Acute dyspnea: Difference between revisions

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==Workup==
{{Adult top}} [[acute dyspnea (peds)]].''
# CXR
==Background==
# ECG
# CBC
# Chem-7
# BNP?
# D-dimer?
# Troponin?
# ABG?


==Diagnosis==
==Clinical Features==
===Emergent Pattern Recognition===
===Emergent Pattern Recognition===
#Pulmonary edema
{| class="wikitable"
#*lungs: b/l rales
| align="center" style="background:#f0f0f0;"|'''Diagnosis'''
#*CXR: interstitial fluid
| align="center" style="background:#f0f0f0;"|'''Lungs'''
#*Tx: ECG (R/O AMI), lasix, nitrates, ACE, BIPAP
| align="center" style="background:#f0f0f0;"|'''[[CXR]]'''
#Bronchoconstriction
| align="center" style="background:#f0f0f0;"|'''[[ECG]]'''
#*lungs: wheezes
| align="center" style="background:#f0f0f0;"|'''Treatment'''
#*CXR: neg/hyperinflated
| align="center" style="background:#f0f0f0;"|'''Contraindicated'''
#*Tx: albuterol, atrovent, steroids, consider anaphylaxis (epi)
|-
#[[Pneumonia]]
| [[Pulmonary Edema]]||Bilateral rales||Interstitial fluid||Normal/abnormal||R/O AMI, [[lasix]], nitrates, [[ACEi]], [[BiPAP]]||[[IVF]]; ?[[albuterol]]; ?[[Beta-blockers]]
#*lungs: focal ronchi/dec BS
|-
#*CXR: infiltrate/effusion
| [[Bronchoconstriction]]||Wheezes||Clear/hyperinflated||Normal/pulmonary strain||Albuterol, atrovent, steroids, consider anaphylaxis (epi)||Beta-blockers; ?aspirin
#*Tx: abx
|-
#[[PE]]
| [[Pneumonia]]||Focal ronchi/decreased breath sounds||Infiltrate/effusion||Normal||[[IVF]], [[antibiotics]]||Rate control; diuresis
#*lungs: clear
|-
#*CXR: clear/Westrmrk/Hmptn
| [[Pulmonary embolism]]||Clear||Clear (most) or Westrmark/Hampton hump||Normal/S1Q3T3||Anticoagulate/[[thrombolytics]]||Rate control
#*Tx: ECG, D-dimer and/or CT; anticoagulate/thrombolytics
|-
#[[Pneumothorax]]/Hemothorax
| [[Pneumothorax]]/[[Hemothorax]]||Unequal||Pneumo/hemo||Normal||Needle [[thoracentesis]]/[[chest tube]]||Rate control
#*lungs: unequal
|-
#*CXR: pneumo/hemo
| [[Dysrythmia]]||Clear/pulmonary edema||Clear/pulmonary edema||Abnormal||Type dependent||[[Albuterol]]; ?[[IVF]]
#*Tx: needle/chest-tube
|-
#[[Dysrythmia]]
| [[ACS]]||Clear/pulmonary edema||Clear/pulmonary edema||Normal/abnormal||[[Aspirin]]; nitrates, anticoagulation, ?[[beta-blockers]], +/- [[thrombolytics]]||[[Albuterol]]; ?[[IVF]]
#*lungs: clear/pulm edema
|}
#*CXR: clear/pulm edema
#*ECG: abnl
#*Tx: rate dependent
#Cardiac Ischemia
#*lungs: clear/pulm edema
#*CXR: clear/pulm edema
#*ECG: nl/abnl
#*Tx: B-block, nitrates, anticoag, +/- thrombolytics


==DDX==
==Differential Diagnosis==
'''EMERGENT'''
{{SOB DDX}}
*Pulmonary
*#Airway obstruction
*#[[PE]]
*#Noncardiogenic edema
*#[[Anaphylaxis]]
*#Spont [[pneumothorax]]
*#[[Asthma]]
*#Cor pulmonale
*#Aspiration
*#[[PNA]]
*Cardiac
*#[[Pulmonary Edema]] ([[CHF]])
*#[[MI]]
*#[[Cardiac Tamponade]]
*#[[Pericarditis]]
*Other Associated with Nl/Increased Resp Effort
*#[[Toxic Ingestion]]
*#[[DKA]]
*#[[Epiglotitis]]
*#Tension [[PNTX]]
*#[[Cardiac Tamponade]]
*#[[Flail Cchest]]
*#[[CO Poisoning]]
*#Abd distension
*#[[Sepsis]]
*#[[Hypotension]]
*#[[Renal Failure]]
*#[[Electrolyte Abnormality]]
*#[[Metabolic Acidosis]]
*#[[PNA]]
*#[[Pneumothorax]]/hemothorax
*#Diaphragmatic rupture
*#[[Anemia]]
*Other Associated with Decreased Resp Effort
*#[[CVA]]
*#[[Organophosphate Poisoning]]
*#MS
*#[[Guillian-Barre]]
*#Tick paralysis


'''Non-Emergent'''
==Evaluation==
#Pleural effusion
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]]
#Neoplam
*[[CXR]]
#[[PNA]]
*[[ECG]]
#[[COPD]]
*CBC
#[[Congenital Heart Disease]]
*Chem-7
#Pregnancy
*[[BNP]]?
#Ascites
*[[D-dimer]]?
#Obesity
*[[Troponin]]?
#Hypterventilation
*[[ABG]]?
#Panic attack
*Bedside [[ultrasound]]?
#[[Fever]]
#[[Thyroid Disease]]
#Rib fx
#ALS
#Polymyositis
#Porphyria


==Source==
{{BLUE Protocol}}
*Rosen


[[Category:Cards]]
==Management==
[[Category:Pulm]]
*Oxygen
*Treat underlying cause
 
==Disposition==
 
==See Also==
*[[Hypoxemia]]
*[[Shortness of breath (peds)]]
 
==Video==
{{#widget:YouTube|id=O2-TFCkSN8E}}
 
 
==References==
<References/>
 
[[Category:Cardiology]]
[[Category:Pulmonary]]
[[Category:Symptoms]]

Revision as of 16:09, 1 July 2020

This page is for adult patients. For pediatric patients, see: acute dyspnea (peds).

Background

Clinical Features

Emergent Pattern Recognition

Diagnosis Lungs CXR ECG Treatment Contraindicated
Pulmonary Edema Bilateral rales Interstitial fluid Normal/abnormal R/O AMI, lasix, nitrates, ACEi, BiPAP IVF; ?albuterol; ?Beta-blockers
Bronchoconstriction Wheezes Clear/hyperinflated Normal/pulmonary strain Albuterol, atrovent, steroids, consider anaphylaxis (epi) Beta-blockers; ?aspirin
Pneumonia Focal ronchi/decreased breath sounds Infiltrate/effusion Normal IVF, antibiotics Rate control; diuresis
Pulmonary embolism Clear Clear (most) or Westrmark/Hampton hump Normal/S1Q3T3 Anticoagulate/thrombolytics Rate control
Pneumothorax/Hemothorax Unequal Pneumo/hemo Normal Needle thoracentesis/chest tube Rate control
Dysrythmia Clear/pulmonary edema Clear/pulmonary edema Abnormal Type dependent Albuterol; ?IVF
ACS Clear/pulmonary edema Clear/pulmonary edema Normal/abnormal Aspirin; nitrates, anticoagulation, ?beta-blockers, +/- thrombolytics Albuterol; ?IVF

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Evaluation

Pulmonary edema with small pleural effusions on both sides.

Bedside Lung Ultrasound in Emergency (BLUE) Protocol[1]

Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea
  • Landmark study by a French intensivist that described various profiles of specific pulmonary disease found on US[2]
  • Ultrasound approaches include anterior zones and PLAPS (posterior or lateral alveolar and/or pleural syndrome) point, which is located at the posterior axillary line similar to FAST view
  • Predominant A lines anteriorly + lung sliding = Asthma/COPD
  • Multiple predominant B lines anteriorly + lung sliding = Pulmonary Edema
  • Predominant A lines anteriorly + lung sliding + positive DVT = PE
  • Absent anterior lung sliding + anterior A lines + positive lung point = Pneumothorax (PTX)
  • PLAPS findings +/- A or B lines +/- abolished lung sliding = Pneumonia
    • PLAPS describes changes at the PLAPS point, usually related to consolidations and pleural effusions[3]
    • Consolidations may include lung hepatization, shred sign, air bronchograms
      • Note that mirroring (normal) may appear similar to hepatization, but mirroring only shows in specific spots due to specific echogenic windows
    • Pleural effusions are visualized as anechoic/hypoechoic areas with possible spine sign or floating lung sign (sinusoid sign on M-mode)
  • A suggested BLUE protocol guides diagnosis of dyspnea; this should be modified as needed based on clinical presentation
    • Check lung sliding in anterior lung fields ---> check for A and B lines ---> check for PLAPS findings

Management

  • Oxygen
  • Treat underlying cause

Disposition

See Also

Video

{{#widget:YouTube|id=O2-TFCkSN8E}}


References

  1. ↑ http://ccm.anest.ufl.edu/files/2012/08/BLUELung.pdf Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure - The BLUE Protocol
  2. ↑ Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25. doi: 10.1378/chest.07-2800. Epub 2008 Apr 10. Erratum in: Chest. 2013 Aug;144(2):721. PMID: 18403664; PMCID: PMC3734893.
  3. ↑ Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014 Jan 9;4(1):1. doi: 10.1186/2110-5820-4-1. PMID: 24401163; PMCID: PMC3895677.
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