Emergency Evaluation of the
Dyspneic Patient
Dr. Didem Ay
Emergency Medicine
Goals
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Definitions
Emergency Department Evaluation
Respiratory Assessment
Treatment
Etiology
• Dyspnea:
– Sensation of breathlessness or inadequate
breathing
– Most common complaint of patients with
cardiopulmonary diseases.
• Dyspnea - common complaint/symptom
– Defined as“shortness of breath” or
“breathlessness”
– “abnormal/uncomfortable breathing”
– “not getting enough air”
• Multiple etiologies – 2/3 of cases - cardiac or pulmonary etiology
Terms
• Tachypnea: Rapid breathing
• Ortopnea: Dyspnea in the recumbent
position
• Paroxysmal nocturnal dyspnea: Orthopnea
that awakens the patient from sleep
Terms
• Trepopnea: Dyspnea associated with only
one of several recumbent positions
• Platypnea: The opposite of orthopnea
(dyspnea in the upright position)
• Hyperpnea: Hyperventilation and is defined
as minute ventilation in excess of metabolic
demand
• Hypoxia: Insufficient delivery of oxygen
to the tissues
• Hypoxemia: Abnormally low arterial
oxygen tension. (PaO2) < 60mmHg or
arteriel oxygen saturation (SaO2) < 90%
Oxyhemoglobin Dissociation
Curve
Attention
• Psychogenic dyspnea should be diagnosed
after exclusion of organic causes
Emergency Department
Evaluation
• There is no one specific cause of dyspnea and no
single specific treatment
• Treatment varies according to patient’s condition
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chief complaint
history
exam
laboratory & study results
Respiration: Inspiration and expiration to
provide sufficient tissue oxygenation
Respiratory distress: Unnatural, uncomfortable,
distressing inspiration and expiration causing
tissue hypoxia
Clinically hypoxia, cyanosis, hypercapnia occur
Respiratory Assesment
• Primary evaluation: Goal is to eliminate life
threatening causes
• Secondary evaluation: Detailed
Respiratory Assesment
• Primary
– Normal: Spontaneous, comfortable, painless,
regular respiration: 12-20/min (in adults)
– Look, listen and feel for breathing
– Wheezing, stridor?
– Consciousness?
– Talking?
– Paradoxal chest movement?(flail chest)
Look, Listen, Feel
Respiratory Assesment
• Primary
– Respiratory distress
– Head-tilt, chin lift or jaw trust
– Open airway
– Reasses breathing
– If breathing present, start oxygen
– If breathing is not present start artificial
ventilation
Baş geriye,
alt çene öne yukarıya
Aspiration
Airways
28
33
34
35
Respiratory Assesment
• Secondary
– History
– Physical examination
– Chest film
History
• Age, past medical condition
• Associated symptoms (Fever, cough, sputum,
angina, pretibial oedema)
• Timing: acuity and duration
(Spontaneous/sudden onset, dyspnea on
effort, orthopnea, PND)
• Severity
• Past medical history
• Smoking, drugs (OKS, HRT), trauma,
immobilization, malignancy
Signs and Symptoms
Serious respiratory distress :
1. Clinical:
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Tachypnea (RR> 35/min), apnea
Cyanosis
Retractions
Agitation, inability to talk, unconscioussness,
coma
5. Rales, wheezes
2. SO2< %90, PaO2<60 mmHg, PCO2>45 mmHg
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Physical Examination
Head to toe
Vital signs
Consciousness
Skin color (paleness, diaphoresis, cyanosis,
erythema, urticaria)
Retractions (intercostal, suprasternal,
abdominal)
Clubbing
Auscultation
Signs of heart failure
Laboratory
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Pulse oxymetry, arterial blood gases
Complete blood count
Chest X-ray, lateral neck X-ray
ECG monitorization
Echocardiography
Biochemical parameters
If needed: CT, ventilation-perfusion
scintigraphy
Pulse Oxymetry
• Rapid, widely available, noninvasive means
of assessment in most clinical situations– insensitive (may be normal in acute dyspnea)
• The % of Oxygen saturation does not always
correspond to PaO2
• The hemoglobin desaturation curve can be
shifted depending on the pH, temperature or
arterial carbon monoxide or carbon dioxide
levels
Arterial Blood Gases
• Commonly used to evaluate acute dyspnea
• Can provide information about altered pH,
hypercapnia, hypocapnia or hypoxemia
• Normal ABGs do not exclude
cardiac/pulmonary diseases as cause of
dyspnea
– Remember- ABGs may be normal even in cases of
acute dyspnea - ABGs do not evaluate breathing
Arterial Blood Gases
Normal values
– PO2
– PCO2
– Sat O2
– pH
– P(A-a) O2
– HCO3
– Base Excess
75-100 mmHg
35-45 mmHg
95-100 %
7.35-7.45
12-20 mmHg
22-26 mEg/l
+or-2
Alveolar-Arterial
Oxygen Partial Pressure Gradient
• A-a O2 gradient measures how well alveolar
oxygen is transferred from the lungs to the
circulation
• P(A-a) O2 = 149 – PaCO2 / 0.8 - PaO2
• N = 2.5 + age X 0.21 (+/-11)
• Any parenchymal disease in lungs?
• Following measure
Respiratory Arrest
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Acute myocardial infarction
Stroke
Foreign body obstruction
Drowning
Electrical injury
Intoxication
Excess narcotics
Trauma (Tension pneumotorax)
Suffocation
Severe metabolic acidosis
Differential Diagnosis
• Four general categories
– Cardiac
– Pulmonary
– Mixed cardiac or pulmonary
– Non-cardiac or non-pulmonary
Pulmonary Etiology
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COPD
Asthma
Pulmonary thromboembolism
Restrictive Lung Disorders
Hereditary Lung Disorders
Pneumonia
Pneumothorax
Cardiac Etiology
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CHF
CAD
MI (recent or past history)
Cardiomyopathy
Valvular dysfunction
Left ventricular hypertrophy
Pericarditis
Arrhythmias
Mixed Cardiac/Pulmonary Etiology
• COPD with pulmonary HTN and/or cor
pulmonale
• Chronic pulmonary emboli
• Pleural effusion
Noncardiac or Nonpulmonary
Etiology
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Metabolic conditions (e.g. acidosis)
Pain
Trauma
Neuromuscular disorders
Functional (anxiety,panic disorders, hyperventilation)
Chemical exposure
Classic Presentations
• COPD: Hyperinflation, diminished breath
sounds, wheezes, use of accessory muscles of
respiration
• Pulmonary Edema: JVD, diffuse rales, cardiac
gallop, peripheral edema
• Upper airway obstruction: Inability to speak,
inspiratory wheeze, diminished breath
sounds
Worry!!
• Confusion, agitation, loss of consciousness
• Diaphoresis, cyanosis, bradycardia,
hypertension
Goals of treatment
• Etiology treatment!
• PaO2 > 60 must be
• SO2 > 90 must be
Havayolu Kardiyak
Akc
Plevra
GDuvarı
Vasküler
Nöromus
küler
Çeşitli
HY kitle
LV yetm
Astım
Pnx
PE
SVO
Anemi
Yb cisim
MI
KOAH
Pl eff.
Hava emb
Frenik sinir
paralizi
Met asidoz
Anjioödem
Perikardit /
P tamponad
Pnömoni
Pl yapışıklık
Yağ emb
Guillain-Barre
Syn.
Şok
HY stenozu
HT kriz
P ödem
G Duv
yaralanmaları
Amn sıvı emb
Botulizm
Düşük kard
out-put
Broşektazi
Aritmi
P kontüzyon
Abd
distansiyon
Pulm HT
Nöropati
Hipoxi
Trakeomalazi
Miyokardit
Atalektazi
Kifoskolyoz
Veno-okluziv
hastalık
miyopati
CO intox
KMP
Alveolit
Pectus
excavatum
Sickle-cell
MetHb
İntrakard şant
P fibrozis
Gebelik
Vaskülit
Ateş,
hiper/hipotiroi
di,
LV çıkış obst
ARDS
AV fistül
psikiyatrik
Kapak bzk
sarkoidoz