Shortness of breath resident survival guide: Difference between revisions

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__NOTOC__
__NOTOC__
{{CMG}}; {{Steven}}
{{CMG}}; {{AE}} {{Steven}}


{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 0 0;" cellpadding="0" cellspacing="0";
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Overview|Overview]]
|-Aortic dissection re
|-Aortic dissection re
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Classification|Classification]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Definitions|Definitions]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach and Treatment|Diagnosis and Treatment]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Dont's|Dont's]]
|}
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* [[Tachypnea]]
* [[Tachypnea]]
::A respiratory rate greater than normal.  
::A respiratory rate greater than normal.  
* [[Bradypnea]]
::A respiratory rate smaller than normal.
* [[Hyperpnea]]
* [[Hyperpnea]]
::Increased minute ventilation to meet metabolic requirements.
::Increased minute ventilation to meet metabolic requirements.
Line 47: Line 44:
::Dyspnea that starts in an upright position.
::Dyspnea that starts in an upright position.
*[[Trepopnea]]
*[[Trepopnea]]
::Dyspnea that starts in one lateral decubitus position as opposed to the other.
::Dyspnea that starts in one lateral decubitus position as opposed to the other.<ref>{{cite book | last = Marx | first = John | title = Rosen's emergency medicine : concepts and clinical practice | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2014 | isbn = 978-1455706051 }}</ref>


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<ref>{{cite book | last = Marx | first = John | title = Rosen's emergency medicine : concepts and clinical practice | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2014 | isbn = 978-1455706051 }}</ref>
* Life-threatening causes of the upper airway
* Life-threatening causes of the upper airway
:* Tracheal foreign objects
:* [[Pulmonary aspiration|Aspiration foreign body]]
:* [[Angioedema]]
:* [[Angioedema]]
:* [[Anaphylaxis]]
:* [[Anaphylaxis]]
Line 64: Line 61:
:* [[Asthma]]
:* [[Asthma]]
:* [[Pneumothorax]] and [[pneumomediastinum]]
:* [[Pneumothorax]] and [[pneumomediastinum]]
:* [[Pulmonary infection]]
:* [[Pneumonia]]
:* [[Adult Respiratory Distress Syndrome]]
:* [[Adult Respiratory Distress Syndrome]]
:* [[Direct pulmonary injury]]
:* [[Chest trauma]]
:* [[Pulmonary hemorrhage]]
:* [[Pulmonary hemorrhage]]


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:* [[Acute decompensated heart failure]]
:* [[Acute decompensated heart failure]]
:* Flash pulmonary edema  
:* Flash pulmonary edema  
:* High output heart failure
:* [[High output failure]]
:* [[Cardiomyopathy]]
:* [[Cardiomyopathy]]
:* [[Cardiac arrhythmia]
:* [[Cardiac arrhythmia]]
:* [[Valvular dysfunction]]
:* [[Valvular dysfunction]]
:* [[Cardiac tamponade]]
:* [[Cardiac tamponade]]
Line 87: Line 84:
:* [[Salicylate poisoning]]
:* [[Salicylate poisoning]]
:* [[Carbon monoxide poisoning]]
:* [[Carbon monoxide poisoning]]
:* Toxin related metabolic acidosis
:* Toxin related [[metabolic acidosis]]
:* [[Diabetic ketoacidosis]]
:* [[Diabetic ketoacidosis]]
:* [[Sepsis]]
:* [[Sepsis]]
:* [[Anemia]]
:* [[Anemia]]
:* Acute chest syndrome- in patients with sickle cell disease
:* Acute chest syndrome- in patients with [[sickle cell disease]]


===Miscellaneous Causes===
===Miscellaneous Causes===
* [[Lung cancer]]
* [[Lung cancer]]
* [[Pleural effusion]]
* [[Pleural effusion]]
* Intraabdominal processes
* [[Intraabdominal infection]]
* [[Ascites]]
* [[Ascites]]
* [[Pregnancy]]
* [[Pregnancy]]
* Massive obesity
* Morbid [[obesity]]
* Hyperventilation and anxiety
* [[Hyperventilation]] and anxiety


==FIRE==
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref>{{cite book | last = Marx | first = John | title = Rosen's emergency medicine : concepts and clinical practice | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2014 | isbn = 978-1455706051 }}</ref>
{{familytree/start |summary=Sample 1}}
{{familytree/start |summary=Sample 1}}
{{familytree | | | | | | A01 | | | |A01=<b>Dyspnea</b>}}  
{{familytree | | | | | | A01 | | | |A01=<b>Dyspnea</b>}}  
Line 111: Line 108:
:❑&nbsp;&nbsp;Heart rate  
:❑&nbsp;&nbsp;Heart rate  
:❑&nbsp;&nbsp;Respiratory rate
:❑&nbsp;&nbsp;Respiratory rate
:❑&nbsp;&nbsp;Blood pressure
:❑&nbsp;&nbsp;Blood pressure  
:❑&nbsp;&nbsp;SaO2
❑&nbsp;&nbsp; <b>Danger signs:</b> Depressed mental status, [[cyanosis]], inability to maintain respiratory effort, use of accessory muscles, abnormal chest movement<br>
:❑&nbsp;&nbsp;Continuous waveform capnography
:❑&nbsp;&nbsp;ECG/cardiac monitor
:❑&nbsp;&nbsp; <b>Danger signs:</b> Depressed mental status, cyanosis, inability to maintain respiratory effort, use of accessory muscles, abnormal chest movement
❑&nbsp;&nbsp;<b><u>Action items</u></b>
❑&nbsp;&nbsp;<b><u>Action items</u></b>
:❑&nbsp;&nbsp; Supplement oxygen
:❑&nbsp;&nbsp; Supplement oxygen
:❑&nbsp;&nbsp; IV access and pulse oximetry
:❑&nbsp;&nbsp; IV access and pulse oximetry
:❑&nbsp;&nbsp;ECG/cardiac monitor
:❑&nbsp;&nbsp;± Continuous waveform capnography
:❑&nbsp;&nbsp;Lab measurements:
:❑&nbsp;&nbsp;Lab measurements:
::❑&nbsp;&nbsp;ABG, A-a gradient
::❑&nbsp;&nbsp;ABG, SaO2, A-a gradient
::❑&nbsp;&nbsp;WBC, Hgb, Hct, Platelets, Smear
::❑&nbsp;&nbsp;WBC, Hgb, Hct, Platelets
::❑&nbsp;&nbsp;BUN, Cr, K, Mg, Phos
::❑&nbsp;&nbsp;BUN, Cr, K, Mg, Phos
::❑&nbsp;&nbsp;Glucose
::❑&nbsp;&nbsp;Glucose
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{{familytree | | | | | | I01 |-|-|-| I02 | | | | |I01=<b>Signs for rapidly reversible causes?</b>|I02=<b>Yes</b>}}
{{familytree | | | | | | I01 |-|-|-| I02 | | | | |I01=<b>Signs for rapidly reversible causes?</b>|I02=<b>Yes</b>}}
{{familytree | | | | | | |!| | | | | |!| | | | | | |}}
{{familytree | | | | | | |!| | | | | |!| | | | | | |}}
{{familytree | | | | | | |!| | | | | J01 | | | | |J01=<div style="text-align: left;"><b><u>[[Tension pneumothorax]]:</u></b>
{{familytree | | | | | | |!| | | | | J01 | J02 | J03 | | | |J01=<div style="text-align: left;"><b><u>[[Tension pneumothorax]]:</u></b>
 
❑&nbsp;&nbsp;Signs:
❑&nbsp;&nbsp;Signs:
:❑&nbsp;&nbsp;Chest pain
:❑&nbsp;&nbsp;[[Chest pain]]
:❑&nbsp;&nbsp;Hypotension
:❑&nbsp;&nbsp;[[Hypotension]]
 
:❑&nbsp;&nbsp;Tracheal deviation
:❑&nbsp;&nbsp;Tracheal deviation
:❑&nbsp;&nbsp;Raised jugular venous pressure
:❑&nbsp;&nbsp;[[Jugular-venous distension]]
:❑&nbsp;&nbsp;Quieter breath sounds/hyperresonant percussion  
:❑&nbsp;&nbsp;Quieter breath sounds/hyperresonant percussion  
 
:❑&nbsp;&nbsp;[[Tachycardia]]/[[tachypnea]]
:❑&nbsp;&nbsp;Tachycardia/tachypnea }}
❑&nbsp;&nbsp;Treatment:
:❑&nbsp;&nbsp;Immediate chest decompression by needle or tube thoracostomy</div>|J02=<div style="text-align: left;"><b><u>[[Upper airway foreign body aspieation]]:</u></b>
❑&nbsp;&nbsp;Signs:
:❑&nbsp;&nbsp;Coughing, [[cyanosis]]
❑&nbsp;&nbsp;Treatment:
:❑&nbsp;&nbsp;[[Bronchoscopy]]/[[Laryngoscopy]]</div>|J03=<div style="text-align: left;"><b><u>[[Pericardial tamponade]]:</u></b>
❑&nbsp;&nbsp;Signs(Becks's triade):
:❑&nbsp;&nbsp;[[Hypotension]]
:❑&nbsp;&nbsp;Muffled heart sounds
:❑&nbsp;&nbsp;[[Jugular-venous distension]]
❑&nbsp;&nbsp;Treatment:
:❑&nbsp;&nbsp;[[Pericardiocentesis]]</div>}}
{{familytree | | | | | | P01 | | | | | | | | | | | |P01=<b>No</b>}}
{{familytree | | | | | | P01 | | | | | | | | | | | |P01=<b>No</b>}}
{{familytree | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | | | |}}
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{{familytree | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | |,|-|-|-|^|-|-|-|.| | | | | | | | |}}
{{familytree | | |,|-|-|-|^|-|-|-|.| | | | | | | | |}}
{{familytree | | |!| | | | | | | M01 | |M01=B01}}
{{familytree | | |!| | | | | | | M01 | |M01=<b>No</b>}}
{{familytree |boxstyle=border-top: 0px | | |!| | | | | | | F01 | |F01=F01 }}
{{familytree |boxstyle=border-top: 0px | | |!| | | | | | | F01 | |F01=<div style="text-align: left;"><u><b>Action items:</b></u>
{{familytree | | X01 | | | | | | |!| | | | | | | | |}}
❑&nbsp;&nbsp;Try to assess ventilation<br>
{{familytree |boxstyle=border-top: 0px| | G01 |-|-|-|-|-| G02 | |G01=G01|G02=xx}}
❑&nbsp;&nbsp;Check breath sounds
{{familytree | | |!| | | | | | | | | | | | | | | | |}}
❑&nbsp;&nbsp;Endotracheal intubation/cricothyrotomy and mechanical ventilation</div>}}
{{familytree | | H01 | | | | | | | | | || | | | | H01=H01}}
{{familytree | | X01 | | | | | | |!| | | | | | | | |X01=<b>Yes</b>}}
 
{{familytree | | |!| | | | | | | |!| | | | | }}
{{familytree | | H01 |-|-|-|-|-|-|'| | | | | | | | H01=<b>Chest x-ray</b>}}
{{familytree | | |!| | | | | | | | | | | | | | }}
{{familytree | | K01 | | | | | | | | | | | | | |K01=<b>Assess breath sounds, obtain history and physical exam</b>}}
{{familytree | | |!| | | | | | | | | | | | | | }}
{{familytree | | L01 | | | | | | | | | | | | | |L01=<b>[[Shortness of breath resident survival guide#Complete Diagnostic Approach|Proceed to Complete Diagnostic Approach]]</b>}}
{{familytree/end}}
{{familytree/end}}


==Complete Diagnostic Approach==
==Complete Diagnostic Approach and Treatment==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention<ref>{{cite book | last = Marx | first = John | title = Rosen's emergency medicine : concepts and clinical practice | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2014 | isbn = 978-1455706051 }}</ref>
{{familytree/start |summary=Sample 1}}
{{familytree/start |summary=Sample 1}}
{{familytree | | | | | | | | A01 |A01=A01}}  
{{familytree | | | | | | | A01 |A01=<div style="text-align: left;"><b><u>History and symptpms:</u></b><br>
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
❑&nbsp;&nbsp;Shortness of breath<br>
{{familytree | | | B01 | | | | | | | | B02 | | |B01=B01|B02=B02}}
❑&nbsp;&nbsp;Grunting or wheezing sounds while breathing<br>
{{familytree | | | |!| | | | | | | | | |!| }}
❑&nbsp;&nbsp;Exposure to something the patient may be allergic to may cause shortness of breath<br>
{{familytree | | | C01 | | | | | | | | |!| |C01=C01}}
❑&nbsp;&nbsp;Exercise may cause shortness of breath<br>
{{familytree | |,|-|^|.| | | | | | | | |!| }}
❑&nbsp;&nbsp;Onset:Sudden or slowly?<br>
{{familytree | D01 | | D02 | | | | | | D03 |D01=D01|D02=D02|D03=D03}}
❑&nbsp;&nbsp;Duration:Slowly progress over weeks to months?<br>
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
❑&nbsp;&nbsp;Positional Changes:Shortness of breath may worsen when the patient changes body position. Sometimes it is worse when you lie flat (orthopnea). Sometimes breathing difficulty occur while the patient is resting. Is there a [[paroxysmal nocturnal dyspnea]]?<br>
{{familytree | E01 | | | | | | | E02 | | | E03 |E01=E01|E02=E02|E03=E03}}
❑&nbsp;&nbsp;Trauma?<br>
{{familytree | | | | | | | | | | |!| | | | |!| }}
❑&nbsp;&nbsp;Past medical illness?</div>}}
{{familytree | | | | | | | | | | F01 | | | F02 |F01=F01|F02=F02}}
{{familytree | | | | | | | H01 |H01=<div style="text-align: left;"><b><u>Physical examination:</u></b><br>
❑&nbsp;&nbsp;Vital signs:
:❑&nbsp;&nbsp;[[Fever]], Tachypnea, Hypopnea, Tachycardia, Hypotension?
❑&nbsp;&nbsp;General appearance:
:❑&nbsp;&nbsp;Cachexia, obesity, pregnancy, barrel chest, "sniffing" position, "tripoding" position, traumatic injury?
❑&nbsp;&nbsp;Neck:
:❑&nbsp;&nbsp;[[Jugular venous distension]], [[stridor]]?
❑&nbsp;&nbsp;Skin and nails:
:❑&nbsp;&nbsp;Tobacco stains, clubbing, pallid skin, muscle wasting, bruising, subcutaneous [[emphysema]], hives, rashes?
❑&nbsp;&nbsp;Lungs:
:❑&nbsp;&nbsp;Wheezing, crackles, rales, unilateral decrease, [[hemoptysis]], Friction rub, abnormal respiratory pattern?
❑&nbsp;&nbsp;Heart:
:❑&nbsp;&nbsp;Heart murmurs, S3, S4, muffled heart sounds?
❑&nbsp;&nbsp;Extremities:
:❑&nbsp;&nbsp;Peripheral edema, palpation of peripheral arteries, signs for [[cyanosis]], swelling or tenderness?
❑&nbsp;&nbsp;Neurologic examination:
:❑&nbsp;&nbsp;Focal deficit, symmetrical deficit, diffuse weakness, hyporeflexia, ascending weakness?
❑&nbsp;&nbsp;Any pain or panic symptoms?</div>}}
{{familytree | | | | | | | I01 |I01=<div style="text-align: left;"><b><u>Laboratory findings:</u></b><br>
The following tests are performed to evaluate dyspnea:<br>
❑&nbsp;&nbsp;Arterial blood gases, pulse oximetry, waveform capnography:
:❑&nbsp;&nbsp;Hypoxia, hyperventilation, CO² retention, obstructive or restrictive respiratory pattern, metabolic vs. respiratory acidosis, A-a gradient, elevated carboxyhemoglobin?
❑&nbsp;&nbsp;Complete blood count:
:❑&nbsp;&nbsp;WBC, Hgb, Hct, anemia, polycythemia, smear, platelets?
❑&nbsp;&nbsp;Chemistry:
:❑&nbsp;&nbsp;BUN, Cr, K, Mg, Phos, Glucose, D-Dimer, Troponin, NT-proBNP, thyroid function tests?</div>}}  
{{familytree | | | | | | | J01 |J01=<div style="text-align: left;"><b><u>Imaging and aditional tests:</u></b><br>
❑&nbsp;&nbsp;Cardiac:
:❑&nbsp;&nbsp;ECG (ischemia, dysrhythmia, S¹Q³T³, right sided heart strain)
:❑&nbsp;&nbsp;Echocardiogram (pulmonary hypertension, valvular disorders, wall motion abnormalities related to ischemia, intracrdiac shunts)
:❑&nbsp;&nbsp;Cardiopulmonary exercise testing
❑&nbsp;&nbsp;Pulmonary function test/ spirometry<br>
❑&nbsp;&nbsp;Radiologic:
:❑&nbsp;&nbsp;CXR (bone structures, mass, diaphragm, mediastinum, cardiac silhouette, soft tissue, lung parenchyma)
:❑&nbsp;&nbsp;V/Q scan (PE?)
:❑&nbsp;&nbsp;Pulmonary angiogram (PE?)
:❑&nbsp;&nbsp;CT (mass lesion, adenopathy, trauma, PE?)
:❑&nbsp;&nbsp;MRI (PE, bony and soft tissue lesions, vascular abnormality?)
:❑&nbsp;&nbsp;Soft tissue neck radiography (epiglottitis, foreign body?)
:❑&nbsp;&nbsp;Ultrasound (pneumothorax, pleural effusion, impaired cardiac function or pericardial effusion?)
❑&nbsp;&nbsp;Fiberoptic:
:❑&nbsp;&nbsp;Bronchoscopy (mass lesions, foreign body, intervention?)
:❑&nbsp;&nbsp;Laryngoscopy (mass lesion, edema epiglottis foreign body?)</div>}}
{{familytree | | | | | | | |!| | | | | | |}}  
{{familytree | | | | | | | K01 | | | | | |K01=<b>Differential diagnosis based on history, physical examination, labaratory and test findings</b>}}  
{{familytree | | |,|-|-|v|-|^|-|v|-|-|v|-|-|v|-|-|.| }}
{{familytree | | B01 | B02 | | B03 | B04| |B05 | B06 | |B01=<div style="text-align: left;"><b><u>[[Chest trauma]]:</u></b><br>
Treatment as fast as possible.<br>
❑&nbsp;&nbsp;Tension pneumothorax: Immediate chest decompression by needle or tube thoracostomy
❑&nbsp;&nbsp;Pulmonary contusion, multiple rib fractures: Pain management
❑&nbsp;&nbsp;Inhalation injury: Early endotracheal intubation</div>|B02=<div style="text-align: left;"><b><u>[[Anaphylaxis]]:</u></b><br>
❑&nbsp;&nbsp;Secure airway if needed: endotracheal intubation, cricothyrotomy<br>
❑&nbsp;&nbsp;Epinephrine IV (extreme) if needed, SQ
❑&nbsp;&nbsp;Steroids IV
❑&nbsp;&nbsp;Diphenhydramine IV
❑&nbsp;&nbsp;Inhaled beta-agonist
❑&nbsp;&nbsp;Consider inhaled racemic epinephrine, heliox
❑&nbsp;&nbsp;H¹/H² blocker IV</div>|B03=<div style="text-align: left;"><b><u>[[Pneumonia]]:</u></b><br>
❑&nbsp;&nbsp;Blood/sputum cultures<br>
❑&nbsp;&nbsp;Initiate appropriate empirical antibiotic, antifungal or antiviral medication promptly
❑&nbsp;&nbsp;Isolation if needed</div>|B04=<div style="text-align: left;"><b><u>[[Cardiac]]:</u></b><br>
❑&nbsp;&nbsp;[[Dysrhythmia]]: antiarrhythmics or cardioversion
❑&nbsp;&nbsp;[[Coronary heart disease]]: nitrates, ASA, pain management, thrombolysis, beta-blockade, PCA
❑&nbsp;&nbsp;[[Heart failure]]: diuretics, nitrates, morphine, ACE</div>|B05=<div style="text-align: left;"><b><u>[[Pulmonary embolism]]:</u></b><br>
❑&nbsp;&nbsp;Initiate anticoagulation with IV heparin or subcutaneous low-molecular-weight heparin<br>
❑&nbsp;&nbsp;Consider systemic thrombolysis if unstable
❑&nbsp;&nbsp;Consider interventional clot lysis with pulmonary angiography</div>|B06=<div style="text-align: left;"><b><u>[[Asthma or COPD exacerbation]]:</u></b><br>
❑&nbsp;&nbsp;Inhaled beta-agonist
❑&nbsp;&nbsp;Steroids IV
❑&nbsp;&nbsp;Consider other adrenergics
❑&nbsp;&nbsp;Treat concurrent infection
❑&nbsp;&nbsp;Counsel smoking cessation if appropiate</div>}}
{{familytree | | |`|-|-|^|-|-|v|^|-|-|^|-|-|^|-|-|'| | }}
{{familytree | | | | | | | | |!| | | | | |}}  
{{familytree | | | | | | | | M01 | | | | |M01=<b>In Case of respiratory failure</b>}}
{{familytree | | | | | | | | |!| | | | | |}}  
{{familytree | | | | | | | | N01 | | | | |N01=❑&nbsp;&nbsp;CPAP/BiPAP (short term) or endotracheal intubation, and mechanical ventilation<br>
❑&nbsp;&nbsp;Treat underlying causes}}  
{{familytree/end}}
{{familytree/end}}
==Treatment==
<div class="mw-collapsible mw-collapsed">
shown
<div class="mw-collapsible-content">
hidden
</div></div>
==Do's==
==Dont's==


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

Latest revision as of 00:10, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Steven Bellm, M.D. [2]

Shortness of breath resident survival guide Microchapters
Overview
Definitions
Causes
FIRE
Diagnosis and Treatment

Overview

Dyspnea is a symptom, it must generally be distinguished from signs that clinicians typically invoke as evidence of respiratory distress, such as tachypnea, use of accessory muscles, and intercostal retractions.[1]

Respiratory discomfort may arise from many clinical conditions, but also may be a manifestation of poor cardiovascular fitness in our increasingly sedentary population. Diagnosis and treatment of the underlying cause of dyspnea is the preferred and most direct approach to improve this symptom, but there are many patients for whom the cause is unclear or for whom dyspnea persists despite optimal treatment.[2]

Definitions

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.[3]
A respiratory rate greater than normal.
A respiratory rate smaller than normal.
Increased minute ventilation to meet metabolic requirements.
It is the result of an increased frequency of breathing, an increased tidal volume, or a combination of both. It causes an excess intake of oxygen and the blowing off of carbon dioxide.
Dyspnea caused by physical effort or exertion.
Dyspnea caused by a recumbent position.
Dyspnea that starts suddenly while reclining at night.
Dyspnea that starts in an upright position.
Dyspnea that starts in one lateral decubitus position as opposed to the other.[4]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.[5]

  • Life-threatening causes of the upper airway
  • Life-threatening pulmonary causes
  • Life-threatening cardiac causes
  • Life-threatening neurologic causes
  • Life-threatening toxic and metabolic causes

Miscellaneous Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[6]

 
 
 
 
 
Dyspnea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial evaluation:

❑   Check Vital Signs:

❑  Heart rate
❑  Respiratory rate
❑  Blood pressure

❑   Danger signs: Depressed mental status, cyanosis, inability to maintain respiratory effort, use of accessory muscles, abnormal chest movement
❑  Action items

❑   Supplement oxygen
❑   IV access and pulse oximetry
❑  ECG/cardiac monitor
❑  ± Continuous waveform capnography
❑  Lab measurements:
❑  ABG, SaO2, A-a gradient
❑  WBC, Hgb, Hct, Platelets
❑  BUN, Cr, K, Mg, Phos
❑  Glucose
❑  D-Dimer, NT-proBNP, Troponin
❑  Keep airway managment equipment ready
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs for rapidly reversible causes?
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tension pneumothorax:

❑  Signs:

❑  Chest pain
❑  Hypotension
❑  Tracheal deviation
❑  Jugular-venous distension
❑  Quieter breath sounds/hyperresonant percussion
❑  Tachycardia/tachypnea

❑  Treatment:

❑  Immediate chest decompression by needle or tube thoracostomy
Upper airway foreign body aspieation:

❑  Signs:

❑  Coughing, cyanosis

❑  Treatment:

❑  Bronchoscopy/Laryngoscopy
Pericardial tamponade:

❑  Signs(Becks's triade):

❑  Hypotension
❑  Muffled heart sounds
❑  Jugular-venous distension

❑  Treatment:

❑  Pericardiocentesis
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ability to maintain own airway?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
Action items:

❑  Try to assess ventilation
❑  Check breath sounds

❑  Endotracheal intubation/cricothyrotomy and mechanical ventilation
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest x-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess breath sounds, obtain history and physical exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to Complete Diagnostic Approach
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach and Treatment

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention[7]

 
 
 
 
 
 
History and symptpms:

❑  Shortness of breath
❑  Grunting or wheezing sounds while breathing
❑  Exposure to something the patient may be allergic to may cause shortness of breath
❑  Exercise may cause shortness of breath
❑  Onset:Sudden or slowly?
❑  Duration:Slowly progress over weeks to months?
❑  Positional Changes:Shortness of breath may worsen when the patient changes body position. Sometimes it is worse when you lie flat (orthopnea). Sometimes breathing difficulty occur while the patient is resting. Is there a paroxysmal nocturnal dyspnea?
❑  Trauma?

❑  Past medical illness?
 
 
 
 
 
 
Physical examination:

❑  Vital signs:

❑  Fever, Tachypnea, Hypopnea, Tachycardia, Hypotension?

❑  General appearance:

❑  Cachexia, obesity, pregnancy, barrel chest, "sniffing" position, "tripoding" position, traumatic injury?

❑  Neck:

❑  Jugular venous distension, stridor?

❑  Skin and nails:

❑  Tobacco stains, clubbing, pallid skin, muscle wasting, bruising, subcutaneous emphysema, hives, rashes?

❑  Lungs:

❑  Wheezing, crackles, rales, unilateral decrease, hemoptysis, Friction rub, abnormal respiratory pattern?

❑  Heart:

❑  Heart murmurs, S3, S4, muffled heart sounds?

❑  Extremities:

❑  Peripheral edema, palpation of peripheral arteries, signs for cyanosis, swelling or tenderness?

❑  Neurologic examination:

❑  Focal deficit, symmetrical deficit, diffuse weakness, hyporeflexia, ascending weakness?
❑  Any pain or panic symptoms?
 
 
 
 
 
 
Laboratory findings:

The following tests are performed to evaluate dyspnea:
❑  Arterial blood gases, pulse oximetry, waveform capnography:

❑  Hypoxia, hyperventilation, CO² retention, obstructive or restrictive respiratory pattern, metabolic vs. respiratory acidosis, A-a gradient, elevated carboxyhemoglobin?

❑  Complete blood count:

❑  WBC, Hgb, Hct, anemia, polycythemia, smear, platelets?

❑  Chemistry:

❑  BUN, Cr, K, Mg, Phos, Glucose, D-Dimer, Troponin, NT-proBNP, thyroid function tests?
 
 
 
 
 
 
Imaging and aditional tests:

❑  Cardiac:

❑  ECG (ischemia, dysrhythmia, S¹Q³T³, right sided heart strain)
❑  Echocardiogram (pulmonary hypertension, valvular disorders, wall motion abnormalities related to ischemia, intracrdiac shunts)
❑  Cardiopulmonary exercise testing

❑  Pulmonary function test/ spirometry
❑  Radiologic:

❑  CXR (bone structures, mass, diaphragm, mediastinum, cardiac silhouette, soft tissue, lung parenchyma)
❑  V/Q scan (PE?)
❑  Pulmonary angiogram (PE?)
❑  CT (mass lesion, adenopathy, trauma, PE?)
❑  MRI (PE, bony and soft tissue lesions, vascular abnormality?)
❑  Soft tissue neck radiography (epiglottitis, foreign body?)
❑  Ultrasound (pneumothorax, pleural effusion, impaired cardiac function or pericardial effusion?)

❑  Fiberoptic:

❑  Bronchoscopy (mass lesions, foreign body, intervention?)
❑  Laryngoscopy (mass lesion, edema epiglottis foreign body?)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential diagnosis based on history, physical examination, labaratory and test findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest trauma:

Treatment as fast as possible.
❑  Tension pneumothorax: Immediate chest decompression by needle or tube thoracostomy ❑  Pulmonary contusion, multiple rib fractures: Pain management

❑  Inhalation injury: Early endotracheal intubation
Anaphylaxis:

❑  Secure airway if needed: endotracheal intubation, cricothyrotomy
❑  Epinephrine IV (extreme) if needed, SQ ❑  Steroids IV ❑  Diphenhydramine IV ❑  Inhaled beta-agonist ❑  Consider inhaled racemic epinephrine, heliox

❑  H¹/H² blocker IV
 
Pneumonia:

❑  Blood/sputum cultures
❑  Initiate appropriate empirical antibiotic, antifungal or antiviral medication promptly

❑  Isolation if needed
Cardiac:

❑  Dysrhythmia: antiarrhythmics or cardioversion ❑  Coronary heart disease: nitrates, ASA, pain management, thrombolysis, beta-blockade, PCA

❑  Heart failure: diuretics, nitrates, morphine, ACE
 
Pulmonary embolism:

❑  Initiate anticoagulation with IV heparin or subcutaneous low-molecular-weight heparin
❑  Consider systemic thrombolysis if unstable

❑  Consider interventional clot lysis with pulmonary angiography
Asthma or COPD exacerbation:

❑  Inhaled beta-agonist ❑  Steroids IV ❑  Consider other adrenergics ❑  Treat concurrent infection

❑  Counsel smoking cessation if appropiate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In Case of respiratory failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑  CPAP/BiPAP (short term) or endotracheal intubation, and mechanical ventilation
❑  Treat underlying causes
 
 
 
 

References

  1. Campbell ML (2008). "Psychometric testing of a respiratory distress observation scale". J Palliat Med. 11 (1): 44–50. doi:10.1089/jpm.2007.0090. PMID 18370892.
  2. Desbiens NA, Mueller-Rizner N, Connors AF, Wenger NS (1997). "The relationship of nausea and dyspnea to pain in seriously ill patients". Pain. 71 (2): 149–56. PMID 9211476.
  3. "Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society". Am J Respir Crit Care Med. 159 (1): 321–40. 1999. doi:10.1164/ajrccm.159.1.ats898. PMID 9872857.
  4. Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.
  5. Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.
  6. Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.
  7. Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.