Acute Respiratory Distress Symptoms, Diagnosis, Treatment

 How to approach respiratory distress in the emergency department?

So whenever we think about respiratory distress we're 

thinking about a patient who comes into the emergency department who's having a very hard time breathing so when we're thinking about someone who is critically ill and is having a hard time breathing we want to make sure we go back to the basics and the basics in the emergency department we go back to our at the 

beginning of our alphabet and we think 

about the ABCs when we're talking about the ABCs first we're going to start with.

The Airway: so when thinking about the 

airway we want to say is the airway Peyton does the patient have anything including their airway do they have a lot of swelling in their airway and an easy way for us to do that is to ask the patient to speak so generally patients who can speak have a Peyton 

airway the other thing we think about is 

is the airway is the patient able to protect their airway so what does that mean that means that if the patient were to vomit or have a lot of secretions would they be able to handle those secretions.

The breathing: we want to make sure 

we're assessing the work of breathing for our patient this is something that can be done using a couple of parameters so one of the first things that we want to do is assess the pulse oximetry so we want to see if the patient has hypoxia is their oxygenation, okay and the other 

thing that we can do when we're thinking 

about this is just looking at our patient and talking to our patient so when looking at the patient are they using accessory muscles is their respiratory rate elevated do you see them using their sternocleidomastoid to help them breathe are they using their abdominal muscles to help them breathe and along with this it's also talking to your patient like I said so can your patients speak to speak you need to be able to breathe.

So patients who come in who are screaming at the top 

of their lungs and saying they're having a hard time breathing most likely they're not necessarily having as much of a hard time breathing so you want to see are they're able to speak one-word sentences are they able to speak you know long longer paragraphs and longer sentences along the way.

Circulation: circulation is the last part of the 

here so you want to check the blood pressure you want to check peripheral pulses and the extremities and along with this you want to feel is the patient's skin cool is their skin warm are they clammy all of that kind of goes into the circulation component so before we can move on to anything else we want to make sure we're starting with our ABCs if we detect a problem in any of these components if we detect a problem with airway with breathing with circulation we always say we have to stop and fix that problem before we can move on so if we detect an airway problem we stop at a we fix it with potentially intubation and then we don't move on until we fixed all of the problems here before we move on to the rest of our process. 

So when someone comes in with respiratory distress we 

want to think about the most important questions you have to ask and sometimes you have to ask?

Think about these things pretty rapidly this is something 

where you're not going to want to take your time your patient is having respiratory distress they're having a hard time breathing you don't want to just kind of wait around so the important questions that you want to be thinking about that you want to be asking right when you see this patient so you want to know when did it start did it start just before they came in did it start five days ago so to start months ago is this a chronic problem for the patient did the symptoms begin suddenly or were they more of gradual onset so the sudden onset of shortness of breath makes you think about certain things more gradual onset of shortness of breath makes you think about other potential etiologies has this ever happened before there are a lot of things that cause respiratory distress.

That have happened before for 

patients so for example COPD asthma those are generally recurrent problems for patients get intermittent exacerbations whereas something like a pulmonary embolus might be something that just happens one time for patient are there any other associated symptoms, for example, is your patient having chest pain have they had leg swelling and any other kind of associated symptom they can have are they having a fever are they having a cough there's lots of other things that you want to make sure that you're asking about and then past medical history what other medical problems does the patient have do they have obstructive lung disease are they a smoker have they had heart attacks before do they have heart failure are there are they on diuretic medication so all of that stuff.

you want to try and formulate as quickly 

as you possibly can now this the history can provide you with lots of clues as to the etiology of a patient shortness of breath so it's important to try and gather as much information as possible and not just gathering as much information as possible but to try and gather this information as quickly as you possibly can now the main issue here when we're dealing with respiratory distress especially for those patients that are severely just Nick so for patients who are really struggling to breathe and 

talk so, for example, that patient that 

can only speak a couple of words at a time they're not going to be able to tell you all of their medical history or when it started necessarily so for those patients what you're going to need to do is you're going to need to utilize other resources you're going to need to reach out the EMTs.

Who brought the patient 

into the emergency department to the family potentially or friends who've been with the person over the last little bit to the medical record can sometimes be very helpful to help obtain historical information so you may be in a situation where you're not necessarily able to ask your patient all of these questions now this may be different than other clinical experiences that you've had in the past oftentimes in the preclinical years of medical school if you have some patient contact usually that's going to be with a stable patient here these patients are going to be very sick potentially and you're going to want to try and gather as much information as quickly as you can and potentially utilize these additional resources.

How to Examine your Patient ? so when someone comes in 

respiratory distress the examination you want to look at the patient you can gather so much information just by looking at the patient from the door you want to listen you want to take a listen to your lungs that can give you a clue as to what's going on with the patient if you hear wheezing that's potentially obstructive lung disease or asthma if you hear rails or crackles that are more likely to be CHF and you want to go ahead and feel the patient's chest you can do tactile fremitus and the key thing in patients with respiratory distress is you're going to be treating them and examining them potentially all at the same time so when someone comes in with severe respiratory distress oftentimes our treatment and our exam and our history are all taking place at the same time.

Because we're moving very quickly to rapidly treat and 

assess the patient now a key thing with respiratory distress is you always want to be reassessing your patient so you always want to be going back to your patient after you've given them a certain treatment after you've given them nebulizer treatments or diuretics or started them on non-invasive ventilation and you always want to be going back and reassessing your patient.

Breaking Down the Physical Examine: now for the physical exam we want to 

focus on the respiratory rate often times when someone is having significant respiratory distress their respiratory rate will be elevated so sometimes you want to go ahead and you want to make sure you're focusing on that and that you're counting the respiratory rate and seeing what it is often times it will be obvious that the patient's respiratory rate is elevated you want your patient to be on a pulse oximeter you want to be able to measure their oxygen saturation and generally peripheral pulse oximeters or non-invasive pulse oximeters do a pretty good job of measuring the patient's oxygenation you also want to think about the patient's position.

So oftentimes our instincts are for people 

to be lying flat in bed or flat on the stretcher but for the most part, if someone's in severe respiratory distress you want to set them up in bed and the reason that you want to set them up in bed is because when you're sitting up you're able to take deeper inhalations and you're able to recruit more of your lung volume when you're laying down flat you're not able to do that the other thing that happens when you sit people up especially if they have some fluid in their lungs is the fluid goes to the bottom of their lungs and then they're able to utilize again larger portions of their lung volume and they're able to fill their lungs with more was more fluid so gravity is your friend go-ahead and sit those patients up the fluid will go down they're going to be able to breathe better in that situation.

lastly is listening on you want to 

definitely take a listen to the lungs you want to see if you hear wheezes if you hear crackles. how up though how far up those go rhonchi or the other thing that you can sometimes hear and all of those things will point you in a direction as to what you think is the most likely etiology of the shortness of breath for a patient.

The importance of the Physical Examine: So in respiratory distress, the physical 

exam can provide you with lots of clues to the etiology of a patient shortness of breath go ahead and utilize that exam, and much of that important information on the physical exam can actually be gathered in the first few seconds simply by walking in the room and looking at your patient looking at your patient you could see if they're in respiratory distress you can touch them very quickly and see if they're cool and clammy or if they're warm and red so there's lots of information that you can just get in those first few seconds make sure that you utilize those first few moments to take a look at your patient.

Initial Testing: So I like said in these situations we're going to 

be doing lots of stuff at the same time we're going to be examining our patient we're going to be intervening on their shortness of breath we're going to be reassessing them and then we're also going to be thinking about what initial tests we want to get so we're gonna start out by talking about some blood tests that you're going to want to get when thinking about shortness of breath we want to focus on the blood gas and 

when we're talking about a blood gas for 

the most part in the emergency department we utilize venous blood gases historically we used to get arterial blood gases so we used to take blood from the artery and send that to the lab to analyze it the advantage of taking an arterial blood gas over a venous blood gases is that an arterial gas can help you further assess oxygenation but like.

I said for the most part our peripheral 

pulse oximeters that go on the patient's finger do a pretty good job of assessing the oxygenation so for the most part in the IDI we send a venous blood gas and 

the venous blood gas can take a pretty 

good look at the ventilation so when we're talking about ventilation we're talking about whether or not that person can adequately expire their carbon dioxide and when we're looking at it this blood gas and arterial blood gas they actually correlate pretty closely together the other problem with an arterial blood gases that can be challenging to get for the most part arterial blood gases were obtained from the radial artery which is the artery in the wrist.

now that's historical can be painful 

for patients so we know that patients report a lot of pain with that procedure so generally, we do the venous blood gas instead and we can just send the venous blood gas off with the rest of the labs that are sent off we want to think about cardiac testing so shortness of breath is sometimes due to problems in the lungs but sometimes it's due to a problem with the heart so we want to think about sending off troponin testing and then other basic lab tests can give you additional information as well so thinking about basic blood tests you can find out if the patient is anemic because the anemia can cause shortness of breath you can find out if there's kidney failure.

The next step is thinking about imaging so on imaging we think 

about getting a chest x-ray the chest x-ray can give you lots of information it can take a look at the lung field you could see if there is a pneumonia and pneumothorax if there's fluid in the lungs and it can give you a lot of information about what's going inside the patient's lungs however additionally if your chest x-ray is potentially not very revealing or you're not sure you can move on and you can get a chest CT after you get some additional information a chest CT scan gives you the advantage of taking a closer look at the patient's lung fields the other thing that it can do is if you administer IV contrast with a chest CT you can take a look at the vessels in the lungs.

And see if there's a blood 

clot there lastly thinking about additional cardiac testing the EKG is something that you can get that will look for ischemia so you can look and you could see if there's any evidence that the patient's having a heart attack or myocardial infarction you can also look for arrhythmias sometimes can make people feel short of breath such as atrial fibrillation or atrial flutter and then an echocardiogram in the emergency department we utilize bedside point-of-care ultrasound quite a lot and an echocardiogram is something can be obtained easily and quickly studies have shown that in the emergency department emergency medicine physicians are good at figuring out if the patient has a good EF a medium EF or a low EF so we're good at kind of approximating that and as technology just keeps getting better and we are training our residents I think that this skill will only get utilized more and moreover the upcoming years.

What's our Differential of C

onsequence: now if you'll remember our differential of consequence is thinking about the things that are most life-threatening to our patient in the easy we want to rule out what's the most likely thing to cause harm or to potentially kill our patient in the next few hours days so what's on our differential of consequence here there's a handful of organ systems which can cause respiratory distress the lungs are the main one that we think about right so you think about all the things that could be going on in the lungs but the heart can also cause respiratory distress as can kidney failure promise with the kidneys liver failure as well and then a handful of systemic stuff such as anemia or a low blood cell count.

Problems with the Lungs: so thinking about the lungs what in the 

lungs can cause shortness of breath pulmonary embolus is one that we always are thinking about in the emergency department and we'll be talking about that all of these in more detail in other lectures on COPD asthma pneumonia and pneumothorax all things in the lungs that can cause a patient to present with shortness of breath.

Problems with the Heart: we think about congestive heart 

failure which leads to pulmonary edema fluid on the lungs we think about acute coronary syndrome so we always have to make sure we're considering these so these are your stem ease your non-stem ease we think about cardiac tamponade this is another key area that an echocardiogram can potentially really help you cardiac tamponade oftentimes presents following trauma but also can be related to you can get larger fusions related to different malignancies as well as related to two pericardial effusions so definitely you want to make sure you're thinking about cardiac tamponade and then acute valvular insufficiency does the patient have severe aortic regurgitation severe aortic stenosis all of those things can lead to shortness of breath. 

Other Problems that lead to Respiratory Distress: Then last but not least we have a big list of other things now this 

is by no means all-inclusive there are a lot of things out there that can make someone feel short of breath symptomatic anemia is one every so often I have a patient in the emergency department who comes in with this gradual onset of shortness of breath and every so often I get the labs back and I'm surprised that a patient is found to have be severely anemic so that they have very low blood cell counts and I say to them that we found the answer for your problem and oftentimes those patients will need a blood transfusion no symptomatic anemia can be due to lots of different things due to bleeding in the GI tract or you know a variety of things but we want to make sure that

we're thinking about this is one of 

those reasons why those basic blood tests that we sent off can really help us out in the appropriate situation you want to think about carbon monoxide poisoning definitely it's a good idea when these people present short of breath especially in the winter months when people are running indoor heaters and various generators to think about carbon monoxide poisoning definitely after a fire kind of a situation you want to think about that pregnancy can but in and of itself cause people to be short of breath and that's due to various physiologic changes in the body during pregnancy kidney failure problems with the kidneys patients who are maintained on hemodialysis can oftentimes get a backup of fluid mainly into their lungs.

So can cause pulmonary 

edema and we know that patients from time to time are non-compliant with their dialysis treatments but they don't go like they're supposed to especially people are vulnerable in times when they're kind of perry dialysis when they're about to be started on dialysis treatments so asking about kidney failure can be key now for patients who come in with severe respiratory distress and you're not sure if they have kidney failure one key thing that you can do for those patients is you can go ahead and again examine your patient you can look for points of dialysis access you can look for an AV fistula you can look to see if they have a lie or if they have had a prior line so indicate that they have had kidney 

failure before and then last but not 

least thinking about liver failure with ascites so in the situation of liver failure your body can develop a lot of ascites or fluid in the abdomen.

if you get significant fluid in the abdomen 

then that can, in turn, push up on the lung fields and potentially cause shortness of breath so thinking about liver failure as well again your examination can help you here does the patient have any stigmata of liver failure do they have scleral icterus AR or yellowing of the eyes does their skin appear to be yellow so before you even get your labs back you can start thinking about this as a possible etiology just by utilizing your physical exam very important here to consider broad differential of consequence this is one of the areas in emergency medicine where potentially early closure can really hurt us so if we see a patient who has a known history of COPD.

who comes in short of breath 

we sometimes automatically assume that this is an exacerbation of their COPD but in reality, you want to also make sure they don't have a pneumonia that they're not having a heart attack and it's not a blood clot in their lungs so you really want to keep that differential of consequence broad to prevent missing a critical diagnosis you want to really try and avoid early closure in these patients so for respiratory distress we are starting out for the management back to the basics back to those ABCs when you walk in that room sit your patient up start them on supplemental oxygen as needed so if they're hypoxic and their oxygen levels are low go ahead and put them either on oxygen.

In their nose with a nasal cannula 

or possibly an honourary their mask as needed oftentimes I say for our patients who are shorter breath better to start off with a higher amount of oxygen and we can always titrate it down so that non-rebreather mask turned all the way up is oftentimes the way to go we want to start thinking about starting our patients on medications I'm not going to go into too much detail here but 

depending on the etiology of the 

shortness of breath we can start medications nice and early sometimes even our medics go ahead and they start people out on nebulizer treatments when they're on their way into the hospital they sometimes will start people out on nitroglycerin if there's a concern for heart failure and lastly we want to start thinking about whether a patient would benefit from non-invasive or invasive ventilation.

So what we mean by non-invasive ventilation is we start the 

patient on either continuous positive airway pressure which stands for CPAP or by level positive airway pressure I BRE v8 it as BiPAP and in those situations we place a tight-fitting mask on the patient's face and hook them up to a machine that delivers either continuous positive airway pressures so it's basically forcing air into the patient's 

lungs with a positive airway pressure 

now what BiPAP does that CPAP does is it provides support both in inspiration and expiration a key thing to remember when you're starting someone on non-invasive ventilation is they have to be able to cooperate with this treatment and they have to be breathing if someone is not able to cooperate with the treatment it's not going to work.

Because it's based on the patient's taking 

spontaneous respirations so it delivers that positive airway pressure basically when the patient inhales so patient needs to be breathing on their own now invasive ventilation is when you intubate a patient so that's when you provide someone with sedation and you go ahead and you put a breathing tube into their trachea non-invasive ventilation has really changed the way we practice emergency medicine it's been a great way to limit intubations in these invasive ventilation for patients and we know that for lots of patients who present with shortness of breath the non-invasive ventilation can decrease the amount of time they stay in the hospital and stay in the intensive care unit new non-invasive ventilation is really best for patients who present with exacerbations of COPD and exacerbations of heart failure for things like pneumonia and various other causes it might not necessarily be of as many benefits but definitely it's a great thing to reach for in order to help prevent someone from having to be intubated and can really stave off a lot of intubations for those patients.