Shortness of Breath
Shortness of Breath
Shortness of Breath
• Heli-ox
Admit or not?
• Depends on: Improvement of symptoms, risk
factors for death, social situation, compliance,
and patient comfort with going home
• In general:
• HOME if complete resolution of symptoms and peak
flow > 70% of predicted
• ADMIT if poor response to treatment and peak flow
< 50% of predicted
• ALL OTHERS – Depends on combination of above
factors, when in doubt ASK THE PATIENT!
Discharge
• All patients need steroids for at least 5 days
• All patients need β2 agonists
• All patients with more than mild intermittent asthma
(need inhaler > 2 x week, peak flow < 80% of predicted) need
inhaled steroids
• Patients with moderate-to-severe asthma (daily symptoms)
should measure daily peak flows
• All patients need close follow up
• All patients need education about asthma
• Smoking cessation counseling
Case #2
• 65 yo M with shortness of breath for past several hours,
getting increasingly worse; now drowsy and difficult to
arouse; pt with hx of smoking 2ppd for many years, is
on home oxygen.
• T: 99.9, HR: 98, R: 30, BP: 165/70, O2sat: 89%
room air, 92% 2LNC
• Physical exam: barrel chest, pursed lips, wheezing,
prolonged expirations, diminished breath sounds
throughout
• Likely diagnosis?
• What else is on your differential diagnosis?
COPD
• Chronic airway • Ask patients about:
inflammation • History of COPD
• Inflammatory cells and
mediators • Change in cough or sputum
• Protease / anti-protease • Fever, infectious signs
imbalance • Medications (steroids)
• Oxidative stress • Environmental exposures
• Increases in lung • Smoking history
compliance
• Becomes an obstructive
process
Physical exam findings in
COPD
• Signs of Hypoxemia • Signs of Hypercapnia
• Tachypnea • Altered mental status
• Tachycardia • Hypopnea
• Hypertension
• Cyanosis
COPD
• Chest X-ray
• Hyperinflation
• Flattened diaphragms
• Increased AP diameter
• EKG
• Wandering pacemaker
• Multifocal atrial
tachycardia (MAT)
• Right axis deviation
Treatment for COPD
• Supplemental oxygen
• Careful in patients that are CO2 retainers
• Loss of hypoxic drive can result in respiratory arrest
• Goal: 90-92% oxygen saturation
• Bronchodilators (Albuterol and atrovent)
• Antibiotics
• (Which antibiotics would be appropriate?)
• Corticosteroids
• 7-14 day course improves FEV1 in exacerbations
• Hyperglycemia is common side effect
Treatment for COPD
• Positive-pressure ventilation
• Indicated for respiratory fatigue, acidosis,
hypoxia, hypercapnia
• Can decrease intubation rates and possibly
improves survival
• Patient needs to be awake, cooperative, and
able to handle secretions
Case #3
• 35 yo previously healthy F c/o one week of
headache, sore throat and muscle aches,
fevers, now with productive cough and
increasing fatigue.
• On physical exam she is febrile and has
decreased breath sounds over the RLL.
• What is your differential and work-up?
Pneumonia
• Clinical features: • On exam:
• Typically: Cough, dyspnea, • Tachypnea, tachycardia,
sputum production, fever, fever
pleuritic chest pain • Inspiratory rales =
• Pneumococcal: sudden onset Alveolar fluid
of fever, rigors, productive • Bronchial breath sounds
cough, tachypnea
= Consolidation
• Atypical pneumonia: Coryza,
low grade fevers, non-
• Dullness/decreased BS =
productive cough Pleural effusion
• Rhonchi = Bronchial
congestion
Pathophysiology
• Usually inhaled/aspirated pathogens
• Risk- Stroke, seizure, intoxication
• Hematogenous spread- Staph. aureus
• Infection within alveoli with intense
inflammatory response
• Filling alveoli with bacteria, WBC, exudate
Which patient groups get
which types?
• Pneumococcus • Atypical
• Staph aureus • Chlamydia
• Klebsiella • Mycoplasma
• Legionella
• Pseudomonas
•
• Haemophilus
Special populations
• Diabetics • Elderly/Nursing home
• HIV • Predictors for morbidity:
• Pneumonia more Tachycardia, tachypnea,
common and has higher temp>100.4,
morbidity than non-HIV somnolence, confusion,
population crackles, leukocytosis
• Pneumococcus= Most • Pathogens:
common bacteria Pneumococcus, gram
negatives, Haemophilus,
• CD4>800: Bacterial influenza
more common
• May just present with
• CD4 250-500: TB, confusion, weakness
cryptococcus, histoplasma
• CD4< 200: PCP, CMV
Pneumonia
• Chest X-ray
• Measure O2 sat,
CBC, electrolytes
• Blood cultures for
admitted patients
(before antibiotics)
Treatment
• Pneumococcal most common, but atypicals
becoming more prevalent
• Outpatient
• Doxycycline
• Newer macrolide (Azithromycin)
• Fluroquinolone (Levofloxacin)
• Also consider MRSA for severe infections
Treatment
• Inpatient
• Early antibiotics lowers mortality
• 3rd gen cephalosporin (Ceftriaxone) or PCN
w/ beta-lactamase inhibitor (Unasyn/Zosyn)
plus macrolide (Azithromycin)
• Fluroquinolone alone (Levofloxacin)
• Add pseudomonal coverage (Cefepime) as
needed i.e. CF patient
Admission or not?
• 75% CAP do not require admission, can be
discharged with follow up
• Admission: Elderly, HIV pts, tachypnea,
oxygen requirement
• PORT score
• ICU: Markedly tachypneic, high oxygen
requirement, evidence of shock
Case #4
• 65 yo M with hx of CAD s/p CABG with
increasing dyspnea on exertion, orthopnea,
increasing swelling in feet and ankles, now today
with acute shortness of breath and respiratory
distress. No chest pain, no fevers; ROS
otherwise negative
• Pt in moderate respiratory distress on exam with
diffuse crackles in all lung fields
• What is your differential diagnosis and approach
to this patient?
Congestive Heart Failure
• Can present with acute
pulmonary edema and
with respiratory distress
• Due to decreasing CO
and rising SVR
• Sympathetic nervous
system and renin-
angiotensin-aldosterone
system are activated
• Result: Volume
overload, pulmonary
edema,resp distress
Causes of acute
decompensation in CHF
• Non-compliance
• Medications: diuretics
• Diet: excessive salt
• Cardiac
• Arrhythmia
• ACS
• Uncontrolled HTN
• Other
• Volume overload due to renal failure
• PE
• Exacerbation of other co-morbidity (ex. COPD)
What are some signs and
symptoms of CHF?
Signs & Symptoms of CHF
• Symptoms • Signs
• Respiratory distress • Elevated JVD
• Cool / diaphoretic skin • S3
• Weight gain • Hypertension
• Peripheral edema • Rales
• Orthopnea • +/- peripheral edema
• Paroxysmal nocturnal • +/- RUQ tenderness
dyspnea (congested liver)
• Abdominal pain • Tachypnea
Evaluation of CHF
• CXR (portable)
• Cardiomegaly
• Vascular congestion
• Pulmonary edema
• Labs
• CBC, electrolytes,
cardiac enzymes, BNP
• EKG
• Search for cause of
decompensation
What is the BNP and why do
we care?
• Natriuretic peptide released by RA when
heart is stretched i.e. volume overload
• Level correlates with CHF severity, rate of
re-hospitalization, and risk of death
• BNP > 480 = 40% risk of re-hospitalization or
death within 6 months
• Helps to distinguish between other causes of
SOB i.e. COPD
Differential Diagnosis
• Pulmonary: • Fluid retentive states:
• Asthma/COPD exacerbation • Liver failure, portal vein
• Pulmonary embolus thrombosis
• Pneumothorax • Renal failure
• Pleural effusion • Nephrotic syndrome
• Pneumonia • Hypoproteinemia
• Cardiac: • High output states:
• ACS, arrhythmia • Sepsis
• Acute valvular insufficiency • Anemia
• Pericardial tamponade • Thyroid dysfunction
Treatment
• Control airway and maintain ventilation
• Supplemental oxygen
• Cardiac monitoring
• Pulse oximetry
• Establish IV access
• +/- ABG
• Frequent vital signs
Which medications are used
to treat CHF?
Treatment of CHF
• Preload reduction
• Vasodilators
• Inotropic support if needed
Treatment of CHF
• Reduce preload and afterload:
• Nitroglycerin by sublingual or IV route
• Volume reduction
• Lasix- Diuresis starts in 15-20 minutes
• If no prior use: 40 mg IV
• Outpatient use: Double last 24 hour usage
• If no effect by 30 minutes, repeat a doubled dose
• Clinical endpoint- Rapidly lower filling pressures to
prevent need for endotracheal intubation
• Place foley catheter and monitor UOP
NIPPV
• Noninvasive Positive Pressure Ventilation
• Controversial but worth a try in severe respiratory
distress
• Temporizes while medical therapy is working
• BiPAP may decrease need for intubation
• Patient cooperation is required
The End
• Any questions?