1. David Carlbom, MD Martin Makela, MD
EM Clerkship: Dyspnea
David Carlbom, MD
Martin Makela, MD vs

2. Objectives Discuss approach to patient with dyspnea
Review differential diagnosis
Develop an understanding of the diagnosis and management of common and serious causes of dyspnea

3. Background Dyspnea: An uncomfortable sensation of breathlessness
Among the most common complaints of patients presenting to ED
May indicate a variety of underlying diseases, from non-urgent to life threatening
Dyspnea is both subjective and objective. Often also defined as shortness of breath, tightness, or difficulty breathing. May occur independently or in association with cough.
Like pain response, dyspnea is individualized and situationally dependent.

4. General Approach
Approach all patients with dyspnea as having a serious cause until proven otherwise
H&P, diagnostic testing and treatment should proceed in parallel given range of possible conditions
Immediate visualization and rapid evaluation
Stabilize and treat prior to full evaluation

5. Diag. Treat Primary Survey Working Dx Life-Saving Therapy Dx Plan
Definitive Therapy
Diagnosis and treatment often occur in parallel for patients with acute dyspnea

6. General Approach Primary Survey: ABCs & Vital Signs
Correct & support life-threatening issues
IV access, O2, Monitor
ECG
Lab
Electrolytes, CBC, Cardiac enzymes
Possibly D-dimer, BNP, ABG
CXR
Peak Flow if asthma or COPD

7. History Onset Associated symptoms Aggravating/Alleviating factors
Fever, cough, chest pain, edema, hives
Aggravating/Alleviating factors
Similarity to prior episodes
PMH
Medications

8. Physical exam Vitals General appearance/color
Assess for respiratory distress
Accessory muscle use/retractions
Ability to speak full sentences (or not)
Lungs
Heart
Extremities
Abdomen
VS: look for fever, tachypnea, hypoxia
Gen: Positioning, level of comfort, fatigue, diaphoresis
Lungs: Look, listen and feel. Discuss findings in CHF, asthma, PNA, effusion, etc.
Extremities: ?edema
Abdomen: Ascites, pregnancy

9. Differential Diagnosis
What are serious causes of dyspnea? PE
PNA
CHF
ACS
Asthma/COPD
Anaphylaxis
Pneumothorax/hemothorax
Arrhythmia
Airway obstruction

10. Differential Diagnosis
What are other causes of dyspnea?
Anxiety
Anemia
URI
Pericarditis
Pleural effusion
Abdominal distention
Ascites
Pregnancy
Aspiration/chemical exposure
Acidosis
Neuromuscular weakness

11. Case 1 ACTIONS? 35yo F with h/o asthma c/o SOB
No relief from repeated albuterol use
VS / %RA
Appears uncomfortable, speaking 3 word sentences
Lungs with diffuse expiratory wheeze
Remainder of exam normal
ACTIONS?

12. Initial Management ABCs IV, O2, monitor, full VS CXR? Medications
Steroids (IV vs. PO)
Inhaled beta agonist and ipratropium
Magnesium if severe exacerbation
Antibiotics if infection

13. Case 1: Course CXR clear Patient receives steroids and 3 nebs
On reexamination, patient still in moderate distress, states “I am (gasp) getting a bit (gasp) tired, Doc (gasp)!”
PMH: 3 intubations for asthma
ACTIONS?

14. Acute Asthma/COPD Exacerbation
Indications for Admission
Incomplete response after initial ED therapy
Failed road test (hypoxia with ambulation)
Indications for Intubation
Respiratory failure
Altered mental status
Patient fatigue after aggressive therapy
Clinical decision more than a laboratory decision

15. Case 2 ACTIONS? 58yo F presents c/o sudden onset SOB
+lightheaded, denies CP, denies cough or fever
PMH: DM, depression/anxiety
Meds: Metformin, tylenol, zoloft, premarin
All: ASA
SH: +tob, -ETOH
FH: DM
ACTIONS?

16. Initial Management ABCs IV, O2, monitor, full VS EKG pCXR Labs:
CBC, M7, Coags, Cardiac enzymes

17. Case 2
VS / %RA
Gen: Alert, obese female, slightly uncomfortable
Lungs: CTAB
Heart: Tachy, regular, no murmur
Legs: Trace edema bilaterally, L>R
Remainder of exam normal

18. Case 2
Normal CXR

19. Case 2
S1Q3T3—rarely present with PE but associated with the right ventricular strain of PE
You should order a CT chest now
ACTIONS? What next?

20. There’s the answer

21. Pulmonary Embolism 650,000 cases/year in the U.S. Mortality
2-12% if diagnosed and treated
30% if undiagnosed
LE DVT is source in 80-90% of cases
Risk factors
Hormone use, malignancy, immobilization, recent surgery, smoking, peripartum/pregnancy
More than perhaps any other single disease, an accurate determination of PE is a challenging combination of History, Physical exam, Lab and Radiographic findings. No single test is perfect.
Initial determination of Low versus High Risk made by “Well’s Score”

22. PE Diagnosis History: Lab: Radiology: Pleuritic chest pain (49%)
Dyspnea (82%)
Tachypnea
Tachycardia (44%)
Lab:
A negative D-Dimer in a low risk patient may r/o PE
D-dimer not helpful if pre-test probability moderate to high (or if risk is very low per PERC rules)*
Radiology:
CXR often normal
CTA Chest test of choice for diagnosis
Chest Xray can find alternate other diagnoses.
Hampton’s hump
Westermark’s sign
*PERC rules: Age<50, HR<100, no hormone therapy, no history of DVT/PE, no recent surgeries or immobilization, O2>94%, no clinical sx suggesting DVT, no hemoptysis
If you meet all of these criteria, then very low risk of PE, consider not even sending d-dimer. J Thromb Haemost 2008; 6:
Hampton’s hump: pleura based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface.
Westermark’s sign: represents a focus of oligemia (vasoconstriction) seen distal to a pulmonary embolus (PE).[1] While the chest x-ray is abnormal in the majority of PE cases, the Westermark sign is seen in only 2% of patients.
Chest CT Angiogram
Sensitive, becoming gold standard
Miss small, sub segmental PE: ?clinical significant?
V/Q scan
No contrast required
Better for chronic VTE disease
Duplex Ultrasound of lower extremities
Best choice in pregnancy
Helpful if DVT found
McGee, S. Evidence Based Physical Diagnosis WB Saunders Company. Philadelphia, PA.

23. PE Therapy Heparin (UF or LMWH), transition to warfarin
Standard of care is hospitalization (for now…)
Thrombolytics, acute surgical or interventional radiologic intervention if in extremis (shock & impending death).

24. Case 3 65yo M presents c/o progressive SOB
+dyspnea on exertion, feeling fatigued, abdominal distention
PMH: HTN, CAD s/p stents x 2
Meds: ASA, Atenolol
All: latex
SH: +tob, +ETOH (social), occ cocaine
FH: CVA
ACTIONS?

25. Initial Management ABCs IV, O2, monitor, full VS EKG pCXR Labs:
CBC, M7, Coags, Cardiac enzymes, BNP

26. Case 3
VS / %RA
Gen: Alert, obese male, sitting forward, uncomfortable
Lungs: symmetric crackles B, ½ way up
Heart: Tachy, regular, no murmur, +S4
Legs: 2+ edema bilaterally
Abd: Obese, mild distention, nontender
EKG sinus tachy, no ST changes

27. Case 3

28. CHF: Diagnostics Labs B-type natriuretic peptide CXR* EKG*
CBC, C7, coags, troponin, BNP
B-type natriuretic peptide
<100 ng/dL Good NPV
Most helpful relative to patient’s baseline
Can be elevated in: PNA, PE, pulm HTN
CXR*
EKG*
CXR to r/o other causes, PNA, etc. and to rule in edema
EKG to r/o ischemia, assess for changes vs. baseline, evaluate rhythm

29. CHF: Treatment Reduce Preload Reduce Afterload
Venodilators (NTG): increase venous capacity
Diuretics: eliminate excess plasma volume
Reduce Afterload
Control BP (NTG): lowers LV work
Positive Pressure ventilation if in extremis
Improve Contractility if in shock
Dobutamine

30. Case 4 77yo M presents c/o progressive SOB
+dyspnea on exertion, feeling fatigued. Denies CP
PMH: Denies any. No doctor for 20 years.
Meds: ASA “my daughter makes me”
All: NKDA
SH: -tob, +ETOH (social)
FH: parents lived to their 90s
ACTIONS?

31. Initial Management ABCs IV, O2, monitor, full VS EKG CXR Labs:
CBC, M7, Coags, Cardiac enzymes, BNP

32. Case 4
VS /68 96%RA
Gen: Alert, thin elderly gentleman, NAD
Lungs: CTAB
Heart: Tachy, regular, II/VI sys murmur
Legs: No edema
Abd: Soft, flat, mild epigastric TTP, no r/g
EKG sinus tachy, no ST changes

33. Case 4
Normal CXR

34. Case 4
Sinus tachycardia

35. Case 4
What is your differential diagnosis now?

36. Case 4 Labs Return to your patient Troponin, C7, BNP all normal
Charge nurse comes to inform you of a critical value
HCT=18
Return to your patient
Detailed ROS reveals dark tarry stools x 3 days
Rectal exam reveals melena
Aha! A non-lung cause of dyspnea
You treat your patient for his GI bleeding anemia

37. Dyspnea
Approach all patients with dyspnea as having a serious cause until proven otherwise
H&P, diagnostic testing and treatment should proceed in parallel given range of possible conditions