Dyspnea and Respiratory Distress
Shortness of breath or dysnpea is the sensation of difficulty the breathing. Acute respiratory distress is a more severe form of dyspnea
History
Want to always get a detailed history from the patient. When did the shortness of breath start, how long does it last, any exacerbating or alleviating factors. Ask about associated symptoms of chest pain, wheezing, nausea, vomiting, fevers, cough, lower extremity swelling. Ask about orthopnea and paroxysmal noctual dyspnea (PND). Are they getting IV fluids, any recent medications?
Physical examination
General: evaluate mental status, are they altered? In respiratory distress with tachypnea, increased work of breathing and using accessory muscles of respiration, nasal flaring?
Get vital signs
Pulmonary exam: look for decreased breath sounds, rales, wheezes, tracheal deviation, poor air movement
Cardiac Exam: listen for murmurs, gallops
Extremities: look for lower limb swelling, bilateral or unilateral, cyanosis? Clubbing?
Causes of respiratory distress
Cardiac:
-left heart failure (due to ischemic heart disease, anemia, cardiomyopathy, myocarditis, pericarditis), pericarditis, valvular heart disease
Pulmonary:
-asthma, COPD, pleural effusions, aspiration, pneumothorax, pulmonary embolism, Tuberculosis or any pulmonary parenchymal disease such as pneumonia, pulmonary hypertension
Diseases of the chest:
-wall and muscles, spine, diaphragm, or pleura
Miscellaneous:
-thyrotoxicosis, acidosis, gross ascites, sepsis, ARDS
Evaluation and Treatment:
-immediately sit the patient up and apply oxygen (in COPD patients, give oxygen but watch closely for hypercapnea, decrease oxygen it patient becomes sleepy)
-obtain a full set of vital signs
-obtain chest xray and EKG
-obtain full blood panel, creatinine
-if you suspect pulmonary edema -> give lasix 40 mg
-if wheezing -> give nebulizer treatments
-if febrile or you suspect pneumonia -> start antibiotics: Amoxicillin is a good first choice. However, if the patient has severe pneumonia, or can't tolerate
Respiratory Distress Clinical Cases
Case 1
50 yo male with history of hypertension presents to the hospital with new left sided hemiparesis of 1 day. When you evaluate the patient, you noted that his GCS score is 8. He is unable to give you much of a history but his wife tells you that he does not take any medication. His blood pressure is 230/110 and heart rate of 100, respiratory rate of 18.He is admitted to the ICU with new stroke and you begin blood pressure management and start tube feeds through a nasogastric tube.
The next day, you find the patient with a respiratory rate of 44 and he looks like his breathing is very uncomfortable.
1. What is your first few steps in management; what imaging tests and lab work do you want to order? (administer supplemental oxygen, perform a thorough physical exam, obtain CXR, FBP, sputum gram stain/culture. If evidence of pulmonary edema, give Lasix right away and control blood pressure. If evidence of pneumonia, start antibiotics. If evidence of bronchospasm, give salbutamol via spacer. If evidence of DVT, check lower extremity ultrasound. Would not want to empirically anticoagulate a patient with a recent stroke)
You get a another set of vital signs, his blood pressure is 180/100 and heart rate is 120. His respiratory rate is 40 and his temperature is high at 39.0 degress celcius. On exam, you note that he is semi-conscious, responding to pain and tachypneic. You hear R sided crepitation, no decreased breath sounds or wheezing. Trachea is not deviated. Heart exam reveal normal rate with no murmurs. Chest xray is pending.
1. What is the most likely diagnosis for acute respiratory distress? (Aspiration pneumonia. Anatomically the most likely location for aspiration pneumonia is the RML, RLL because the R main stem bronchus is shorter, wider and more vertically positioned than the left main stem)
2. How will you management this patient? Will you start any new medication? (Start Antibiotics: Ceftriaxon 1 g IV daily, and Metronidazole 500 mg 8 hourly. Try to prevent further aspiration events make sure you keep the patient's head of teh bed elevated at least 30 degrees at all times)
3. What are you looking for in the chest xray? (opacification in the right lung with possible obscuring of the right heart border and/or right hemidiaphragm. Likely will also see caqrdiomegaly given long standing poorly controlled hypertension)
