Shortness of breath resident survival guide

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

Shortness of breath resident survival guide Microchapters
Overview
Definitions
Causes
FIRE
Diagnosis
Treatment
Do's
Dont's

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.

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.

Definitions

• Dyspnea

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.

• Tachypnea

A respiratory rate greater than normal.

• Hyperpnea

Increased minute ventilation to meet metabolic requirements.

• Hyperventilation

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 on exertion

Dyspnea caused by physical effort or exertion.

• Orthopnea

Dyspnea caused by a recumbent position.

• Paroxysmal nocturnal dyspnea

Dyspnea that starts suddenly while reclining at night.

• Platypnea

Dyspnea that starts in an upright position.

• Trepopnea

Dyspnea that starts in one lateral decubitus position as opposed to the other.

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 of the upper airway

• Tracheal foreign objects
• Angioedema
• Anaphylaxis
• Infections of the pharynx and neck
• Airway trauma

• Life-threatening pulmonary causes

• Pulmonary embolism
• COPD
• Asthma
• Pneumothorax and pneumomediastinum
• Pulmonary infection
• Adult Respiratory Distress Syndrome
• Direct pulmonary injury
• Pulmonary hemorrhage

• Life-threatening cardiac causes

• Acute coronary syndrome
• Acute decompensated heart failure
• Flash pulmonary edema
• High output heart failure
• Cardiomyopathy
• Cardiac arrhythmia
• Valvular dysfunction
• Cardiac tamponade

• Life-threatening neurologic causes

• Stroke
• Neuromuscular disease

• Life-threatening toxic and metabolic causes

• Poisoning
• Salicylate poisoning
• Carbon monoxide poisoning
• Toxin related metabolic acidosis
• Diabetic ketoacidosis
• Sepsis
• Anemia
• Acute chest syndrome- in patients with sickle cell disease

Miscellaneous Causes

• Lung cancer
• Pleural effusion
• Intraabdominal processes
• Ascites
• Pregnancy
• Massive obesity
• Hyperventilation and anxiety

FIRE: Focused Initial Rapid Evaluation

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

Dyspnea

Initial evaluation: ❑   Check Vital Signs: ❑  Heart rate ❑  Respiratory rate ❑  Blood pressure ❑  SaO2 ❑  ECG/cardiac monitor ❑  ± Continuous waveform capnography ❑   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 ❑  Lab measurements: ❑  ABG, A-a gradient ❑  WBC, Hgb, Hct, Platelets, Smear ❑  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 ❑  Raised jugular venous pressure ❑  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

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Treatment

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Do's

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References