A man with shortness of breath
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HKCEM College Tutorial. A Man With Shortness Of Breath. Author Dr. Lau chu leung , terry Nov., 2013. A Man With Shortness Of Breath…. Issue(s) identified ? HT Tachypnea Tachycardia DDx of SOB ? COPD CHF Asthma APO Pneumothoax Upper airway obstruction

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A Man With Shortness Of Breath

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A man with shortness of breath

HKCEM College Tutorial

A Man With Shortness Of Breath

Author

Dr. Lau chuleung, terry

Nov., 2013


A man with shortness of breath1

A Man With Shortness Of Breath…

  • Issue(s) identified?

    • HT

    • Tachypnea

    • Tachycardia

  • DDx of SOB?

    • COPD

    • CHF

    • Asthma

    • APO

    • Pneumothoax

    • Upper airway obstruction

  • Any red flags of headache?

  • M/65 Chronic smoker

  • SOB for 2 days

    • Increased when lying supine

  • Headache, facial swelling

  • BP 178/84 mmHg

  • Pulse 124 bpm

  • RR 20 /min, SpO2 97% RA

  • T - 37.3 ºC


What are your immediate management

What are your immediate management?

  • ABC - secure airway if necessary

  • Oxygen

  • Set intravenous access

  • Monitoring – BP/P, SpO2, cardiac monitor

  • While you get further history from patient, you notice…

  • What are the DDx of SOB with dilated neck veins?


A man with shortness of breath

Revise your DDx?

  • Facial Swelling

    • Nephrotic syndrome

    • Cellulitis

    • Angioedema

    • Myxedema

    • Moon face (chronic steroids)

    • Superior vena cava obstruction

    • Melkersson-Rosenthal Syndrome - orofacial edema

  • SOB + Dilated neck veins

    • Congestive heart failure

    • Right ventricular infarct

    • Superior vena cava obstruction

    • Cardiac tamponade

    • Constrictive pericarditis

    • Tension pneumothorax

    • Massive haemothorax

    • Massive pulmonary embolism


What is superior vena cava syndrome

What is Superior Vena Cava Syndrome?

  • Conglomeration of s/s that results from compression or occlusion of the SVC

    • SVC receives venous drainage from H&N, UL

    • Thin walled  extremely susceptible to extrinsic compression

  • Immediately life-threatening oncologic emergency if airway compromise or CNS symptoms are present


Svco when to suspect common causes

SVCO – When to suspect? Common causes?

  • Dilatation of the two external jugular veins

  • Increasing symptoms when the patient is in a horizontal position

  • Malignant (90%)

    • Ca bronchus

      • Small-cell lung cancer (SCLC)

      • Non-small-cell cancer (NSCLC)

    • Lymphoma

    • Metastatic disease

    • Germ-cell cancer

    • Thymoma

    • Mesothelioma

  • Benign (10%) - compression, infiltration, thrombosis

    • Indwelling central venous catheters

    • Thoracic aortic aneurysm (ascending)

    • Substernal goiter

    • Constrictive pericarditis

    • Primary thrombosis

    • Idiopathic sclerosingaortitis

    • Fibrosingmediastinitis

    • Radiation

    • Arteriosclerotic

    • Infection - TB mediastinitis, luetic(syphilitic) aneurysm, histoplasmosis


If suspected svco

If suspected SVCO….

  • Early symptoms

    • Edema of face, neck, UL

    • SOB

    • Venous distension of upper chest, neck and face

    • Ruddy complexion (Plethora)

    • Dysphagia

    • Chest pain

  • Late symptoms

    • Severe respiratory distress

    • Cyanosis

    • Headache

    • Visual disturbances

    • Coma

    • Convulsions

    • Death

  • What are the common presentations?

  • Physical signs?

    • Facial edema, plethora

    • Jugular venous distention

    • Prominent superficial vascularity

      • Neck & upper chest

    • Stokes sign – tightness of shirt collar

    • Edema of larynx or pharynx

    • Hoarseness, stridor

    • Cerebral edema, increased ICP

    • Papilledema

    • Confusion, coma


If venous dilatation over abdomen significant

If venous dilatation over abdomen…significant?


Any specific physical sign

Any specific physical sign?

  • Pemberton Sign

    • Exaggeration of edema and flushing with placement of the patient’s arms overhead

  • Indicates compression of vascular structures in the thoracic inlet

    • Highly indicative of SVCO

    • Substernalgoitre


Svco management aims

SVCO – Management Aims

  • Recognition of life-threatening symptoms - airway compromise and/or cerebral edema

  • Confirmation of the presence of venous obstruction

  • Imaging +/- interventions to establish the etiology

  • Relief obstruction

  • Treatment of the underlying cause


Svco ed management

SVCO – ED Management

  • Revise your Mx? Any precautions?

    • Propped up position

      • Elevate patient's head - hydrostatic pressure (edema)

    • Potential difficult airway

      • Cannot lie flat

      • Edematous epiglottis and vocal cords and narrowed glottic opening

      • Mediastinaltumour

      • Superior Mediastinal Syndrome – SVCO + tracheal compression


Svco intravenous access

SVCO – Intravenous Access

  • Should be considered in lower limbs in the case of complete SVC obstruction

    • With partial obstruction, upper limb access is acceptable

  • UL iv access  delays in resuscitation fluids and drugs reaching the central circulation

    • Induction time will be prolonged

    • Overdose is a potential risk

  • In the absence of major bleeding / hypotension, fluid restriction is the watchword

    • Diuretics must be used judiciously to avoid hypovolemia


Svco any role of steroid

SVCO – Any role of steroid?

  • Glucocorticoid therapy (dexamethasone, iv 4 mg Q6H)

    • Work mainly by reducing tumour and airway oedema

    • Benefits documented only in case studies

    • Generally used in conjunction with radiotherapy because of concern about radiation-induced oedema

    • Reduce tumor burden in lymphoma & thymoma  reduce obstruction

    • Risk

      • Obscuring the tissue diagnosis, especially if lymphoma is suspected

      • Steroid-induced acute tumourlysis syndrome


Svco imaging

SVCO - Imaging

  • Confirming the diagnosis of SVCO

    • Identify the site and extent of the occlusion

    • Presence of intravascular thrombus and collateral circulations

      • Presence of collateral vessels is highly suggestive of SVCO

        • Sensitivity of 96% and a specificity of 92%

  • Identify its underlying cause

  • Planning treatment

    • Information on the length of the lesion

    • Any involvement of the brachiocephalic veins


Svco cxr signs

SVCO – CXR signs

  • Signs of the development of collateral circulation

    • Opacity above the right stem bronchus  dilation of the arch of the azygos

    • Sub-aortic opacity or ‘‘aortic nipple’’ sign  dilation of the left superior intercostal vein

  • Neck mass – substernalgoitre

  • Superior mediastinal widening

  • Hilar mass - bronchogenic carcinoma

  • Anterior mediastinal mass – lymphoma

  • Calcification – Histoplasmosis

  • Pleural/pericardial effusion


Svco cxr

SVCO - CXR

  • Small-cell lung cancer


Svco ct

SVCO - CT

(a) Axial CT - Large right hilar mass obstructing SVC

Multiple chest wall collateral vessels

(b) Coronal CT - Compression of SVC distally (arrow)

Thrombosis of proximal SVC and brachiocephalic veins

(c) 3D CT - appearance of multiple collaterals of chest wall


Svco ct venogram

SVCO – CT Venogram

  • 4-cm thrombus in the SVC


Svco venogram

SVCO - Venogram

  • Invasive venography - gold standard

    • Carried out prior to stenting to delineate the presence of an SVC stenosis or occlusion, and to identify the extent of the obstruction

    • Cannot be performed in isolation, as it cannot identify the cause of the obstruction

  • Simultaneous bilateral arm venogram

    • Defines obstruction and collateral circulation

    • Identifies thrombus

    • Figure

      • severe compression of both the right and left subclavian veins (RSV and LSV)

      • a thrombus in the left subclavian vein

      • multiple venous collaterals


Kishi scoring system

Kishi Scoring System


Svc stenting

SVC stenting

  • Advantages

    • Rapid relief of the symptoms of venous congestion

      • Relief can be immediate, but in most series, it is reported within 24 to 72 hours following the procedure

    • Allowing treatment of underlying pathology to be initiated

      • Stent can be placed before a tissue diagnosis is available

      • Allows early cisplatin based chemotherapy to commence (requires hydration)

    • Prevent the risk of death due to laryngeal or bronchial oedema

  • Indications

    • Symptomatic malignant SVCO

    • Symptomatic benign SVCO

    • known chemotherapy and radiation-resistant tumors

  • No absolute contraindications to SVC stenting

  • Relative contraindications

    • Patient cannot lie flat or semisupine on the table

    • Patient with malignancy with a very good chance of cure or remission


Svc stenting1

SVC stenting

  • Complications 3-7%

    • Stent migration

    • Bleeding

    • Infection

    • Thrombosis (Figure: Reocclusion of the stent by thrombus on an (a) axial CT and (b) coronal CT)

    • SVC rupture

    • Pericardial tamponade

    • Hematoma at insertion site

    • Acute tumourlysis syndrome

    • Late complications

      • Bleeding (1-14%), death (1-2%)


Svco further management

SVCO – Further Management

  • In the absence of a need for urgent intervention, the management should focus initially on establishing the correct diagnosis

  • Treatment is directed at the underlying pathological process

  • When malignancy is suspected without known primary cancer  tissue biopsy

    • Sputum cytology

    • Pleural fluid analysis

    • Excisional LN biopsy

    • Bone marrow

    • Bronchoscopy with transbronchial needle aspiration


Svco management options

SVCO – Management Options


Svco malignancy management

SVCO (Malignancy) - Management

  • Urgent treatment with radiotherapy and corticosteroids should be used only for life-threatening situations

    • Stridor, hypotension, collapse

  • Stenting is becoming increasingly used

    • Useful procedure for patients with severe symptoms such as respiratory distress that require urgent intervention

  • No evidence to support routine anticoagulation in patients with malignant SVCO in the absence of thrombosis

  • After a tissue diagnosis has been obtained and the extent of the disease has been determined, a decision should be made to address control of the malignant process in either a curative fashion or palliatively

    • Radiation, chemotherapy, or stent placement, or a combination of these modalities


Svco malignancy chemotherapy

SVCO (Malignancy) - Chemotherapy

  • Chemotherapy responsive tumour

    • Non-Hodgkin lymphomas, small cell lung cancer, and germ cell tumors are widely regarded as chemotherapysensitive tumors

    • Good prognosis - high rates of response and quick onset of tumor shrinkage

  • Less responsive tumours - non-small cell lung cancer, B-cell lymphoma

    • Stents or RT/chemotherapy


Svco malignancy radiotherapy

SVCO (Malignancy) - Radiotherapy

  • Relative contraindications

    • Previous treatment with radiation in the same region

    • Certain connective tissue disorders - scleroderma

    • Known radioresistant tumor types – sarcoma

  • Majority of tumor types are sensitive

  • Improvement is often apparent within 72 hours


Svco malignancy surgical management

SVCO (Malignancy) – Surgical Management

  • Thymomas are relatively resistant to chemotherapy and radiation  Surgery

    • Bypass grafting using an autologous vein graft or a synthetic tube

  • Good patency rates (80–90%)

  • Major surgical procedure that requires careful patient selection

  • High morbidity and 5% mortality rate


Svco benign management

SVCO (Benign) - Management

  • More insidious course  development of adequate collaterals

  • Treatment is usually directed at the underlying cause

  • Medical management with diuretics and steroids  NOT useful

  • If symptoms caused by thrombus formation

    • Thrombolysis followed by anticoagulation with heparin or warfarin

    • Less effective in chronic thrombosis (with onset of symptoms more than 10 days previously)

  • If symptoms develop rapidly

    • SVC bypass surgery

    • Endovascular stenting


Svco iatrogenic thrombotic

SVCO – Iatrogenic / thrombotic

  • Result from indwelling vascular hardware

  • No evidence that removing the catheter in the ED provides any benefit

  • Anticoagulation

  • Percutaneous transluminal angioplasty +/- metallic stent

  • SVCO may coexist with pulmonary embolism


A man with shortness of breath

SVCO - Complications

  • Superior mediastinal syndrome

  • Rubin Syndrome – SVCO + spinal cord compression

  • Steroid-induced acute tumourlysis syndrome

  • ‘‘Overload syndrome’’

    • Opening of a SVC stenosis inducing a fast cardiac return of the third compartment (oedema) may generate an ‘‘overload syndrome’’ with pre-capillary pulmonary hypertension and pulmonary oedema

  • Increased intracranial pressure

  • Spontaneous intracranial hemorrhage


References

References

  • Postgrad Med J 2013;89(1050):224–30

  • Journal of Clinical Neuroscience 2013;20:1040–1

  • Q J Med 2013;106:283–4

  • Rosen’s Emergency Medicine 8th ed.

  • Journal of Emergency Medicine 2012;43(6):1079–80

  • South Afr J AnaesthAnalg 2012;18(1):20-4

  • BMJ 2011;343:d4466

  • Visual Diagnosis in Emergency and Critical Care Medicine (2011)

  • Ann Emerg Med. 2010;56:305

  • Emerg Med Clin N Am 2009;27:243–55

  • Irwin and Rippe’s Intensive Care Medicine (2008)

  • NEJM 2007;356(18):1862-9

  • Critical Care – Just the facts (2007)

  • NEJM 2006;354 (8): e7

  • Can J Emerg Med 2005;7(4):273-7


The end

The end


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