Acute dyspnea: Difference between revisions

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==Workup==
{{Adult top}} [[acute dyspnea (peds)]].''
# CXR
==Background==
# ECG
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]
# CBC
# Chem 7
Consider:
# BNP
# D-dimer
# Troponin
# ABG


==Diagnosis==
==Clinical Features==
EMERGENT PATERN RECOGNITION
===Emergent Pattern Recognition===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Diagnosis'''
| align="center" style="background:#f0f0f0;"|'''Lungs'''
| align="center" style="background:#f0f0f0;"|'''[[CXR]]'''
| align="center" style="background:#f0f0f0;"|'''[[ECG]]'''
| align="center" style="background:#f0f0f0;"|'''Treatment'''
| align="center" style="background:#f0f0f0;"|'''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]]
|}


#Pulmonary edema
==Differential Diagnosis==
#*lungs: bilat rales
{{SOB DDX}}
#*CXR: interstitial fluid
#*Tx: ECG (R/O AMI), lasix, nitrates, ACE, BIPAP
#Bronchoconstriction
#*lungs: wheezes
#*CXR: neg/hyperinflated
#*Tx: albuterol, atrovent, steroids, consider anaphylaxis (antihistamines, epi)
#Pneumonia
#*lungs: focal ronchi/dec BS
#*CXR: infiltrate/effusion
#*Tx: abx, goal directed,
#PE
#*lungs: clear
#*CXR: clear/Westrmrk/Hmptn
#*Tx: ECG, D-dimer and/or spiral CT; anticoagulate/thrombolise
#Pneumo/Hemo-Thorax
#*lungs: unequal
#*CXR: pneumo/hemo
#*Tx: needle/chest-tube
#Dysrythmia
#*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, +/- thrombolitics
Consider ABG


==DDX==
==Evaluation==
'''EMERGENT'''
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]]
*Pulmonary
*[[CXR]]
*#Airway obstruction
*[[ECG]]
*#PE
*CBC
*#Noncardiogenic edema
*Chem-7
*#Anaphylaxis
*[[BNP]]?
*#Spont pneumothorax
*[[D-dimer]]?
*#Asthma
*[[Troponin]]?
*#Cor pulmonale
*[[ABG]]?
*#Aspiration
*Bedside [[ultrasound]]?
*#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 chest
*#CO poisoning
*#Abd distension
*#Sepsis
*#Hypotension
*#Renal failure
*#Electrolyte abnl
*#Metabolic acidosis
*#PNA
*#Pneumo/hemo-thorax
*#Diaphragmatic rupture
*#Anemia
*Other Associated with Decreased Resp Effort
*#CVA
*#Organophosphate poisoning
*#MS
*#Guillian-Barre
*#Tick paralysis


'''Non-Emergent'''
{{BLUE Protocol}}
#Pleural effusion
#Neoplam
#PNA
#COPD
#Congenital heart dz
#Pregnancy
#Ascites
#Obesity
#Hypterventilation
#Panic attack
#Fever
#Thyroid dz
#Rib fx
#ALS
#Polymyositis
#Porphyria


==Source==
==Management==
3/7/06 DONALDSON (adapted from Rosen)
*Oxygen
*Treat underlying cause


[[Category:Cards]]
==Disposition==
[[Category:Pulm]]
*Depends on underlying diagnosis
 
==See Also==
*[[Hypoxemia]]
*[[Shortness of breath (peds)]]
 
==References==
<References/>
 
[[Category:Cardiology]]
[[Category:Pulmonary]]
[[Category:Symptoms]]

Latest revision as of 18:38, 24 April 2024

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

Background

Lobes of the lung with related anatomy.

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

  • Depends on underlying diagnosis

See Also

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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