CRANA Remote Emergency Care Programme

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The Short of Breath Patient
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Outline

• Differential Diagnosis
• Assessment
• Investigations
• Management
• Specific Treatments
• Summary

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Causes ?
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Differential Diagnosis

• Asthma / COAD
• Pulmonary oedema
• Pulmonary embolism
• Pneumonia / chest infection
• Pneumothorax
• Chest trauma
• NON-respiratory disease (DKA!!!)

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Assessment

• Look
• Resp Rate, effort and symmetry
• Colour
• Listen
• Breath Sounds
• Feel
• Trachea
• Pulse

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Assessment

• Past History
• Previous episodes, medications?
• Current Episode
• Precipitants, rapidity of onset?
• Associated symptoms?
• Initial treatment and response?

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Examination

• Primary survey / ABCs
• Resuscitation
• Oxygen, oxygen, oxygen
• Secondary survey
• Definitive treatment

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Look at the Patient

• Look at the patient from a distance
• Posture, speech
• Air hunger
• Anxiety / conscious state
• Pain limiting movement
• Look at the chest from a distance
• Respiratory rate
• Even movement
• Flail segments
• Retractions or tracheal tug

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Listen to the Patient

• Speech
• Stridor or Wheeze
• Absent breath sounds?
• Crepitations or crackles
• Rubs

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Touch the Patient

• Trachea Midline?
• Fractured Ribs?
• Surgical Emphysema?
• Pulse rate, BP, paradox?

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Respiratory Distress

• How bad are they?
• How do you know?
• What do you look for?

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Respiratory Distress Mild Mod. Severe
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Investigations

• Peak Flow
• Monitor trends and response
• Counting test if no PEFR meter (20)
• Pulse oximetry
• ECG
• AMI
• PE

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Investigations

• Blood gases
• Oxygenation and ventilation
• Acid base status
• Chest x-ray
• Utilise early if available
• Often provides diagnosis
• Full blood Count
• Anaemia
• Infection

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Investigations

• UE
• BNP
• Cardiac Markers
• CKMB
• Myoglobin
• Troponin 1

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Investigations

• Capnography
• Look at the patient!
• The tiring patient has an increasing CO2
• They develop
• A far away look
• Eyes roll back
• Sweat
• Not answering questions any more
• Quicker than blood gases

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Respiratory Distress Mild Mod.
Severe
Beware the hypoxic patient with normal CO2!!!
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Treatment
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Non-Oxygen Therapy?

• Reassurance and explanation
• Better airway if required
• Better posture On side, sitting up
• Antidotes...drug induced problem?
• Not loss of Hypoxic drive?
• Specific therapy for diagnosis

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Oxygen

• Hypoxia due to numerous causes
• Not all primarily lung related!!
• Impairs function of all organs
• Brain, heart, kidneys, lungs
• Hypoxia leads to restlessness!!!!
• (Sedation is not a Rx for hypoxia!)
• Oxygen can be life saving
• DONT withhold if hypoxic

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Oxygen Toxicity

• Many toxicities
• Primary problem is loss of hypoxic drive
• Balance between hypoxia and hypercapnia!!
• Consider patients normal hypoxia

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Oxygen Therapy

• Intranasal O2 prongs
• Maximum 2 lit/min
• Provides about 24 O2
• Hudson type mask
• Minimum 6 lit/min
• Prevents any CO2 retention

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Oxygen Therapy

• Venturitype mask
• More accurate O2 delivered

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Respiratory Support

• CPAP
• Continuous Positive Airway Pressure
• Recruits collapsed alveoli
• Useful in pulmonary oedema especially
• Pseudo-CPAP with bag and mask

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Respiratory Support

• Intubation and Ventilation
• The ultimate control in respiratory failure

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Case 1.

• 70 year old male
• History of IHD
• Acute SOB, sweaty, chest pain
• Tachycardia, tachypnoea
• Difficulty talking, altered mentation
• Creps to midzones
• Pink frothy sputum

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What is wrong?

• Acute pulmonary oedema..
• Whats the treatment?

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Acute Pulmonary Oedema

• Sit upright
• High flow Oxygen
• IV Frusemide 1mg/kg
• Vasodilators GTN infusion
• CPAP
• Treat the precipitant
• M.I.
• Arrythmia

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Case 2.

• 45 year old female smoker
• Sharp left sided chest pain
• Fevers, sweats and rigors
• Yellow sputum
• Tachycardiac, tachypnoea
• Hypotensive
• Coarse creps and bronchial breathing

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Whats the likely diagnosis

• Infection, ?? pneumonia.
• Whats the treatment

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Pneumonia

• Oxygen
• IV antibiotics ASAP
• IV Augmentin 1.2gms
• IV Klacid 500mgs
• Cultures if possible
• But dont allow to delay antibiotics!
• Physiotherapy
• Posture
• Bronchodilators (Salbutamol 5mgs Nebuliser)

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Case 3.

• 60 year old male smoker
• Increasing SOB 2 hours
• Tachycardia, tachypnoea
• Pale, sweaty
• No creps, no wheezes
• No air entry detectable!!!!

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Whats the diagnosis?

• COAD / asthma / emphysema
• Whats the treatment?

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Asthma / COAD

• Reassurance
• Oxygen
• Continuous salbutamol nebs 5mgs /- 500mcgs
  Atrovent
• IV steroids Hydrocortisone 200mgs I.V.
• Aminophylline infusion (little/no data to support
  usage)
• Consider Magnesium infusion
• Cosider Salbutamol infusion?

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Case 4

• 26 year old man
• Sudden onset right sided chest pain
• Shortness of breath at rest
• Difficulty talking
• Tachycardia, Hypotensive, Hypoxic

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Pneumothorax

• Tension pneumothorax
• Respiratory distress
• Asymmetrical chest movement / sounds
• Tracheal deviation
• Mediastinal shift
• Distended neck veins
• Cardiovascular collapse

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Needle Thoracostomy

• Temporary measure
• Wide bore cannula
• 2nd interspace, MCL
• Remove sylet, leave cannula in
• Prepare for definitive ICC

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Case 5

• 53 year old woman
• Cigarette smoker
• Hx of Ovarian Carcinoma
• Sudden onset shortness of breath
• Asociated chest pain
• Palpitations

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Whats the diagnosis ?

• Pulmonary embolus

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Treatment

• High flow 02
• Low Molecular weight Heparin (Clexane 1mg/kg)
• Warfarin 10 mgs
• Consider thrombolysis
• Consider embolectomy
• /- inotropic support

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Questions

• ?

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Summary

• Past history helpful
• Severity can be assessed at the bedside
• Dont forget to examine the chest

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Summary

• Therapy may have to start before the diagnosis is
  confirmed
• Give complete Rx more than just oxygen

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Croup

• Steroids standard care
• Route of administration not
• Inhaled, oral or parenteral
• Adrenaline Neb (11000) 5mg in 5ml
• Intubation rarely

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Open Pneumothorax

• Sucking chest wound
• Close the wound!!
• Seal with opsite, dressing etc.
• Intercostal catheter

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Chest Trauma

• Penetrating trauma
• Lung, cardiac, vascular, GIT injuries
• Abdominal injuries too!
• Blunt trauma
• Dont need to break ribs etc
• Pulmonary contusion
• Aspiration