Acute Shortness of Breath in the Hospital

Setting: A Step-Wise Approach

Gregory C. Kane, MD, FACP

The Jane and Leonard Korman Professor of Medicine

Chair of the Department of Medicine
Acute Dyspnea: The Basics
• ABC’s
• Airway is the airway patent?
• Breathing are respirations present, labored?
• Circulation what are the pulse and BP?
• Place the patient on oxygen
• Now take your own pulse
• Consider the setting/obtain the history
• Examine the patient
• Establish a Differential Diagnosis
Basic Evaluation
• ECG
• CXR
• ABG
• General Blood work; CBC for anemia, SMA for acidosis
Secondary Evaluation
• D-dimer
• CBC, Chemistry panel (7)
• U/S LE
• Echo
• CT angiography
• V/Q scan
• Blood gas with co-oximetry
Causes of Dyspnea
 Causes of Dyspnea
• Metabolic

• Cardiac • Poison

• Pulmonary • sepsis

• Metabolic
• Anemia

? Anemia
Acute Dyspnea: Cardiac Causes
• Myocardial ischemia/infarction with pulmonary edema
• Decompensated heart failure
• Pericardial tamponade
• Tachyarrhythmia
• Post – MI complications
• MR,
• VSD,
• free wall rupture
Cardiac Risk Factors
• Age and sex
• Family history
• Diabetes
• Smoking
• HTN
• Lipids
• Obesity
• Other (C reactive protein, homocysteine, alcohol)
 Acute Dyspnea: Pulmonary Causes
• Airway obstruction
• Bronchospasm
• Pneumonia
• Aspiration
• Drug reaction
• Non-cardiogenic pulmonary edema (ARDS)
• Pulmonary embolism
• Neuromuscular failure
• Large pleural effusion or hem thorax
 Acute Dyspnea: Other
• Anemia
• Sepsis
• Toxin
• Drug reaction
Case 1
• 42 yr. woman with metastatic breast cancer (bone and liver)
is hospitalized for neutropenia and fever.
• She is treated with Abx and fluids
• On the 3rd hospital day she has improvement in fever and
return of WBC.
• On the 4th day she develops sudden shortness of breath and
lightheadedness
Case 1 - Exam
• BP 90/70, P 116, R 28, SpO2 92% on 4liters O2, afebrile.
• JVD is noted and generalized LE edema.
• Lungs are clear, except a few crackles noted at left base
• Heart rate is rapid, but regular.
Case 1 - Differential
Case 1 - Differential
• PE
• Pneumonia
• CHF (? Adriamycin)
• Pericardial metastasis
• Pleural effusion (metastasis)
Hampton’s Hump
Case 1 - Studies
• EKG Sinus tachycardia, no ST changes
• WBC now 7.5 with 80% polys
• Platelets 172K
• CXR (shown); no CHF
• Echo good LV function, no effusion, TLS
Case 1 – Action Plan
Case 1 – Action Plan
• Anticoagulation?
• Diagnostic studies
• Follow-up
Case 1 Further Course
• The patients peripheral IV is lost
• There are no good veins due to chemotherapy
• A decision is made to attempt a R subclavian line but with
out success
• Just after this dyspnea worsens
Case 2
• 60 year old man, recovering from an MI on hospital day 3
develops sudden shortness of breath.
Case 2 - Exam
• BP 100/60, P 126, R 32, SpO2 88% on 4liters O2, afebrile.
• The patient is awake and anxious.
• Lungs show crackles bilaterally
• Heart rate is rapid, but regular. A blowing 3/6 murmur is heard
at apex radiating into the apex
Case 32 A.
Radiographic Findings in CHF
• Cephalization
• Pleural effusion (fluid in the fissure)
• Cardiomegaly
• Perihilar fullness
• Pulmonary vascular congestion
• Alveolar infiltrates (basilar and dependent)
• Kerley B lines
• Peribronchial cuffing
 Karley's A, B, and C Lines

Kerley's A lines (arrows) are linear opacities extending from the periphery to the hila; they are
caused by distention of anastomotic channels between peripheral and central lymphatics. Kerley's
Koga T, Fujimoto K. Med 2009;360:1539-
B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural
1539.
surface at the lung base; they represent edema of the interlobular septa.
Kerley's C lines (black arrowheads) are reticular opacities at base's: Kerley's B lines en face.
Case 2 - Differential
Case 2 - Differential
• Extension of MI
• New ischemia
• Rupture MV chordae with wide MR
• VSD
• Pericardial tamponade
Case 2 - Studies
• EKG shows similar findings from the 2nd day
• ABG 7.42, PaCo2 32, PaO2 54mmHg
• CXR shows pulmonary edema
• Echo shows severe MR, LV function moderately reduced
Case 2 – Action Plan
• Diuresis
• Oxygen
• IABP
• Call your CT surgeon
Case 3
• A 58 yr. man comes to the ER with intermittent chest pain
and dyspnea.

• He has a history of increased cholesterol and leads a

stressful lifestyle as a salesman for a busy medical device
company. His father had an MI at age 60.
Case 3 - Exam
• BP 170/95, P 98, R 24, SpO2 92% on RA, afebrile.
• No JVD.
• Lungs are clear.
• Heart rate is rapid, but regular. No murmur
• Patient appears anxious.
ECG obtained in the ER
What is the concern?
Course in ER
• Patient is given aspirin, oxygen, SL Ntg and pain is relieved
after 10-15 minutes
• Follow-up ECG is obtained
• Initial enzymes are negative
Case 3 - Differential
Case 3 - Differential
Case 3 - Management
• Anti- platelet
• Glycoprotein IIb/IIIa
• Anticoagulation
• Analgesia?
• Oxygen
• Beta blockade
• Blood pressure control
• Invasive strategies
Case 3 – A Different ECG
Diagnosis of MI

• Clinical presentation
• ECG
• Laboratory confirmation
Diagnosis of MI
Test Onset Peak Duration

CK and CK- 3-12 hrs. 18-24 hrs. 36-48 hrs.

MB
Troponins 3-12 hrs. 18-24 hrs. Up to 10
days
Myoglobin 1-4 hrs. 6-7 hrs. 24 hrs.

LDH 6-12 hrs. 24-48 hrs. 6-8 days

Case 4
• A 68 year retired banker is receiving radiation for a large
esophageal cancer.

• PMHx was otherwise negative

• Social hx significant for heavy alcohol use and smoking.
• He is admitted with dehydration for IVF’s.
Case 4
• After 3 days of rehydration a decision is made to place a PEG
tube.

• That night the patient develops fever and shortness of

breath.
Case 4 - Differential
Case 4 - Differential
• Pneumonia
• Aspiration
• Sepsis
• PE
• CHF
• MI
Case 4 - Management
• Studies (ECG, Doppler U/S)
• Oxygen
• Antibiotics
• Cultures and evaluation for source
• Possible ICU transfer
• DVT prophylaxis if no acute clot
Case 5
• 21 yr. woman was injured in a MVC
• Unrestrained driver
• Prior alcohol abuse, depression

• Intubated in the field

• Admitted to a trauma unit
Course
• ORIF left arm, left leg
• Multiple facial fractures
• Extubated and did well on day 5
• Discharged day 7
In Rehab Hospital
• One week after admission
• Gestures at throat
• Intermittent wheezing, ? stridor
• Seems to worsen with albuterol?
• Given racemic epinephrine
• Improves and is observed
What is the DDx?
Flow Volume Loop
Action Plan
• Concern for tracheal stenosis
• IV steroids, racemic epinephrine nebulizer
• Start Heliox (lower resistance gas)
• Consult ENT, Trauma, Anesthesia
• Oral intubation may be hazardous
 Airflow Through Tubes

R tube= 8 n length
. Pi x (radius)4
Acute Dyspnea in the Hospital: Summary
• ABC’s
• Airway is the airway patent?
• Breathing are respirations present, labored?
• Circulation what are the pulse and BP?
• Consider the setting/obtain the history & exam
• Establish a Differential Diagnosis
• Rule out the worst first (MI, PE, CHF,
Pericardial disease)
• Pursue Preliminary Diagnostic Studies
• Consider empiric therapy
• Establish Final Diagnosis
Keep in Mind What You are Going to See?
 Table 4. Reasons, Interventions, and Disposition Following RRT Activation (n = 143)a.

Sharek, P. J. et al. JAMA 2007;298:2267-2274

.
Establishing a Rapid Response Team (RRT) in an Academic Hospital:
One Year's Experience

Journal of Hospital Medicine

Volume 1, Issue 5, pages 296-305, 11 OCT 2006 DOI: 10.1002/jhm.114
http://onlinelibrary.wiley.com/doi/10.1002/jhm.114/full#fig3
Diagnoses in RRT Activation
Table 1. Diagnoses in Rapid Response Team
(RRT) Activation
Pulmonary 32%
Hypoxia/Respiratory
Distress (32%)
Neurological 14%
Change of mental
status (7%)
Syncope (7%)
Cardiac 11%
Hypotension (8%)
Arrhythmia (2%)
Hypertension (1%)
Hematologic 2%
Bleeding (2%)
Endocrine 1%
Hypoglycemia (1%)
Other reason not listed 32%
No reason given 9%
Acute Dyspnea in the Hospital: Summary
• ABC’s
• Airway is the airway patent?
• Breathing are respirations present, labored?
• Circulation what are the pulse and BP?
• Consider the setting/obtain the history & exam
• Establish a Differential Diagnosis
• Rule out the worst first (MI, PE, CHF,
Pericardial disease)
• Pursue Preliminary Diagnostic Studies
• Consider empiric therapy
• Establish Final Diagnosis
Right sided Pneumothorax
Congestive Heart Failure
Pleural Effusion
Westermark’s Sign for PE
Hampton’s Hump