Approach to Respiratory Distress PDF

Approach to respiratory distress Dr Ali Husam Hadi FABHS-EM Case A 58 year old woman is brought in by EMS with acute onset respiratory distress. Over the last few hours, she has found it increasingly di cult to breathe. On arrival, she is diaphoretic and using accessory muscles. She is...

Approach to respiratory distress Dr Ali Husam Hadi FABHS-EM Case A 58 year old woman is brought in by EMS with acute onset respiratory distress. Over the last few hours, she has found it increasingly di cult to breathe. On arrival, she is diaphoretic and using accessory muscles. She is quite tachypneic at a rate of 45 breaths per minute, and her oxygen saturation is 82%. How do you approach a patient with undi erentiated respiratory distress? ff ffi  Our approach to respiratory distress Our “ rst 10 minutes” approach to a Positive end expiratory pressure sick patient with undi erentiated di culty breathing is focused on rapidly Positive pressure ventilation nding the right therapy, but not necessarily on nding the right Chest decompression diagnosis. Bronchodilators (and steroids There are only a limited number of eventually) things that we can do to help a patient with dyspnea and we want to quickly Epinephrine pick the best therapies from the following menu: Nitroglycerin Airway management Cardioversion Oxygen (including high ow humidi ed Thrombolytics / PCI nasal oxygen) Pericardiocentesis fi ffi fi fi fl ff fi Position the patient Almost all dyspneic patients will be better in the sitting position. Raise the head of the bed, or allow the patient to assume their own position of maximal comfort. Is the airway patent? The airway assessment should be very rapid. Can the patient speak? Is the patient alert? Is there stridor or gurgling? Is there respiratory e ort without any air movement? Look in the mouth and feel the anterior neck. If I am concerned about airway, I start with basic airway maneuvers. If the basic airway maneuvers aren’t enough, the patient will require intubation, but it is important to ask: is this patient ready for an RSI? ff Respiratory assessment: oxygen saturation and work of breathing Oxygenation and ventilation are two separate processes, and it can be helpful to consider them separately. However, in the rst few minutes, consider them together. Even in the setting of normal oxygen saturation, sometimes the patient has an increased work of breathing and in need of ventilatory support. If the patient is hypoxic, provide oxygen. (Start with high concentration, then titrate down later). Also apply oxygen if you think there is a chance of early intubation. However, routinely providing high ow oxygen to patients who are not hypoxic has been shown to be harmful in multiple trials, so avoid oxygen therapy if it is not required. Persistent hypoxia despite face mask oxygen is likely a sign of shunt physiology or an alveolar di usion problem (assuming you have ruled out airway obstruction and apnea). This is treated with PEEP (positive end expiratory pressure), which can be accomplished either by holding a good 2 hand seal on a bag valve mask that has a PEEP valve attached, by starting CPAP, or by intubating and providing PEEP with the ventilator. fi fl ff Is the patient moving enough air? Take a moment to look at the respiratory rate, tidal volume, and work of breathing. Apnea requires bag valve mask ventilation and empiric naloxone. Treat poor ventilatory e ort with BPAP or assist breathing with a bag valve mask. Similarly, if the tidal volume is adequate, but the patient is working very hard to achieve those tidal volumes, non-invasive positive pressure ventilation is warranted, as the patient will get tired. If agitation (often the result of dyspnea, hypoxia, or hypercarbia) is preventing the adequate delivery of face mask oxygen or noninvasive ventilation, small boluses of ketamine can be used for sedation. (This is known as delayed sequence intubation). ff What about the rest of the vital signs? Get the patient on the monitor, get a full set of vital signs, and have a team member start working on vascular access. Obvious life threats, such as cardiac arrhythmias, shock, or apnea, should be addressed before moving on. Directed history and physical to guide initial empiric therapy Perform a quick exam. In addition to the airway assessment above, focus on breath sounds, breathing pattern, heart sounds, and a skin exam. In general, history sometimes is more valuable than physical exam, although it is frequently impossible to gather history from a patient with signi cant dyspnea. If the patient can’t speak, don’t worry about the history. Just get empiric therapy started, and move on to your adjuncts like ultrasound. fi  Start empiric therapies based on the clues. At this point, the goal is starting treatment rather than making a de nitive diagnosis. The initial diagnosis and empiric therapy may turn out to be wrong, but that is OK. For example, even though CHF can present with wheeze, in the initial minutes be comfortable treating all wheezing patients with salbutamol. The key is not getting anchored to one strategy instead change treatment strategies as more information becomes available. fi  Wheeze → salbutamol, ipratropium, steroids Crackles with a normal or high blood pressure → nitroglycerin and CPAP Unilateral decreased breath sounds → nger thoracostomy (usually, but not always, after con rmation with an ultrasound or x-ray) Hives → Intramuscular epinephrine fi fi Add bedside diagnostic tests While waiting for the initial empiric therapy to work, there are three diagnostic tests that almost every dyspneic patient will get: an ECG, a chest xray, and a bedside ultrasound. Get an early ECG to rule out STEMI and arrhythmias. A portable chest x ray is also valuable (although with the advent of bedside ultrasound it may be less important.)  Point of care ultrasound is incredibly helpful in the management of dyspneic patients. There are a number of algorithms available. Start with a rapid lung ultrasound to rule out pneumothorax and large pleural e usion. Look at multiple locations on both sides of the chest, to check whether there are di use B lines, A lines, or more focal disease. Next look at the heart, rst to rule out a pericardial e usion, then to get a sense of the left heart function, and nally to look at the size of the right ventricle. ff ff fi fi ff Reassess It is rare to have a de nitive diagnosis for dyspneic patient in the initial minutes in the resuscitation room. Empiric therapy is often started without a diagnosis. They key is reassessment, both to determine ongoing treatment and to get on the correct diagnosis. In fact, reassessment plays a central role in all resuscitations. fi Determine definitive testing and plan disposition If the diagnosis remains unclear despite gathering a more thorough history, performing a complete ultrasound, and watching the response to empiric therapy, it is time to consider further diagnostic tests. Blood work will likely have been sent automatically. CT is helpful if pulmonary embolism is being considered, as well as in the diagnosis of atypical infections, in ammatory conditions, and neoplasms. An urgent formal echocardiogram may be required, especially in the context of a murmur where an acute valvular disorder is suspected. Contact the ICU or appropriate admitting team, or work on getting the patient transferred if necessary. fl Key Blood Tests in Respiratory Distress Arterial Blood Gas (ABG): To assess oxygenation, Cardiac Markers (Troponin/BNP): To assess for ventilation, and acid-base status. cardiac causes of dyspnea. PaO2: Hypoxemia (< 60 mmHg) Troponin: Suggests myocardial infarction PaCO2: Hypercapnia (> 45 mmHg) BNP: Elevated in heart failure pH: Acidosis or alkalosis Electrolytes and Renal Function: To check for metabolic disturbances or organ dysfunction. Complete Blood Count (CBC): To identify anemia, infection, or other systemic causes. Na, K, Ca, Mg: Electrolyte imbalances Leukocytosis/Leukopenia: Infection or sepsis BUN/Creatinine: Renal function and perfusion status Anemia: Reduced oxygen-carrying capacity Lactate: To assess for tissue hypoxia and sepsis. Platelets: Coagulopathy or hemorrhage risk Elevated lactate indicates poor tissue D-dimer: To rule out pulmonary embolism (PE). oxygenation or sepsis. X-ray and CT scan of the chest Chest X-Ray (CXR): Rapid, non-invasive imaging to assess lung and heart conditions. Pneumonia: Consolidation or in ltrates Pneumothorax: Loss of lung markings, visible pleural line Pulmonary Edema: Kerley B lines, bilateral in ltrates, or pleural e usion Pleural E usion: Blunted costophrenic angles Cardiomegaly: Enlarged cardiac silhouette (heart failure) CT Chest: High-resolution imaging for detailed evaluation, particularly for suspected PE, masses, or complex lung pathology. Pulmonary Embolism (PE): CT pulmonary angiography (CTPA) is the gold standard for diagnosing PE. Interstitial Lung Disease: Ground-glass opacities, honeycombing Masses/Neoplasms: Identify lung tumors or metastases Trauma: Rib fractures, hemothorax, or pneumothorax in trauma patients ff fi fi ff Pneumothorax Pneumothorax Hemothorax or plueral effusion Hemopneumothorax Pneumonia Pneumothorax Hemothorax Ground glass appearance Review a checklist Finally, after the initial interventions are done and empiric therapies started, review a checklist to help ensure you are not missing an important diagnosis.  Upper airway Valvular disease Forgein body Blood or vomit Others (myocarditis, cardiomyopathy, congenital disease) Allergy Trauma Apnea Mass Not really “distress”, but still common cause of hypoxemia/hypercapnia Laryngospasm Epiglottitis / other infections Drugs (opioids) Lungs Neurologic disasters Pneumothorax Hypoglycemia Pneumonia Others PE Acidosis (DKA/ ASA overdose) Bronchospasm (asthma, COPD, Carbon monoxide anaphylaxis) Methemoglobinemia Pleural e usion Anemia Others ( brosis, neoplasms) Neuromuscular weakness (Guillain Barre syndrome, myasthenic crisis) Heart MI Chest wall (obesity, burns) Tamponade Abdominal pressure (ascites, abdominal compartment syndrome) Acute pulmonary edema Arrhythmia (bradycardia or tachycardia) Anxiety fi ff Thank you