Dyspnea

ABCs

  • vitals and keep on cardiac monitor 
  • desaturation → attach 15 L NRB mask
  • keep above 94% unless COPD/CO2 retention then target is 88 to 92% (if you are not sure keep around 92% and send urgent VBG to look for hypercapnia)

HPI & Examination

  • organ failure: heart, liver or kidney
    • overload orthopnea, PND or LL edema
    • history of diuretic use
    • history of dialysis 
  • history of IHD
    • chest pain
    • diaphoresis
    • nausea
  • venous thromboembolism or on ocps
  • fever, productive cough, sick contact, etc. 
  • history of anxiety/panic attacks
  • asthma, COPD, ILD or any underlying lung conditions
  • Review medications including diuretics or nebulizers
RED FLAGS
  • Dyspnea at rest
  • Chest pain
  • Diaphoresis​​
Examination
  • cardiopulmonary examination
  • Lower limbs → edema or signs of Dvt
RED FLAGS
  • pulmonary → low SpO2, cyanosis, stridor, signs of increased work of breathing
  • cardiac → hypotension, distant heart sounds, new murmur, pulsus paradoxus
  • neurological → decreased level of consciousness, agitation, focal neurological deficits
Plan
  • urgent ABG/VBG and CXR +/- BNP
  • keep oxygen reach target SpO2
  • Hstrop d-dimer and ECG if chest pain
THEN
  1. upper airway disease Angioedema, Anaphylaxis, Deep neck space infections or Foreign body aspiration → call for assistance to contact anesthesia and/or ENT if the airway is compromised
  2. pneumothorax → urgent CXR and call for assistance and surgical consultation 
  3. lung collapse → (unequal/absent breath sounds) urgent CXR and call for assistance and respiratory consultation 
  4. pneumonia/HAP → trace CXR for any patches send CRP PCT LFT RFT and consider empirical antibiotics after consulting with your senior
  5. pulmonary embolism → arrange CTPA if patient stable for shifting after signing consent, reviewing renal function and contacting radiology and your senior, anticoagulation might be started if CTPA could not be done or delayed. Bedside echo can be done in this case.
  6. asthma exacerbation call for assistance if silent chest, confused, drowsy, highnormal pCO2, pO2 < 90% or signs of impending respiratory failure call for assistance and ICU assessment 
    • keep on oxygen 15 L NRB
    • nebulized SABA: Ventolin 2.5 mg every 20 minutes
    • PLUS nebulized SAMA: Atrovent 0.5 mg every 20 minutes
    • PLUS IV Methylpred 40 – 60 mg 
    • reassess after 3 doses of SABA + SAMA (1 hour)
  7. signs and symptoms of overload: history of CHF, history of dyspnea orthopnea PND LL edema, high BNP, congested CXR → give IV diuretic if BP stable 
  8. stable aortic dissection call for assistance →
    • arrange CTA after signing consent, reviewing renal function and contacting radiology and your senior
    • control hypertension and heart rate: target SBP 100–120 mmHg and HR ≤ 60 
    • Start beta blocker (use nondihydropyridine CCB if β-blocker contraindicated)
    • Evaluate end-organ damage: send troponin, RFT, and lactate
  9. unstable aortic dissection → call for assistance
    • Arrange urgent bedside imaging: TEE (preferred), portable CXR, TTE, or POCUS
    • Cardio-thoracic surgeon to be involved 
    • hypotensive → hemodynamic support to target MAP ∼ 70 mm Hg 
    • hypertension → SBP 100-120 mmHg and HR ≤ 60 
    • Evaluate end-organ damage: send troponin, RFT, and lactate 
    • +/- Preoperative studies: CBC, type and screen, RFT, and coagulation profile
Notes
  • PO lasix dose is 50% of IV lasix dose 
  • lasix naive usually start with 20 to 40 mg IV
  • already on Lasix usually require 1 to 2.5 times the total daily oral maintenance dose once as bolus IV
  • if the initial dose does not result in diuresis, double the individual dose (rather than administer the same dose more frequently) until diuresis occurs
  • higher-than-usual doses may be required for patients with nephrotic syndrome or kidney failure
  • maximum effective single dose: 80 to 200 mg; maximum recommended total daily dose: 600 mg/day
MOC