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Acute Dyspnea

Acute Dyspnea

When notified about a patient experiencing acute dyspnea, the initial step is to categorize them into two groups:

  1. Non ETT Patients: Patients feeling breathless or appearing breathless (rapid breathing, using accessory muscles, abdominal breathing), with a drop in O2 saturation.

  2. Patients on Ventilators: Patients appearing breathless, a drop in O2 saturation, and breathing not synchronized with the machine.

Perform a thorough history and physical examination to guide initial diagnostic steps as outlined in the table.

System: Common Diseases, History, Physical Examination, Diagnostic Tests

Respiratory:

  • Airway:

  • Secretion Obstruction: Significant sputum, improvement post-suction.

  • Physical Exam: Coarse crepitation.

  • Tests: Not required.

  • COPD/Asthma:

  • History: Chronic smoking, recurrent symptoms, chronic cough/phlegm.

  • Physical Exam: Purse lips, barrel chest, wheezing, poor air entry, prolonged expiration.

  • Tests: Chest X-ray (CXR), Complete Blood Count (CBC).

  • Alveolar:

  • Pneumonia: Fever, cough, fatigue, change in sputum.

  • Physical Exam: Localized crepitation.

  • Tests: CXR, CBC, sputum gram stain and culture/sensitivity.

  • Pleural:

  • Pneumothorax, Pleural Effusion: Sudden onset dyspnea, difficulty breathing, pleuritic chest pain.

  • Physical Exam: Decreased breath sounds, dull vs resonant percussion, tracheal shift.

  • Tests: CXR.

Vascular:

  • Pulmonary Embolism:

  • History: Bedridden, post-op, cancer, sudden onset dyspnea.

  • Physical Exam: Signs of Deep Vein Thrombosis (DVT) like unilateral leg edema.

  • Tests: EKG, troponin, CXR, CT Angiography (CTA) PE protocol.

Cardiovascular System (CVS):

  • Heart Failure (Right or Left side), Pulmonary Embolism:

  • History: Dyspnea, orthopnea/Paroxysmal Nocturnal Dyspnea (PND), life-threatening factors (CHAMP), fluid intake/diuretics/Intake & Output (IO).

  • Physical Exam: Jugular vein engorgement, shifted Point of Maximal Impulse (PMI), S3 gallops, crepitation/wheezing.

  • Tests: CXR, Echocardiogram.

  • Myocardial Infarction (MI):

  • Usually presents with chest pain, pressure/lightness on the chest, dyspnea.

  • Tests: 12-lead EKG, troponin.

Metabolic:

  • Related to chronic diseases/medications.

  • Tests: Blood glucose, Blood Urea Nitrogen (BUN), Creatinine (Cr), Electrolytes, CBC.

Management:

  1. Invasive Ventilation:

  • Consider Endotracheal Tube (ETT) intubation in cases of airway obstruction, GCS < 9, PaCO2 > 50, PaO2 < 50, or inability to maintain goal O2 saturation despite mask with bag. Remember to perform Arterial Blood Gas (ABG) analysis, provide advice, and consider sedation before ETT.

  1. Troubleshooting in Patients with Mechanical Ventilators:

  • For ETT patients, address issues based on DOPE (Displacement, Obstruction, Pneumothorax, Equipment failure).

  • If the patient appears restless, check ABG for hyperventilation, consider causes like pain, constipation, fever, and provide sedation if no other correctable cause is found.

Specific Case Evaluation and Initial Management for Acute Decompensated Heart Failure (ADHF):

  • Identify life-threatening etiology using CHAMP criteria.

  • Management for pulmonary congestion includes vasodilators for SBP > 90, diuretics monitoring urine output, inotropes like Dobutamine, Dopamine, and vasopressors like Norepinephrine.

  • COPD/Asthma management includes oxygen supplementation, ventilator support, bronchodilators (e.g., Berodual), steroids (e.g., Dexamethasone or Prednisolone), and antibiotics (e.g., Azithromycin) if there's a significant change in sputum.

Non-Invasive Ventilation (NIV) Role:

  1. As an alternative weaning mode after early extubation.

  2. For prophylaxis against re-intubation, especially in older patients or those with underlying cardiac/respiratory diseases.

  3. Strongly recommended for COPD patients with Acute Exacerbations and Hypercapnia.

  4. In cases of acute respiratory failure in immunocompromised hosts, like HIV with opportunistic infections or hematologic malignancies.

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