Dyspnea

1. Dyspnea Monika Pitzele, M.D.,Ph.D. Mt. Sinai Hospital Chicago, IL

2. Dyspnea: definition • A subjective feeling of difficult, labored, or uncomfortable breathing, which patients often describe as “shortness of breath,” “breathlessness,” or “not getting enough air.”

3. Differential diagnosis of dyspnea

4. Outline • Definition • Signs of imminent respiratory failure • How to differentiate cardiac from pulmonary causes • Pneumonia • Pneumothorax • Pulmonary embolism

5. Patient in respiratory distress Use of accessory respiratory muscles Tachypnea Tachycardia Inability to speak Stridor Altered mental status Paradoxical abdominal wall movement

6. Patient in respiratory distress • Evaluate for signs and symptoms that would indicate imminent respiratory failure: worsening tachycardia and tachypnea, use of accessory muscles, stridor, decreased breath sounds, inability to speak, lethargy

7. Patient in respiratory distress • Administer oxygen • Consider non-invasive ventilation if possible (BiPap, CPAP) • Anticipate need for airway control and mechanical ventilation

8. Cardiac vs. pulmonary causes of dyspnea

9. Cardiac vs. pulmonary causes of dyspnea • Very important and very difficult step that determines further treatment • There are parts of history and physical exam as well as diagnostic findings that can facilitate process

10. Findings not very helpful in determination of the cause • Wheezing • Dyspnea on exertion • Orthopnea • Paroxysmal nocturnal dyspnea • Leg edema

11. Physical exam findings that support CHF • Overall physician’s clinical assessment • Presence of JVD • S3 gallop

12. JVD (jugular venous distention) m http://emsbasics.com/2011/10/17

13. Measurement of JVD • Patient at 45 degree angle • Measure vertical distance between a horizontal line drawn at the sternal angle and the highest point of jugular venous pulsations • Venous pulsations (to differentiate them from carotid) are not palpable and change with respiration and position

14. Extra heat sound: S3 “Lub-dub-ta” or “Slosh-ing-in” From www.darwin.unmc.edu meded.ucsd.edu/clinicalmed/heart.ht

15. S3 gallop • Occurs in the beginning of diastole • May be benign in children and occasionally in pregnancy, but its appearance later in life may signal cardiac problems such as failing LV • Best heard at the apex with patient in left lateral decubitus position • Low pitch

16. CXR findings that support diagnosis of CHF • Pulmonary venous congestion • Interstitial edema • Alveolar edema • Pleural effusion

17. Pulmonary venous congestion Normal www.radiologyassistant.nl

18. Interstitial edema www.radiologyassistant.nl

19. Interstitial edema www.radiologyassistant.nl

20. Alveolar edema www.radiologyassistant.nl

21. Pleural effusion

22. Laboratory findings in CHF BNP (B-type or brain natriuretic peptide: a 32-amino acid polypeptide secreted by the ventricular myocytes in response to stretching of the cardiac muscle medical.siemens.com

23. BNP – B-type natriuretic peptide • Cutoff of BNP<100 pg/dLor NT-proBNP 300pg/dL make acute failure syndrome unlikely • Levels between 100 and 500 picograms/mL are not useful • If BNP>500pg/dL or NT-proBNP 1,000pg/dL, acute CHF likely

24. Findings facilitating differentiation between cardiac and pulmonary causes • Overall clinical impression • JVD • S3 • CXR • BNP

25. Pneumonia

26. Pneumonia • Community acquired pneumonia (CAP) accounts for app 4mln cases and 1mln hospitalizations in US • It is the sixth leading cause of death, particularly among older adults • The incidence of pneumonia caused by atypical or opportunistic infections is increasing

27. Pneumonia classification • CAP Community-Acquired Pneumonia • HAP Hospital-Acquired Pneumonia • VAP Ventilator-Acquired Pneumonia • HCAPHealth care-Associated Pneumonia

28. Pneumonia classification

29. Pneumonia Infection of alveolar portion of the lungs nhlbi.nih.gov

30. Epidemiology of pneumonia • Epidemiology varies by geographical location and patient population • Studies done on adult CAP patients in US identified pathogens 24% of the time

31. Bacterial pathogens that cause CAP • In order of the most to less common: • Streptoccocuspneumoniae • Staphylococcus aureus • Pseudomonas aeruginosa • Haemophilusinfluenzae • Klebsiellapneumoniae

32. Other pathogens that cause CAP • Atypicals: Mycoplasma, Chlamydophila, Legionella • Viruses: influenza, rhinovirus, respiratory syncytial virus, parainfluenza, coronavirus, adenovirus, human metapneumovirus

33. Presentation of patient with pneumococcal pneumonia • Cough (79-91%) • Sudden onset of illness with fever (71-75%) • Episode of severe rigor (chills) • Dyspnea (67-75%) • Sputum (60-65%) – often blood tinged • Chest pain – pleuritic (39-49%) • Tachycardia • Tachypnea • Abnormal lung exam

34. Patients at highest risks for pneumococcal pneumonia ● Elderly ● Children <2 ● Minorities ● Children in day care ● Patients with underlying medical conditions (HIV, sickle cell) Guardian.co.uk

35. Pneumococcal pneumonia CXR Lobar infiltrate Occasionally patchy Occasional pleural effusion pneumoniacontagious.gasscam.com

36. Other bacterial pneumonias

37. Atypical pneumonia • Older children, young adults, elderly • Organisms include Mycoplasma, Legionella, Chlamydophila • Mycoplasma and Chlamydophilia cause mild subacute illness • Legionella is often complicated with GI symptoms

38. ED work-up • History and physical exam are the most accurate predictors • Patients that will be admitted may need blood count, serum electrolytes, creatinine and glucose levels • Consider ABG in patient with respiratory distress

39. Role of imaging • “In addition to constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for diagnosis of pneumonia” per American Thoracic Society Guidelines • So… order a CXR

40. Blood cultures Are routine blood cultures indicated in patients admitted with CAP?

42. Level A recommendations: None specified • Level B recommendations: Do not routinely obtain blood cultures in patients admitted with CAP • Level C recommendations: Consider obtaining blood cultures in higher-risk patients admitted with CAP (severe disease, immunocompromise, significant comorbidities, etc. )

43. American Thoracic Society Guidelines

44. Having said that…

45. From the Specifications Manual for National Hospital Quality Measures for Pneumonia Measure Set

46. Outpatient therapy • Previously healthy patient: • Macrolide (azithromycin, clarithromycin, erythromycin) (level I) • Doxycycline (level III) • Patient with comorbidities: • Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin 750mg) (level I) • Β-lactam (high dose amoxicillin, Augmentin, cephalosporin) and macrolide (level I)

47. Inpatient therapy, non-ICU • Respiratory fluoroquinolone (level I) • Β-lactam (cefotaxim, ceftriaxone, ampicillin) and macrolide (level I)

48. Inpatient therapy, ICU • Β-lactam (cefotaxime, ceftriaxone, ampicillin-sulbactam) plus either azithromycin (level II) or respiratory fluoroquinolone (level I) • For penicillin allergy: respiratory fluoroquinolone and aztreonam

49. Special concerns • Risk factors for Pseudomonas (neutropenia, hospitalization, central venous catheters, burn wounds, bronchiectasis, cystic fibrosis, HIV (+)) or community acquired MRSA – additional coverage

50. How soon to give antibiotics? • Hospital quality measures • American Thoracic Society: during the ED stay • ACEP Clinical Policy: There is insufficient evidence to establish a benefit in mortality or morbidity from antibiotics administered in less than 4,6 or 8 hours from ED arrival in adult patients with CAP without severe sepsis