Severe dyspnea:

diagnosis,assessment,
treatment

Elisabeta Badila
Emergency Hospital of Bucharest
What is dyspnea?
shortness of breath;
ai hu ge
subjective symptom
of breathlessness;
normal in heavy
exertion;
pathological if it occurs
in unexpected situations.
Dyspnea is a symptom,
not a disease !
 There is no one specific cause of dyspnea
and no single specific treatment!
Differential Diagnosis
Composed of 4 general categories:
Cardiac
Pulmonary
Mixed cardiac and pulmonary
Non-cardiac or non-pulmonary
Metabolic
Hematologic
Psychogenic
Causes of acute dyspnea
Cardiovascular system
Acute myocardial ischemia/ACS
Heart failure/pulmonary edema
Cardiac tamponade
Respiratory system
Bronchospasm (COPD, asthma)
Pulmonary embolism
Pneumothorax
Pulmonary infection
ARDS
Pulmonary contusion
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Causes of acute dyspnea
Upper airway Chest wall
obstruction
Angioedema Rib fractures
Anaphylaxis Flail chest
Pharyngeal/deep neck infections Neurological
Foreign body Stroke
Neck trauma Neuromuscular disease (myasthenia,
Guillan Barre syndrome, poliomyelitis)

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Causes of acute dyspnea
Toxic / metabolic Miscellaneous

Organophosphate poisoning Hyperventilation

Salicylate poisoning Anxiety
CO poisoning Lung tumor

Toxic ingestion Pleural effusion

Diabetic ketoacidosis Intra-abdominal process

Sepsis Ascites
Anemia Massive obesity

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Evaluation of the adult with
dyspnea in the emergency
department
First !

Airways, breathing, and circulation are the

emergency clinician's primary focus when
beginning evaluation and management of
the acutely dyspneic patient.
oWhat will you do?

ABCs
5 vitals: RR, P, BP, T, 02 sat.

O2, IV, Monitor, ECG

Evaluation
Degree of urgency
Is the patient going to live long enough to give you a
history?

Assess the patient

Is the patient not able to breathe adequately?

Locate the problem

cardiac, respiratory, mechanical, metabolic, cerebral, psychological

Correct the problem

Breathlessness Scale
The Modified Borg Scale
Grade Degree of dyspnea
0 no dyspnea except with strenuous exercise
1 only when walking up incline or hurrying
2 slow on level, or stops after 15 minutes
3 stops few minutes of walking on the level
4 minimal activity such as getting dressed
too dyspneic to leave the house
! Tachypnea may not represent a respiratory
abnormality and may reflect a non-
pulmonary disease - eg, metabolic acidosis
or impending herniation of the brainstem !
Tools to evaluate dyspnea
Suspicion / Clinical knowledge
If you dont think of it, you ill ne er find it.

History
PE including:
Vital Signs, pulse ox
Vital Signs
Stable vs unstable
How do they change over time?
What does this tell us?
The meaning of each value depends on its
context!
A slowing respiratory rate in a bad asthmatic
may mean he is about to die !
A slowing respiratory rate in an anxious
bystander may mean he is getting better !
Rapid Assessment - General

Ability to speak
Mental status (agitation, confusion)
Positioning
Cyanosis
Rapid Assessment
Does this person need immediate treatment?
Salbutamol
Nitroglycerin
Aspirin
Furosemide
Non invasive ventilation
Needle decompression
History
Psychiatric conditions
Psychogenic causes for acute dyspnea represent
diagnoses of exclusion in the ED.

Organic causes MUST be thoroughly considered

first.
PHYSICAL EXAMINATION
Physical examination - focused exam
Accessory muscles
Facial expression, color.
Chest wall, lungs, heart
Observation, Palpation, Auscultation
with and without a stethoscope.
Abnormal breath sounds
Stridor
Wheezing
Diminished breath sounds
Crackles - rales
! however, the absence of crackles does not
rule out the presence of pneumonia, ADHF,
or pulmonary fibrosis
 Keep in mind that an
unremarkable pulmonary and
cardiac examination does NOT
rule out significant disease !
Physical examination
Signs that portend imminent respiratory
arrest:
Altered mental status
suggests severe hypoxia or hypercarbia
toxins, hypoglycemia, sepsis
Inability
to maintain respiratory effort
Cyanosis
 acute decompensated heart failure
chronic obstructive pulmonary disease
pulmonary embolism
pneumonia
asthma

The most common diagnoses among patients presenting to an

ED with a complaint of acute SOB and manifesting signs of
respiratory distress (RR >25, SpO2 <92%)
What other tools?
ABG
Other blood tests
CXR
EKG
CT scan
UltraSound
Pulse oximetry
healthy individuals SO2 95%;
elders / obese / smokers - 92 95%;
severe chronic lung disease - SO2 < 92%.

!!! standard pulse oximeters are NOT accurate in

the setting of hypothermia, shock, carbon
monoxide poisoning, and methemoglobinemia
Arterial Blood Gases (ABG)

Must be interpreted in context.

3 important components:
pH, CO2 and O2
Co plete ABG i cludes lactate
Venous blood gases (VBG) sometimes very
useful.
in the assessment of the patient presumed to be
somnolent from CO2 retention.
Blood tests
What else, and why?
d-Dimer
BNP or NT-proBNP
Basic Metabolic Panel
Cardiac Enzymes
D-Dimer
Use of the D-Dimer depends upon the patient's
pretest probability for PE.
Patients at low risk for PE according to a validated scoring
system (eg, modified Wells criteria for PE) and a negative
ELISA D-Dimer can be ruled out for PE without further
testing.
It is NOT appropriate to use a D-dimer to screen
patients at higher risk for thromboembolic disease.
Patients with malignancy or recent surgery and
elderly patients are more likely to have a falsely
elevated D-Dimer.
Brain natriuretic peptide (BNP)
helpful when the diagnosis of HF is in
question.
significance:
BNP < 100 pg/mL has a negative predictive value
of > 90 % for ADHF.
BNP > 500 pg/mL strongly suggests ADHF, with a
positive predictive value over 90%.
ACS: A word about troponin
Just because there is no troponin,
does t ea its ot AC
Just because there is troponin,
does t ea its AC
Troponin is prognostic more than
diagnostic
Chest radiography (CXR)
Do your own read !
the radiologist may not know what you are
looking for and may overlook the most important
clue!
Look for:
pneumothorax, aortic dissection, pneumonia,
pleural effusions, atelectasis, pulmonary
i filt ates
Chest x-ray (CXR)

Nevertheless, many
lifethreatening causes
of dyspnea may not
manifest any abnormality
on CXR !
ECG
Lots of clues as to cause of dyspnea
Look for:
pericarditis (diffuse low voltage, electrical alternans)
pulmonary embolism (S1Q3T3, right axis deviation)
myocardial infarction (ST segment elevation)
new onset atrial fibrillation
right heart strain

! Clinicians must remember that a nondiagnostic

ECG cant rule out a cardiac disease in the ED!
Pulmonary Embolism S1Q3T3
Acute MI (STEMI, NSTEMI)
ACS: ECG
Pericarditis
Pericarditis
CT Scan of the Chest
Usual speed, with contrast.

CT more rapid, safer, detects other potential causes

of dyspnea with better accuracy than V/Q Scan

Regular protocol requires normal Cr or GFR. Why?

Complications - contrast-induced nephropathy,

allergic reaction to contrast, and radiation
Ultrasonography & Echocardiography

TTE = Transthoracic echocardiogram:

aortic dissection
cardiac tamponade
acute valvular lesion
Case 1: Woman, 60 yrs old
Progressive SOB over 6 mo,
worse over 24 hours
Chronic cough
usually with white sputum
now worse with change in
sputum amount and colour
associated fever
Some orthopnea
Heavy smoker (35 pack years)
Differential diagnosis

COPD with acute infective exacerbation

CHF with acute decompensation

Exam & investigations
Unwell, RR 26, T 37.8,
HR 90, BP 140/80
ABG: pH 7.28/pCO2
O2 Sat 88% 73/pO2 52/HCO3 26
Evidence of work of
breathing and use of What do these show?
accessory muscles
Signs of hyperinflation
chest expansion
hyper-resonant
percussion Acute type II respiratory
Prolonged expiration with failure
wheeze
COPD
hyperlucent
lung fields

increased
retrosternal
air
low set
diaphragm increased
AP
flat
diameter
diaphragm
vertical
heart
Diagnosis
Infective exacerbation of COPD with
acute respiratory failure (type 2)
COPD - Advanced Dx
secondary polycythemia
cyanosis
tremor, somnolence
and confusion due to
hypercarbia
secondary pulmonary HTN
w or w/o cor pulmonale
COPD Treatment Strategy
Controlled Oxygen
if oxygen saturation < 90% at rest on room air
titrate 2-4 l/min in type 2 RF; monitor pC02
Non Invasive Ventilation (NIV) / mechanical V (MV)
Bronchodilators Beta-agonists and anticholinergics
Salbutamol, ipratropium bromide - via nebuliser
Corticosteroids
ex. Solumedrol 125 mg IV
Theophylline: ! poor bronchodilator
Antibiotics
beta-lactam / fluorquinolona
 COPD and PE

!!! Pulmonary embolism may be responsible for up

to 25% percent of apparent "COPD exacerbations"
and should be suspected when the patient fails to
improve with standard COPD treatment measures !
COPD - Emphysema
Not enough lung tissue. There is a paucity of
the blood/air interface.

T eat e t ew lu gs.
Case 2: Male, 25 years old

A young man presents to the Emergency

Department via ambulance.
He complains of sudden onset of SOB.

Present for a few hours and now quite severe.

 Further history
Previously well, smokes 10 cigarettes/day
Left sided chest pain
Moderate
Pleuritic
Started with the SOB

What is your ddx?

Differential diagnosis
Pneumothorax Much less likely
Pneumonia
Arrhythmia
Not to be mentioned
Pulmonary Embolism before all organic
causes considered
Asthma (less likely) Anxiety
Examination findings
Looks unwell, quite Is this serious?
distressed with SOB
What is your immediate
RR 28, HR 125/min, BP management?
80/60, afebrile
Saturation 93% RA
Reduced chest expansion
on the left
Hyper-resonance to
percussion on the left
Absent breath sounds on
the left
CXR mediastinal shift, trachea deviated
Diagnosis

Pneumothorax
Pneumothorax: Diagnosis
CXR: look for pleural line
500ml of air required to
visualize on x-ray
can be difficult in patients
with COPD
Management

Initial therapy?

Urgent chest tube

! This may have even been done without
a CXR if the patient was unwell enough
Treatment Options
Observation
if pneumothorax involves < 15-20% (< 2 cm) of
hemithorax and patient is relatively asymptomatic
repeat CXR in 24 hrs

Simple Aspiration
Tube thoracostomy
If > 2cm , chest tube
If hemodynamically unstable, chest tube
Case 3: Woman, 30 yrs old
Chest tightness, rapidly progressive SOB, now present at rest,
dry cough, wheezing over 14 h
following exposure to an alergen (dust)
PE: O2 saturation 91% on RA, use of accessory muscles,
diaphoresis, agitation, RR 26/min, BP 100/60 mmHg, HR
110/min
Treatment at home: Salbutamol inhaled in crisis (Childhood
asthma)
After 1 h from presentation in ED (treated with GCS +
nebuliser SABA) - pulsus paradoxus, diminished breath
sounds, cessation of wheeze, RR 12/min, HR 60/min
What is your diagnosis?
Severity of atack?
 Asthma
Reversible bronchoconstriction

Treatment goals:
to reverse airway obstruction rapidly through the
aggressive use of beta2-agonist agents and early use of
corticosteroids
to correct hypoxemia by monitoring and administering
supplemental oxygen
to prevent or treat complications such as pneumothorax
and respiratory arrest.
Life threatening acute asthma
SO2 < 92% on RA or < 95% on oxygen
PEF < 33% of normal
Brief fragmented speech
Silent chest (no wheeze)
Use of accessory muscles
Cyanosis; profound diaphoresis
Extreme fatigue
Depressed mental status
Bradicardia, hypotension
Failure to respond to aggressive treatment
Asthma Treatment
Oxygen (via mask)
Nebulized -adrenergic drugs
repeat salbutamol 5 mg nebuliser at 5 to 15 min intervals
until symptoms are controlled
Corticosteroids
Hydrocortisone 200 mg i.v.
Nebulized anticholinergics
Ipratropium 0.5 mg via nebuliser (may be mixed with
salbutamol)
Magnesium sulfate
Fluid replacement in the presence of dehidration
Status Asthmaticus
an acute exacerbation of asthma that remains unresponsive
to initial treatment with bronchodilators
100 % oxygen
continuous nebulised salbutamol and ipratropium
solumedrol 125 mg IV
magnesium S04 2 gm over 2 min
nonselective beta2-agonists - epinephrine 0.2mg IV over 5
min then 1-20 g/min
tracheal intubation and mechanical ventilation are indicated
for respiratory failure.
Indications for intubation and mechanical
ventilation in asthma
Apnea or respiratory arrest

Diminishing level of consciousness

Significantly rising PCO2 with fatigue, and altered level of

consciousness

Significant hypoxemia that is poorly responsive or

unresponsive to supplemental oxygen therapy alone
Case 4, Female 60 years old
Sudden onset of SOB
present now for 1 hour, quite severe
Right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago,
persistent leg swelling since then
Non smoker
No previous cardio/respiratory disease
No injury
What is the differential diagnosis?

Most likely Less likely

PE Pneumothorax
Pneumonia Arrhythmia
AMI
ECG
On examination & tests
Not too unwell, but CXR normal
clear evidence of
tachypnea and some ABG pH 7.5/CO2
WOB 30mmHg /p02
62mmHg on RA
RR 24, T 37.6, HR 110,
BP 110/70
O2 Sat 93% on RA
Most likely diagnosis?
Chest clear with
normal percussion and What test(s) will you
normal breath sounds perform?
What can you see?

Pulmonary embolism
Pulmonary embolism
The diagnosis should be considered in any patient
with acute dyspnea.
Risk factors include:
a history of deep venous thrombosis or pulmonary embolism
prolonged immobilization
recent trauma or surgery (particularly orthopedic)
pregnancy
malignancy
stroke or paresis
oral contraceptive use and smoking
a personal or family history of hypercoagulability.
Classic triad of signs/symptoms

Hemoptysis
Dyspnea
Chest Pain
These symptoms are not sensitive or specific and occur in
fewer than 20% of patients diagnosed with PE
Massive PE - Signs/Symptoms
Tachypnea -96%
Accentuated second heart sound - 53%
Tachycardia - 44%
Fever - 43%
S3 or S4 gallop - 34%
Signs/symptoms suggestive of
thrombophlebitis - 32%
Lower extremity edema - 24%
Cardiac murmur - 23%
Cyanosis - 19%
Pulmonary embolism
ABG: Hypoxemia, CO2 usually normal/.
Physical Exam
Massive PE causes hypotension due to acute cor
pulmonale
Physical findings in early submassive PE may be
completely normal
Initially, abnomal findings are absent in most patients
with PE
Massive PE Diagnostic Studies
V/Q scan
Pulmonary angiography
CT scan
Echocardiography
Pulmonary artery catheterization
D-dimer
Blood gases
PE: Anticoagulation
Enoxaparin 1mg/kg q12H
UFH: 80 IU/kg then 18 IU/hr (aPTT x2)
Fondaparinux
5mg daily if < 50kg; 7.5mg daily if 50-100kg
10mg daily if >100kg
! If clinical suspicion is high, initiate
anticoagulation prior to confirming diagnosis
Long term management:
V-K antagonists
NOACs
LMWH preferred in
patients with malignancy
or pregnancy
Duration:
1st provoked: 3 mo
1st unprovoked, malignancy
or recurrent, consider
indefinite Tx
What do you think if you see this CXR?
Case 5 Male, 65 years old
Medical history
Orthopnea, Paroxysmal
nocturnal dyspnea, SOB -
all present to a minor
degree over the 6 mo, but
worse for 24 hours
Palpitations - last 24 h
Previous MI 4 years ago
Ex-smoker, Hypertension,
Diabetes
How does this change your
diagnostic reasoning
compared to the last case?
a few clues point to
ca diac.
Heart Failure
Arrhythmia
Acute myocardial
infarction/angina
COPD
Anaemia
Physical Examination
Unwell looking with increased work of breathing
RR 26, without fever, HR Irreg 130, BP 100/70
Sat 90% RA
JVP, swelling of ankles
Displaced apex beat, no cardiac murmurs, 3rd heart
sound present
Normal chest expansion but stony dull percussion in
the bases (R>L), bilateral inspiratory crepitations
just above the dull areas
ECG what is your diagnosis?
Case 5 Diagnosis ADHF
Chronic heart failure with an acute exacerbation
due to new onset rapid AF
Treatment of AF & heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
! ADHF is among the most common causes
of acute respiratory failure among
patients over 65 years.
ADHF - Treatment
Diuretics
ACE inhibitors
Beta blockers
when the patient has no congestion
Digitalis
Peripheral vasodilators/NTG
Positive inotropic agents
Oxygen
Pulmonary edema
Pulmonary edema
Sudden onset; respiratory distress
Rales, ronchi; foamy sputum; sometimes
blood tinged.
High BP (vasoconstriction)

88
Principles of Management
Acute Pulmonary Edema
Position for comfort usually sitting upright
Oxygen via non-rebreathing mask
Use CPAP / BiPap - non-invasive positive pressure ventilation
(NIPPV) - if available increase airway pressure, to force
fluids back into the vascular system
Consider assisting ventilation if respiratory failure
12 lead ECG - to rule out ACS
400 g nitroglycerin spray
if SBP > 90 mmHg
Principles of Management
Acute Pulmonary Edema
Furosemide 40 mg IV
repeated at 10 min intervals to a max dose 160 mg
Nitroglycerin IV - if SBP > 90 mmHg
Morphine 2-4 mg IV (up to 20 mg)
Monitor respirations and assist ventilation if respiratory
depression becomes evident
Consider salbutamol 5 mg via nebuliser
only in the presence of wheeze
Pneumonia
Pneumonia objective examination
Increasing dyspnea
Dry cough becoming productive
Fever
Pleuritic chest pain
Pleuritic rub
Consolidation dull to percussion
Crackles over affected area
Principles of Management
Pneumonia
Oxygen to maintain 02 sat > 95%
BiPAP as required
Antibiotics:
Macrolides
Fluroquinolones
2nd or 3rd generation cephalosporin
Beta agonists if wheeze
Fluid replacement in the presence of dehydration
Adult Respiratory Distress Syndrome (ARDS)/
Noncardiogenic pulmonary edema
Recognized as the most severe form of acute lung injury,
a form of diffuse alveolar injury.
Defined as an acute condition characterized by bilateral
pulmonary infiltrates and severe hypoxemia in the absence
of evidence for cardiogenic pulmonary edema.

Potential causes include: sepsis, shock, severe trauma,

toxic inhalations (aspiration, thermal injury, anhydrous
ammonia, chlorine), infections (Hantavirus, SARS), blood
transfusion, and drug overdose (cocaine, opioids).
CXR in ARDS
ARDS
ARDS - Treatment
Oxigen
Ventilation noninvasive or mechanical
Tracheostomy
Extracorporeal Membrane Oxygenation
Corticosteroids benefits?
Surfactant
Nitric oxide
Fluid management
Nutritional Support
Summary of learning

Dyspnea is a symptom (subjective)

Think systematically
Multiple causes / multiple tools to diagnose
the problem
Diagnosis of the breathlessness patient
e ui es you to look fo clues
Whe you a t reathe,
ot u h else atters.