Rosen & Barkin's 5-Minute Emergency Medicine Consult (229 page)

• Difficult, labored, or uncomfortable breathing
  
• Upper airway:
  
  • Stridor
    
  • Upper-airway obstruction
    
• Pulmonary:
  
  • Tachypnea
    
  • Accessory muscle use
    
  • Wheezing
    
  • Rales
    
  • Asymmetric breath sounds
    
  • Poor air movement
    
  • Prolonged expiratory phase
    
• Cardiovascular:
  
  • S3 gallop
    
  • Murmur
    
  • Jugular venous distention
    
• CNS:
  
  • Altered levels of consciousness
    
• General:
  
  • Diaphoretic/cool vs. hot/dry skin
    
  • Pallor
    
  • Upright patient position
    
  • Clubbing
    
  • Cyanosis
    
  • Edema
    
  • Ketotic breath odor
    

• Previous history of dyspnea
  
• Time course, abruptness of onset, triggers, and severity
  
• History of stridor or wheezing
  
• Exercise (activity) tolerance
  
• Medications and recent compliance
  
• Exposure to allergens
  
• Past medical history
  
• Associated symptoms:
  
  • Chest pain
    
  • Fever
    
  • Cough
    
  • Hemoptysis
    

• Signs of acute distress:
  
  • Altered mental status
    
  • Cyanosis
    
  • Respiratory rate
    
  • Retractions suggest severe disease
    
• Listen for abnormal lung sounds:
  
  • Stridor
    
  • Rales
    
  • Wheezing
    
  • Decreased breath sounds
    

• Pulse oximetry:
  
  • May be falsely elevated due to increased ventilation or carbon monoxide
    
• End tidal CO
  ₂
  :
  
  • Quickly gives hint of PaCO
    ₂
    
  • Waveform can give clue to etiology
    
• CXR:
  
  • For diagnosis of pulmonary conditions
    
  • Assess heart size and evidence of CHF
    
• ABG:
  
  • Oxygenation
    
  • Calculate arterial–alveolar gradient:
    
    • A–a (at sea level) = 150 – (PO
      ₂
      – PCO
      ₂
      )/0.8, normal 5–20
      
  • Assess degree of acidosis
    

• CBC:
  
  • Evaluation for anemia
    
  • Neutrophil count helpful in evaluation of infectious processes
    
• Electrolyte, BUN, creatinine, glucose:
  
  • Consider when specific metabolic derangements are suspected
    
  • B-type natriuretic peptide may be elevated in CHF
    
• Toxicology screen
  
• Methemoglobin/carboxyhemoglobin level
  
• Thyroid function tests
  
• D
  -dimer (ELISA):
  
  • Useful for excluding pulmonary embolus if normal
    

• Chest x-ray for infiltrate, effusion, pneumothorax, or vascular consolidation
  
• Ventilation–perfusion scan or CT pulmonary angiogram for suspected pulmonary embolism
  
• Soft tissue neck radiograph or fiberoptic visualization for suspected upper airway obstruction
  

• EKG for suspected myocardial ischemia, CHF, suspected pericardial effusion/tamponade
  
• Peak expiratory flow/spirometry to assess for reactive-airway disease
  
• Tensilon test for suspected myasthenia gravis
  

• Anticholinergic or adrenergic toxidrome
  
• Thyroid storm
  
• Munchausen syndrome
  

TREATMENT

• Place all patients on supplemental oxygen, pulse oximetry, end tidal CO
  ₂
  , and cardiac monitor.
  
• Initiate therapy for suspected cause of dyspnea when indicated:
  
  • Asthma
    
  • COPD
    
  • CHF
    
• Utilize advanced airways in the face of impending respiratory failure.
  

• ABCs
  
• Immediate intubation for impending respiratory arrest:
  
  • Altered mental status
    
  • Unstable vital signs
    
• BiPAP in alert patients:
  
  • Contraindications:
    
    • Cardiac instability
      
    • Suspicion of upper airway obstruction
      
    • Inability to protect airway
      
    • Upper GI bleeding
      
    • Status epilepticus
      

• Based on underlying etiology
  
  • Antibiotics and fluid for pneumonia
    
  • CPAP and diuretics for CHF
    
  • Bronchodilators and steroids for asthma
    
  • Aspirin, heparin, and lyrics/cath lab for MI
    
  • Other treatments as necessary for other etiologies
    
• Palliative care with opiates is indicated for the relief of dyspnea in terminally ill patients.
  

FOLLOW-UP

• Assisted ventilation
  
• Hypoxia
  
• A–a gradient >40
  
• Medical condition requiring hospital therapy
  

• Adequate oxygenation
  
• Stable medical illness that can be managed as outpatient
  
• Adequate ambulatory pulse ox
  

Based on suspected underlying etiology

• Patients should be told not to smoke while short of breath and to try to quit to help with some of the causes, as well as to prevent others from getting worse.
  
• The patient should return for any of the following problems:
  
  • No improvement or worsening in 24 hr
    
  • New chest pain, pressure, squeezing, or tightness
    
  • Shaking chills, or a fever >102°F
    
  • New or worsening cough or wheezing
    
  • Abdominal (belly) pain, vomiting, severe headache
    
  • Dizziness, confusion, or change in behavior
    
  • Any serious change in symptoms, or any new symptoms that are of concern
    

• Altered mental status is an indication for immediate airway management in a patient with severe dyspnea.
  
• Dyspnea can and should be quantified.
  
• Dyspnea and tachypnea may occur without a respiratory etiology because of metabolic derangement or a catastrophic CNS event.
  

• Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Expert Panel Report 3 guidelines for the management of asthma exacerbations.
  J Allergy Clin Immunol
  . 2009;124(2 suppl):S5–S14.
  
• De Peuter S, Van Diest I, Lemaigre V, et al. Dyspnea: The role of psychological processes.
  Clin Psychol Rev
  . 2004;24(5):557–581.
  
• Mahler DA, Selecky PA, Harrod CG, et al. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
  Chest
  . 2010;137(3):674–691.
  
• Stenton C. The MRC breathlessness scale.
  Occup Med (Lond)
  . 2008;58:226–227.
  
• Weintraub NL, Collins SP, Pang PS, et al., Acute heart failure syndromes: Emergency department presentation, treatment, and disposition: Current approaches and future aims: A scientific statement from the American Heart Association.
  Circulation
  . 2010;122:1975–1996.
  

See Also (Topic, Algorithm, Electronic Media Element)

Respiratory Distress

CODES

• 786.05 Shortness of breath
  
• 786.07 Wheezing
  
• 786.09 Other respiratory abnormalities
  

BASICS