Acute dyspnea: Difference between revisions

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==Workup==
{{Adult top}} [[acute dyspnea (peds)]].''
==Background==
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]


# CXR
==Clinical Features==
# ECG
===Emergent Pattern Recognition===
# CBC
{| class="wikitable"
# Chem 7
| align="center" style="background:#f0f0f0;"|'''Diagnosis'''
| align="center" style="background:#f0f0f0;"|'''Lungs'''
Consider:
| align="center" style="background:#f0f0f0;"|'''[[CXR]]'''
* BNP
| align="center" style="background:#f0f0f0;"|'''[[ECG]]'''
* D-dimer
| align="center" style="background:#f0f0f0;"|'''Treatment'''
* Troponin
| align="center" style="background:#f0f0f0;"|'''Contraindicated'''
* ABG
|-
| [[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==
{{SOB DDX}}


==Diagnosis==
==Evaluation==
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]]
*[[CXR]]
*[[ECG]]
*CBC
*Chem-7
*[[BNP]]?
*[[D-dimer]]?
*[[Troponin]]?
*[[ABG]]?
*Bedside [[ultrasound]]?


{{BLUE Protocol}}


EMERGENT PATERN RECOGNITION
==Management==
*Oxygen
*Treat underlying cause


#Pulmonary edema
==Disposition==
#*lungs: bilat rales
*Depends on underlying diagnosis
#*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


==See Also==
*[[Hypoxemia]]
*[[Shortness of breath (peds)]]


==DDX==
==References==
<References/>


 
[[Category:Cardiology]]
EMERGENT
[[Category:Pulmonary]]
 
[[Category:Symptoms]]
A. Pulmonary
 
    1) Airway obstruction
 
    2) PE
 
    3) Noncardiogenic edema
 
    4) Anaphylaxis
 
    5) Spont pneumothorax
 
    6) Asthma
 
    7) Cor pulmonale
 
    8) Aspiration
 
    9) PNA
 
B. Cardiac
 
    1) Pulmonary edema (CHF)
 
    2) MI
 
    3) Cardiac tamponade
 
    4) Pericarditis
 
C. Other Associated with Nl/Increased Resp Effort
 
    1) Toxic ingestion
 
    2) DKA
 
    3) Epiglotitis
 
    4) Tension PNTX
 
    5) Cardiac tamponade
 
    6) Flail chest
 
    7) CO poisoning
 
    8) Abd distension
 
    9) Sepsis
 
    10) Hypotension
 
    11) Renal failure
 
    12) Electrolyte abnl
 
    13) Metabolic acidosis
 
    14) PNA
 
    15) Pneumo/hemo-thorax
 
    16) Diaphragmatic rupture
 
    17) Anemia
 
D. Other Associated with Decreased Resp Effort
 
    1) CVA
 
    2) Organophosphate poisoning
 
    3) MS
 
    4) Guillian-Barre
 
    5) Tick paralysis
 
 
Non-Emergent
 
1) Pleural effusion
 
2) Neoplam
 
3) PNA
 
4) COPD
 
5) Congenital heart dz
 
6) Pregnancy
 
7) Ascites
 
8) Obesity
 
9) Hypterventilation
 
10) Panic attack
 
11) Fever
 
12) Thyroid dz
 
13) Rib fx
 
14) ALS
 
15) Polymyositis
 
16) Porphyria
 
 
==Source==
 
 
3/7/06 DONALDSON (adapted from Rosen)
 
 
 
 
[[Category:Pulm]]

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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