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Respiratory Distress

Resident Teaching Conference

July 16, 2010

Outline

• Definitions and Case Presentation

• Review Causes of Respiratory Distress

• Work Up/Evaluation

• Interventions/Management

Respiratory Distress

• Outwardly evident, physically labored breathing– Tachypnea                             ‐‐

Anxious

– Dyspnea                                 ‐‐

Accessory Muscle Use

– Air Hunger                             ‐‐

Short Sentences

• Hypoxemic Respiratory Failure– PaO2 <60

• Hypercarbic Respiratory Failure– PaCO2 >45

Mrs. Jones9south: ‘having some difficulty breathing’

• 65 y/o woman

• POD 3 – Low Anterior Resection – Rectal Ca.• PMHx: HTN, HLD, PVD, TIA, Rectal Ca.

• PSHx: LAR, TAH‐BSO (Hormone Replacement)

• SocHx: Tobacco 60 pk yrs, No EtOH, Retired• Exam: AF  110  140/68  28  86% 6LPM

– Generally anxious, sitting upright in bed– Wheezes throughout, Accessory mm use

Other Information….• Hospital Course  First event? Nebs?

• Timing if SOB  Acute vs. Gradual; Vitals Trend

• Associated Sx  Chest Pain/Tightness, Leg Pain

• Meds  Heparin Sub‐Q? SCD? (Ambulating?)

• Prior episodes of SOB (pre‐operative)? Admits?

Differential Diagnosis

‐

Pulmonary

‐

Cardiac

‐

Other

Differential Diagnosis• Pulmonary

– Atelectasis– Pulmonary Embolism– Pneumothorax ‐> Central Line? Thoracic Operation?– Pneumonia (CAP vs. HAP vs. VAP)– COPD– Pleural Effusion– Asthma– Aspiration– Mucous Plugging

Differential Diagnosis

• Cardiac– Acute MI

• SOB = Anginal Equivalent– CHF

• Volume Overload

– Tamponade• Aortic Dissection? Trauma? Cardiac Surgery?

Differential Diagnosis

• Other Causes of SOB/Resp. Distress/Desat.– Oversedation

• Anesthesia• Narcotics• Other Sedating Meds

– Phenergan– Benadryl– Benzodiazepines– Ambien

– CO2 Narcosis

Work‐Up

• CXR• ECG• ABG• Cardiac Enzymes

• BNP• HCT• Lytes/Creatinine• Additional Steps: LE Duplex/CT Chest

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

CXR QUIZ

A.

Pneumothorax

B.

Atelectasis

C.

Pulmonary Edema

D.

Pleural Effusions

E.

Pneumonia

F.

Mucous Plugging/Whole Lung Atelectasis

G.

COPD

ECG QUIZ

ABG 101• pH

– Acidemia (<7.35) – Normal – Alkalemia (>7.45)

• PCO2– Low (<35) – Normal – High (>45)

• HCO3 (Calculated)– Normal 24

– Check BMP CO2

ABG QUIZ• 7.21 / 68 / 26 

– Acute Respiratory Acidosis

• 7.29 / 30 / 14– Metabolic Acidosis with Resp. Compensation

• 7.20 / 60 / 18– Mixed Metabolic and Respiratory Acidosis

• 7.40 / 65 / 30– Chronic, Compensated Respiratory Acidosis

DO2 = CO x [1.34 x Hb x O2Sat] + [0.003 x PaO2]

Oxygenation   vs.   Ventilation

PaO2 and O2Sat PCO2

Management ‐

Oxygenation• Supplemental Oxygen

– Nasal Cannula

– Simple Mask

– Venturi Mask

– Non‐Rebreather

Mask

– Intubation

CPAP and BIPAP

• CPAP (PEEP)– Upper airway obstruction (Sleep Apnea)– Maintenance of functional residual capacity 

(atelectatsis)

• BIPAP– Rapidly reversible causes of respiratory distress

• Pulmonary Edema

• COPD Exacerbation

9 North and SICU Transfers

• Physiological Instability– Need monitoring or advanced nursing care

• Unclear Etiology– Need further workup/procedures

• Advanced Interventions– CPAP/BIPAP and Intubation

• Lack of Response to Basic Interventions

Review

• Respiratory Distress: Always See the Patient• Focused History and Examination

– Gather Data ‐> Patient, Nurse, Chart• Differential Diagnosis and Interventions• Work‐Up

• Interventions• Notify Upper Level & Consider SICU Transfer