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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

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?
slide4

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
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
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 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
slide31

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
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