive (may be normal in acute dyspnea)

• The % of Oxygen saturation does not always The % of Oxygen saturation does not always correspond to PaOcorrespond to PaO22

• The hemoglobin desaturation curve can be The hemoglobin desaturation curve can be shifted depending on the pH, temperature or shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levelsarterial carbon monoxide or carbon dioxide levels

Pulse OxymetryPulse Oxymetry

• Commonly used to evaluate acute dyspneaCommonly used to evaluate acute dyspnea• CCan provide information about altered pH, an provide information about altered pH,

hypercapnia, hypocapnia or hypoxemiahypercapnia, hypocapnia or hypoxemia• NNormal ABGs do not exclude ormal ABGs do not exclude

cardiac/pulmonary dcardiac/pulmonary diseasesiseases as cause of as cause of dyspneadyspnea– Remember- ABGs may be normal even in cases of Remember- ABGs may be normal even in cases of

acute dyspnea - ABGs do not evaluate breathing acute dyspnea - ABGs do not evaluate breathing

Arterial Blood GasesArterial Blood Gases

Arterial Blood GasesArterial Blood Gases

Normal valuesNormal values– POPO22 75-100 mmHg 75-100 mmHg

– PCOPCO22 35-45 mmHg 35-45 mmHg

– Sat OSat O22 95-100 %95-100 %

– pH 7.35-7.45pH 7.35-7.45– P(P(A-aA-a)) O O22 12-20 mmHg12-20 mmHg

– HCOHCO33 22-26 mEg/l22-26 mEg/l– Base ExcessBase Excess +or-2+or-2

Alveolar-ArterialAlveolar-ArterialOxygen Partial Pressure GradientOxygen Partial Pressure Gradient

• A-a OA-a O22 gradient gradient measures how well alveolar measures how well alveolar oxygen is transferred from the lungs to theoxygen is transferred from the lungs to the circulationcirculation

• P(A-a) OP(A-a) O22 = 149 – PaCO = 149 – PaCO22 / 0.8 - PaO / 0.8 - PaO22

• N = 2.5 + age X 0.21 (+/-11)N = 2.5 + age X 0.21 (+/-11)

• Any parenchymal disease in lungs?Any parenchymal disease in lungs?• Following measure Following measure

Respiratory ArrestRespiratory Arrest• Acute myocardial infarctionAcute myocardial infarction• StrokeStroke• Foreign body obstructionForeign body obstruction• DrowningDrowning• Electrical injuryElectrical injury• IntoxicationIntoxication• Excess narcoticsExcess narcotics• Trauma (Tension pneumotorax)Trauma (Tension pneumotorax)• SuffocationSuffocation• Severe metabolic acidosisSevere metabolic acidosis

Differential Diagnosis Differential Diagnosis

• FFour general categoriesour general categories– CardiacCardiac– PulmonaryPulmonary– Mixed cardiac or pulmonaryMixed cardiac or pulmonary– NNon-cardiac or non-pulmonaryon-cardiac or non-pulmonary

Pulmonary EtiologyPulmonary Etiology

• COPDCOPD• AsthmaAsthma• Pulmonary thromboembolismPulmonary thromboembolism• Restrictive Lung DisordersRestrictive Lung Disorders• Hereditary Lung DisordersHereditary Lung Disorders• PneumoniaPneumonia• PneumothoraxPneumothorax

Cardiac EtiologyCardiac Etiology

• CHFCHF• CADCAD• MI (recent or past history)MI (recent or past history)• CardiomyopathyCardiomyopathy• Valvular dysfunctionValvular dysfunction• Left ventricular hypertrophyLeft ventricular hypertrophy• PericarditisPericarditis• ArrhythmiasArrhythmias

Mixed Cardiac/Pulmonary Mixed Cardiac/Pulmonary EtiologyEtiology

• COPD with pulmonary HTN and/or cor COPD with pulmonary HTN and/or cor pulmonalepulmonale

• Chronic pulmonary emboliChronic pulmonary emboli• Pleural effusionPleural effusion

Noncardiac or Nonpulmonary Noncardiac or Nonpulmonary EtiologyEtiology

• Metabolic conditions (e.g. acidosis)Metabolic conditions (e.g. acidosis)• PainPain• TraumaTrauma• Neuromuscular disordersNeuromuscular disorders• Functional Functional (anxiety,panic disorders, hyperventilation)(anxiety,panic disorders, hyperventilation)

• Chemical exposureChemical exposure

Classic Presentations Classic Presentations

• COPD: Hyperinflation, diminished breath COPD: Hyperinflation, diminished breath sounds, wheezes, use of accessory muscles of sounds, wheezes, use of accessory muscles of respirationrespiration

• Pulmonary Edema: JVD, diffuse rales, cardiac Pulmonary Edema: JVD, diffuse rales, cardiac gallop, peripheral edemagallop, peripheral edema

• Upper airway obstruction: Inability to speak, Upper airway obstruction: Inability to speak, inspiratory wheeze, diminished breath inspiratory wheeze, diminished breath soundssounds

Worry!!Worry!!

• Confusion, agitation, loss of consciousnessConfusion, agitation, loss of consciousness• Diaphoresis, cyanosis, bradycardia, Diaphoresis, cyanosis, bradycardia,

hypertensionhypertension

Goals of treatmentGoals of treatment

• Etiology treatment!Etiology treatment!

• PaOPaO22 >> 60 must be 60 must be

• SOSO22 >> 90 must be 90 must be

Havayolu Kardiyak Akc Plevra

GDuvarı

Vasküler Nöromusküler

Çeşitli

HY kitle LV yetm Astım Pnx PE SVO Anemi

Yb cisim MI KOAH Pl eff. Hava emb Frenik sinir paralizi

Met asidoz

Anjioödem Perikardit / P tamponad

Pnömoni Pl yapışıklık Yağ emb Guillain-Barre Syn.

Şok

HY stenozu HT kriz P ödem G Duv yaralanmaları

Amn sıvı emb Botulizm Düşük kard out-put

Broşektazi Aritmi P kontüzyon Abd distansiyon

Pulm HT Nöropati Hipoxi

Trakeomalazi Miyokardit Atalektazi Kifoskolyoz Veno-okluziv hastalık

miyopati CO intox

KMP Alveolit Pectus excavatum

Sickle-cell MetHb

İntrakard şant P fibrozis Gebelik Vaskülit Ateş, hiper/hipotiroidi,

LV çıkış obst ARDS AV fistül psikiyatrik

Kapak bzk sarkoidoz