The patient with shortness of breath
Differential diagnosis
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Asthma
COPD
Pneumonia
Heart failure
PE
Other
Asthma assessment
Symptom/sign
Mild
Moderate
Severe
Breath sounds,
wheeze
Expiratory
Variable
Insp/exp
Mod-loud
Variable/“silent”
Sats
>94%
<90%
Resp rate
<20
>30
Speaks in
sentences
Barely/words
PEFR
>60%
<40%
Pulse
<100
>120
Exhaustion
Accessory muscles
yes
Yes
Yes, paradoxical
Level of
consciousness
decreased
ABG
yes
Asthma…
pertinent negatives and positives
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Fever, green sputum, pleuritic pain (?CXR?antibiotics)?
On oral steroids already?
ICU admissions in the past?
Social situation, time of day?
(Is this asthma)?
(smoking)?
Asthma management
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Steroids
Beta agonist (+ipratropium bromide (atrovent))
Oxygen
The kitchen sink
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Review frequently (at least hourly)
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Asthma management
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Prednisone 40 mg 5 days PO
(Hydrocortisone 200mg iv if unable to tolerate PO)
Asthma management
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Salbutamol
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Nebs 5mg
Inhaler (100µg) via spacer 8 puffs
A suggested approach for moderate severity
 5mg salbutamol neb q 20mins x3.
 Then, if required, 5mg q30mins x2
 Then, if required, 5mg q60mins x1
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R/V hourly (pre neb)
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PEFR, RR, Sats, breath sounds
@ 3 hours from start…decide…admit / discharge / a bit longer…
Asthma management
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Ipratropium bromide
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O.5mg nebs, q 20 mins x3
Oxygen to get sats >93%
Asthma management
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The kitchen sink includes, in Resus
continuous neb salbutamol
 magnesium iv,
 salbutamol iv bolus+infusion,
 iv aminophylline,
 NIV/intubation
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Asthma
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Who can go home?
Well patients
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those with mild severity a reasonable time after last
treatment
Varies between patients, eg initial severity and response
to therapy
 Those who require less than 2/24 salbutamol
 PEFR >75% of best/predicted 2 hours after initial
Rx
BUT!!!!
 Social situation, time of day, prior asthma history, etc
 ASK for a senior opinion
Asthma discharge
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Instructions
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Meds
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when to return
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prednisone,
salbutamol (technique)
increasing severity
Increasing salbutamol use
“More concerned”
follow up with GP
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depends on the patient
Not improving >24 hours
Pneumonia
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Assessment (diagnosis and severity)
 Hx
 Exam (OBS!!!)
 Ancillary (CXR, Bloods, ECG)
 CURB65
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Sick, not sick?
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Based on patient factors, obs, clinical
findings, results of investigations, gestalt
Pneumonia
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Management
 General
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Specific
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iv fluids,
oxygen,
antipyretics
antibiotics
Disposition
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sick/not sick?
CURB65
Pneumonia
Antibiotics (RMO handbook)
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Outpatient
 “risk factors”
 Yes : augmentin + macrolide/doxycycline
 No : macrolide or doxycycline
Inpatient
 Iv augmentin/cefuroxime + macrolide/doxycycline
PE
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Should be considered when it is either
 very obvious, or
 nothing else fits
Wells criteria …
 Do not order a d-dimer until you have thought
long and hard about it! You must have other
investigations back first.
 Discuss with your senior before the d-dimer
PE
PERC Rule for Pulmonary Embolism
Age < 50?
Yes
HR < 100?
Yes
O2 Sat on Room Air >94%?
Yes
No Prior History of DVT/PE?
Yes
No Recent Trauma or Surgery?
Yes
No Hemoptysis?
Yes
No Exogenous Estrogen?
Yes
No Clinical Signs Suggesting DVT?
Yes
According to the PERC Study, there is less than 2% risk of PE in this patient.
The PERC rule only applies if all 8 criteria are met.
COPD management…oxygen
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“CO2 retainer”…use hypoxia for respiratory drive
Not common, not rare
Assess…
 old notes/gas results/patient LOC/VBG/ABG
 If there is respiratory acidosis, there is some degree of acute
respiratory failure.
 If there is elevated CO2 but no/minimal acidosis, there is a
degree of chronic compensation (HCO3 elevated)
 Acute on chronic respiratory failure is often found
Use venturi mask to titrate oxygen to maintain sats >88%
COPD exacerbation
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Management
 General : oxygen, iv fluids, antipyretics
 Specific :
 salbutamol,
 ipratropium,
 antibiotics,
 steroids,
 NIV
 Disposition : usually admit
Heart failure
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Assessment
 Hx
 Exam
 Ancillary : CXR, ECG, BNP (last resort when, despite
thorough assessment, cause of SOB uncertain. Used
to EXCLUDE CCF)
Management
 General : oxygen
 Specific : diuretics
 Disposition : usually admit