Advanced Medical Life Support

Chapter 5

Dyspnea, Respiratory Distress, or Respiratory Failure

Introduction
Dyspnea can result from a range of disorders, and can be perceived in many ways. It is a common emergency complaint, and deserves serious attention.

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Topics
Anatomy & Physiology
Assessing Respiratory Compromise

Differential Diagnosis
General Approach to the Patient in Respiratory Distress

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C ASE S TUDY
Situation
Afternoon call for respiratory distress Met in front of residence by elderly man, who says his wife is having trouble breathing.

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C ASE S TUDY
Situation
History & Findings
Patient recently released after 2-week hospital stay related to same complaint. Patient is a long-term smoker, uses home O2 at night. Patient struggling for air @ 40 breaths/min. Patient wheezing audibly & appears confused.
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Anatomy & Physiology

The Respiratory System
Nasopharynx Pharynx Epiglottis Larynx Carina R. Main Bronchus

Alveoli Thyroid cartilage Cricoid cartilage Trachea Bronchiole L. Main Bronchus Diaphragm LUNGS
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(Alveolar sacs)

Anatomy & Physiology

The Respiratory System
Superior lobe
Apex

Superior lobe
(costal surface)

Cardiac notch
Middle lobe
(in mediastinal surface)

Inferior lobe

Base RIGHT LUNG LEFT LUNG

Inferior lobe
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ANTERIOR VIEW

Anatomy & Physiology

Muscles of Respiration
Sternocleidomastoids Scalenes
(Behind sternocleidomastoids)

Intercostals

Diaphragm

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Important to Note...
There is no direct relationship between chemical hypoxia and the severity of respiratory distress.
Some patients who describe severe dyspnea exhibit normal PaO2 levels; some with abnormally low PaO2s do not complain.
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Assessing Respiratory Compromise

Scene Size-Up

Home oxygen devices Nebulizers Signs of smoking Medications

Nitrates Steroids Diuretics Antibiotics Digitalis preparations Anticoagulants
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Assessing Respiratory Compromise

Initial Impression

Posture: sitting upright Leaning on arms Using accessory muscles Unable to complete sentences Breathless at rest
Beware of bradypnea, bradycardia, agonal respiratory patterns, apnea -- all morbid signs

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Initial Patient Assessment

Quickly Consider the Essentials

Airway Breathing

Circulatory status
Mentation

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Initial Patient Assessment

Potential Respiratory Failure

Agitated (hypoxia) Confused / lethargic (hypercapnea) Bradycardic (failure imminent) Bradypneic Hypopneic Hypotensive (ominous)
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Important to Note...
When you detect respiratory failure, support respirations aggressively and without delay.
Initially via pocket mask or BVM Intubate as necessary

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Focused History
Conduct a SAMPLE history, using the OPQRST mnemonic to help you understand the history of the chief complaint.

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Focused History
SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime
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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime

ONSET: Did shortness of breath develop gradually, or suddenly?

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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime

PALLIATION / PROVOCATION: What makes symptoms better? What makes them worse?
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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime

QUALITY: Describe dyspnea? Any pain with it? (Describe the pain?)

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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation/location S everity T ime

RADIATION: If there is pain, where is it? Does it go anywhere?

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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime

SEVERITY: Does dyspnea restrict normal activities? Does it occur at rest? On a scale of 1 to 10, how severe is it?
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Focused History (continued)

OPQRST: History of the Chief Complaint

OPQRST Questions
O nset P alliation/provocation Q uality R adiation S everity T ime

TIME: How sudden was onset (over what period of time)?

Is this a new problem, or a recurrent one?

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Focused History (continued)

ADDITIONAL CONSIDERATIONS:

Have there been additional symptoms? What medications is patient taking?

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Focused Physical Examination

The physical exam should focus on determining the possible underlying causes of dyspnea.
Upper airway obstruction Cardiac disorders Respiratory disorders Neuromuscular disorders Others
anemia hyperthyroidism metabolic acidosis psychogenic causes hyperventilation

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Important to Note...
The patients overall appearance can provide important clues about underlying causes of dyspnea.
# of words / sentence Skin color Body position Overall bodily appearance
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Focused Physical Exam (continued)

First Few Steps

Assess the vital signs. Be alert for signs of respiratory failure

(bradycardia, bradypnea, apnea)

Consider temperature
(May indicate pneumonia, epiglottitis, croup, possibly pulmonary embolus)
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Focused Physical Exam (continued)

Abnormal Respiratory Patterns

Pattern Agonal
Cheyne-Stokes

Description
Cycles of alternating apnea/hyperventilation
Long, deep breaths w/ periods of apnea Deep, rapid respirations

Etiology
Elderly patients, metabolic disorders
Severe CNS disorders Metabolic acidosis

Slow, irregular, shallow, Respiratory failure, gasping breaths early resp. arrest

Apneustic
Kussmaul

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Focused Physical Exam (continued)

Areas of Special Concern

Orophyarynx
obvious foreign bodies (if visible) evidence of infection (caution!)

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Focused Physical Exam (continued)

Areas of Special Concern

Orophyarynx Chest (with cardiac examination)

inspect palpate auscultate

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Differential Diagnosis of Dyspnea

Dyspnea is a symptom, not a diagnosis!

Upper airway obstruction Respiratory disease Cardiac disease Neuromuscular disorder

Other causes
(anemia, hyperthyroid disease, metabolic acidosis)
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Causes of Dyspnea
Typical Findings: AIRWAY OBSTRUCTION
Cause Scene Size-Up History Physical Exam
Evidence of Foreign Body ingestion Sudden onset; Foreign body visible? sensation in throat Gradual onset; dysphagia Evidence of Sudden postingestion/exposure exposure onset Fever, difficulty opening mouth Itch, rash, wheezing, hypotension, nausea, cramps

Infection

Anaphylaxis
Angioedema

Sudden onset; use Swelling of face, hands, of ACE inhibitors abdominal organs

Other

Use of anticoagulants

Evidence of infection, irritants, etc. laryngospasm

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Causes of Dyspnea
Typical Findings: RESPIRATORY CAUSES
Cause Asthma Scene Size-Up
Asthma meds (esp. inhalants)

History

Physical Exam

Sudden onset, Coughing, wheezing, DOE, chest prolonged expiratory phase tightness, asthma Hx, sensation in throat Emphysema: thin, barrelchested, normal SaO2 Bronchitis: obese, low SaO2 Both: wheezing, productive cough
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COPD

Home O2 equipment Gradual onset, & /or inhalants relief w/ coughing, restrictive dyspnea, Hx of COPD

Causes of Dyspnea
Typical Findings: RESPIRATORY CAUSES
Cause Pneumonia Scene Size-Up History
Gradual onset of chills, pleuritic pain

Physical Exam
Fever, tachycardia, tachypnea, crackles, rhonchi, breath sounds in affected areas

Pleural effusion

Gradual onset of breath sounds & dullness pleuritic pain; on percussion of affected other Sx related to side underlying cause (i.e., CHF, etc.) Gradual onset Occasional friction rub
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Pleuritis/ pleurodynia

Causes of Dyspnea
Typical Findings: RESPIRATORY CAUSES
Cause Pneumothorax Scene Size-Up History
Sudden onset of pleuritic pain

Physical Exam
breath sounds, especially in apices; bass-drumlike sounds on percussion. Tension: tracheal shift, hypotension, escalating resistance to ventilatory efforts

Pulmonary embolism

Sudden onset of Cough; occasional syncope, pleuritic pain; Hx hematemesis, chest wall of recent surgery, tenderness stasis of lower limbs, or clotting impairment
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Causes of Dyspnea
Typical Findings: CARDIAC CAUSES
Cause General
Meds: diuretics digoxin, nitrates

Scene Size-Up

History

Physical Exam

Past chest pain; Basilar crackles (L-sided); cardiac Hx or risk muffled S1, split S2, gallop factors or other abnormal rhythm Gradual onset of chronic dyspnea, esp. if exertional or positional Gradual onset; positional dyspnea Rales or wheezing, ankle edema, enlarged liver, distended neck veins, esp. when liver compressed JVD, BP, muffled HS, pulsus paradoxus, narrowed pulse pressure, cardiac friction rub, enlarged liver
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CHF

Cardiac tamponade

Causes of Dyspnea
Typical Findings: NEUROMUSCULAR CAUSES
Cause ALS Scene Size-Up History
Crutches, walker, wheelchair, respirator Gradual onset; progressive muscle wasting Gradual onset; progressive muscle wasting Gradual onset; progressive muscle wasting

Physical Exam
Weakening of muscles of swallowing, speech, breathing, & proximal limbs Weakening of distal-toproximal regions, including chest muscles; sensory loss, impaired reflexes. Weakening of proximal muscles & facial muscles, worsened by use & improved by rest
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Guillian-Barre Crutches, walker, wheelchair, Syndrome respirator Myasthenia Gravis

Crutches, walker, wheelchair, respirator

Causes of Dyspnea
Typical Findings: OTHER CAUSES
Cause Anemia Hyperthyroidism Scene Size-Up History
Gradual onset Gradual onset Gradual onset Gradual or sudden onset

Physical Exam
Pale skin & membranes, HR & BP w/ bleeding Thin, oily skin hair loss; enlarged thyroid; hyperreflexia Kussmauls respirations; clear breath sounds (Diagnosis of exclusion)

Metabolic Acidosis
Psychogenic hyperventilation

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Treatment Pathway for Dyspnea

Scene Size-up Initial Assessment Airway obstruction? Respiratory failure? YES BLS measures: AIRWAY! Focused History & Physical Exam NO

General supportive measures: O2, IV access, ECG, pulse oximetry, ventilate prn Cardiac? Respiratory? Neuromuscular /other?

(continued)
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Treatment Pathway for Dyspnea (continued)

Cardiac? Respiratory? Neuromuscular /other?

Ischemic heart disease: nitrates, morphine

CHF: diuretics, nitrates, morphine

Asthma, COPD: Inhaled beta agonists

Anaphylaxis resulting in airway obstruction: epinephrine & inhaled beta agonists

Continue general supportive measures, including ventilations prn

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C A S E S T U D Y F O L L O W-U P
Assessment
Dispatched to home of elderly female c/o dyspnea. Hx: lung & heart probs, long-time smoker, home O2 at night. Recently hospitalized w/ water in her lungs; has been sleeping in a chair lately, per spouse. Impression: looks sick. Seated upright, breathing @40 & labored but via patent airway. Seems confused. Cyanosis noted around mouth & in nail beds; auscultation reveals crackles in both lungs & a gallop murmur. Pitting edema in both ankles. ECG reveals sinus tach @ 120.

Meds include albuterol & Atrovent inhalers, digoxin, Lasix and an antibiotic.

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C A S E S T U D Y F O L L O W-U P
Assessment Treatment
Administer 100% O2 via NRB mask, apply pulse oximeter, keep patient comfortable in position of choice (sitting upright). Give aerosolized albuterol, 2.5 mg & start an IV. Administer furosemide, 80mg IV and NTG SL. Transport, monitoring mentation & respirations. Respirations become more relaxed, rate drops to 32. HR falls to 104. On arrival at ED, you transfer care to staff.
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