1. The patient with shortness of breath

2. Differential diagnosis Asthma Asthma COPD COPD Pneumonia Pneumonia Heart failure Heart failure PE PE Other Other

3. Asthma assessment Symptom/signMildModerateSevere Breath sounds, wheeze ExpiratoryVariableInsp/expMod-loudVariable/“silent” Sats>94%<90% Resp rate <20>30 Speaks in sentencesBarely/words PEFR>60%<40% Pulse<100>120 Exhaustionyes Accessory muscles Yes Yes, paradoxical Level of consciousness decreased ABGyes

4. Asthma… pertinent negatives and positives Fever, green sputum, pleuritic pain (?CXR?antibiotics)? Fever, green sputum, pleuritic pain (?CXR?antibiotics)? On oral steroids already? On oral steroids already? ICU admissions in the past? ICU admissions in the past? Social situation, time of day? Social situation, time of day? (Is this asthma)? (Is this asthma)? (smoking)? (smoking)?

5. Asthma management Steroids Steroids Beta agonist (+ipratropium bromide (atrovent)) Beta agonist (+ipratropium bromide (atrovent)) Oxygen Oxygen The kitchen sink The kitchen sink Review frequently (at least hourly) Review frequently (at least hourly)

6. Asthma management Prednisone 40 mg 5 days PO Prednisone 40 mg 5 days PO (Hydrocortisone 200mg iv if unable to tolerate PO) (Hydrocortisone 200mg iv if unable to tolerate PO)

7. Asthma management Salbutamol Salbutamol Nebs 5mg Nebs 5mg Inhaler (100µg) via spacer 8 puffs Inhaler (100µg) via spacer 8 puffs A suggested approach for moderate severity A suggested approach for moderate severity 5mg salbutamol neb q 20mins x3. 5mg salbutamol neb q 20mins x3. Then, if required, 5mg q30mins x2 Then, if required, 5mg q30mins x2 Then, if required, 5mg q60mins x1 Then, if required, 5mg q60mins x1 R/V hourly (pre neb) R/V hourly (pre neb) PEFR, RR, Sats, breath sounds PEFR, RR, Sats, breath sounds @ 3 hours from start…decide…admit / discharge / a bit longer… @ 3 hours from start…decide…admit / discharge / a bit longer…

8. Asthma management Ipratropium bromide Ipratropium bromide O.5mg nebs, q 20 mins x3 O.5mg nebs, q 20 mins x3 Oxygen to get sats >93% Oxygen to get sats >93%

9. Asthma management The kitchen sink includes, in Resus The kitchen sink includes, in Resus continuous neb salbutamol continuous neb salbutamol magnesium iv, magnesium iv, salbutamol iv bolus+infusion, salbutamol iv bolus+infusion, iv aminophylline, iv aminophylline, NIV/intubation NIV/intubation

10. Asthma Who can go home? Who can go home? Well patients Well patients those with mild severity a reasonable time after last treatment those with mild severity a reasonable time after last treatment Varies between patients, eg initial severity and response to therapy Varies between patients, eg initial severity and response to therapy Those who require less than 2/24 salbutamol Those who require less than 2/24 salbutamol PEFR >75% of best/predicted 2 hours after initial Rx PEFR >75% of best/predicted 2 hours after initial Rx BUT!!!! BUT!!!! Social situation, time of day, prior asthma history, etc Social situation, time of day, prior asthma history, etc ASK for a senior opinion ASK for a senior opinion

11. Asthma discharge Instructions Instructions Meds Meds prednisone, prednisone, salbutamol (technique) salbutamol (technique) when to return when to return increasing severity increasing severity Increasing salbutamol use Increasing salbutamol use “More concerned” “More concerned” follow up with GP follow up with GP depends on the patient depends on the patient Not improving >24 hours Not improving >24 hours

12. Pneumonia Assessment (diagnosis and severity) Assessment (diagnosis and severity) Hx Hx Exam (OBS!!!) Exam (OBS!!!) Ancillary (CXR, Bloods, ECG) Ancillary (CXR, Bloods, ECG) CURB65 CURB65 Sick, not sick? Sick, not sick? Based on patient factors, obs, clinical findings, results of investigations, gestalt Based on patient factors, obs, clinical findings, results of investigations, gestalt

13. Pneumonia Management Management General General iv fluids, iv fluids, oxygen, oxygen, antipyretics antipyretics Specific Specific antibiotics antibiotics Disposition Disposition sick/not sick? sick/not sick? CURB65 CURB65

14. Pneumonia Antibiotics (RMO handbook) Outpatient Outpatient “risk factors” “risk factors” Yes : augmentin + macrolide/doxycycline Yes : augmentin + macrolide/doxycycline No : macrolide or doxycycline No : macrolide or doxycycline Inpatient Inpatient Iv augmentin/cefuroxime + macrolide/doxycycline Iv augmentin/cefuroxime + macrolide/doxycycline

15. PE Should be considered when it is either Should be considered when it is either very obvious, or very obvious, or nothing else fits nothing else fits Wells criteria … Wells criteria … Do not order a d-dimer until you have thought long and hard about it! You must have other investigations back first. Do not order a d-dimer until you have thought long and hard about it! You must have other investigations back first. Discuss with your senior before the d-dimer Discuss with your senior before the d-dimer

16. PE PERC Rule for Pulmonary Embolism Age < 50? Yes HR < 100? Yes O2 Sat on Room Air >94%? Yes No Prior History of DVT/PE? Yes No Recent Trauma or Surgery? Yes No Hemoptysis? Yes No Exogenous Estrogen? Yes No Clinical Signs Suggesting DVT? Yes According to the PERC Study, there is less than 2% risk of PE in this patient. The PERC rule only applies if all 8 criteria are met.

17. COPD management…oxygen “CO2 retainer”…use hypoxia for respiratory drive “CO2 retainer”…use hypoxia for respiratory drive Not common, not rare Not common, not rare Assess… Assess… old notes/gas results/patient LOC/VBG/ABG old notes/gas results/patient LOC/VBG/ABG If there is respiratory acidosis, there is some degree of acute respiratory failure. If there is respiratory acidosis, there is some degree of acute respiratory failure. If there is elevated CO2 but no/minimal acidosis, there is a degree of chronic compensation (HCO3 elevated) If there is elevated CO2 but no/minimal acidosis, there is a degree of chronic compensation (HCO3 elevated) Acute on chronic respiratory failure is often found Acute on chronic respiratory failure is often found Use venturi mask to titrate oxygen to maintain sats >88% Use venturi mask to titrate oxygen to maintain sats >88%

18. COPD exacerbation Management Management General : oxygen, iv fluids, antipyretics General : oxygen, iv fluids, antipyretics Specific : Specific : salbutamol, salbutamol, ipratropium, ipratropium, antibiotics, antibiotics, steroids, steroids, NIV NIV Disposition : usually admit Disposition : usually admit

19. Heart failure Assessment Assessment Hx Hx Exam Exam Ancillary : CXR, ECG, BNP (last resort when, despite thorough assessment, cause of SOB uncertain. Used to EXCLUDE CCF) Ancillary : CXR, ECG, BNP (last resort when, despite thorough assessment, cause of SOB uncertain. Used to EXCLUDE CCF) Management Management General : oxygen General : oxygen Specific : diuretics Specific : diuretics Disposition : usually admit Disposition : usually admit