acute dyspnea

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I- Introduction :

  • The DA is a common medical emergency, a leading cause of consultation d & rsquo; emergency
  • Etiologies multiples, some can be life-threatening
  • The CEO relies on & rsquo; clinical examination and simple diagnostic tests
  • Recognize respiratory major emergencies, cardiovascular or metabolic, dg which require immediate and urgent treatment

II- Definitions :

  • Dyspnea is a subjective painful sensation, a gene during breathing, felt as shortness of breath, lack of & rsquo; air, suffocation
  • Acute symptoms = < 2 weeks
  • polypnoea (tachypnée) Rapid breathing = EN > 20/me, +/- superficial
  • Orthopnea = D decubitus forcing the patient to breathe in a sitting position

III- pathophysiology :

  • Complex, imperfectly known
  • Perception in respi Device muscles, voltage mismatch (SNC) and length
  • Imbalance between & rsquo; activation of central inspired command (activator signal) and ventilatory movement (inhibitory mechanisms)
  • Signals R thoracic wall, lung, bronchial, YOU, Chemor central and Device
  • Integration in the brain stem, cortex central

IV- Diagnostic approach :

1- Examination :

  • major
  • May be sufficient alone to make the diagnosis
  • Age and sex
  • medical history
  • Features clinical dyspnea
  • cardiovascular history :
Table I. – severity of clinical signs in the presence of & rsquo; dyspnea.

+ HTA, coronary disease (angor, IDM, bridging)
+ diffuse atherosclerosis (AVC, artérite Ml)
+ Risk Factors MTE (ATCD, surgery, he tement, neoplasia)

  • pleuropulmonary history: Signs of COPD, occupational exposure (asbestos, silica, aerosols), pharmaceuticals, smoking (> 20 PA)
  • Immunodépression (VIH, blood disease, chemo) swallowing disorders, context
  • Caractéristiquescliniques:
  • Intensity
  • continuing, intermittent, repos, activity
  • Mode d&rsquo;installation, spontaneous, brutal, progressive
  • Terms & rsquo; appearance: schedule, season, triggers
  • pace, time (inspiratory, expiratory)
  • Modification parla position
  • Aggravation night
  • Seniority
  • accompanying signs

2- Physical exam :

  • simple actions
  • Signs of gravity
  • Lets make the dg, the most likely cause

A- exam Pleuropulmonaire :

  • Inspection
  • pace, thoracic deformity, abnormal movements
  • Expansion of the chest (BPCO, asthma, emphysema)
  • Decrease in & rsquo; & rsquo expansion; a hemithorax
  • Neck Inspection, hollow suprasternal, supraclavicular (print, mass, turgescence)
  • Contraction inspiratoire du muscle SCM
  • Balancement thoraco-abdominal, paradoxical chest movement
  • Flaring nose
  • Cyanose
  • Physical examination of the chest
  • Percussion : unilateral tympany, dullness
  • Auscultation : asymmetry, decreased breath sounds, crackles, wheezing, stridor, pleural friction
Dyspnea : etiological according to the & rsquo; auscultation

B- Cardiovascular review :

  • Signs of & rsquo; heart failure: jugular turgor, reflux Hépatujug, painful HPM, edema Lower limb, BP measurement
  • Auscultation: gallop, breath, arrhythmia, pericardial friction

C- Physical examination :

  • The rest of the & rsquo; examination must be complete
  • infectious syndrome, signs & rsquo; anemia, neck palpation and thyroid, cervical lymph node areas

3- Additional tests :

  • useful, confirm dgou assess the impact of the underlying disease
  • 3 simple tests: Rxthorax- ECG -gazométrie
  • Other based on context, l & rsquo; clinical examination, and results of simple tests

A- Radiography of the Thorax :

  • Oriente etiological dg
  • great interpretation sd radiological (alveolar interstitial, bronchial, vascular, pleural,,,)
  • thoracic distension (Asthma, IRSC)
  • Size of heart

B- arterial blood gases :

  • two situations: hypoxemia with hypercapnia,hypoxemia without hypercapnia
  • Hypoxemia, hypocapnia = shunt effect
  • EP, asthma, OAP, bacterial pneumonia
  • Hypercapnie

C- Electrocardiogram :

  • cardiac causes
  • myocardial ischemia, rhythm disorder, Hypertrophy, signes d & rsquo; EP (AD deviation, S1Q3, BBD…)

D- echocardiography :

  • Non invasive, cardiac cause
  • Valvulopathie, hypokinésie, cardiopathie hypertensive, pericardial effusion, signes d & rsquo; EP (acute cor pulmonale

E- other exams :

  • D-dimer
  • inflammation markers (CRP, PCT)
  • cardiac enzymes (Tropo, myoglobine, CPK, transaminases)
  • B-type natriuretic peptide (BNP) and NT-proBNP
  • CT scan
  • lung Ultrasound

V- etiological diagnosis :

1- acute asthma :

  • Dgfacile to & rsquo; history
  • Young, Crisis sibilant dyspnea night, effort or spring, ATCD personal or family d & rsquo; allergy, childhood asthma, bronchiolites)
  • wheezing, expiratory braking
  • RT (thoracic distension, triggering factor)
  • Signs of gravity, threat syndrome
  • severe asthma

etiological treatment

  • acute asthma:

β2-mimetic aerosols : Salbutamol-terbutaline (Ventoline-Bricanyl)

anticholinergic : Atrovent – Bromide & rsquo; nebulized ipratropium 5mg / 0,5mg20min, 3 times / h and then every 4 hours Corticosteroids : Solumedrol 2mg / kg, Hydrocortisone 15 mg/kg

2- bronchopneumonia :

  • Table III. – Clinical manifestations of & rsquo; hypoxia and hypercapnia.

    TIME, fever, chills, tachypnée, tachycardia

  • Cough, expectorations purulentes, pain tho
  • Dullness, crackles, breath tubal
  • opacity systematized, pleurisy, bilateral pictures
  • Specimens

Treatment :

Probabilistic antibiotic therapy early

  • fMactamine, + acid clavAmoxicilline
  • C3G: cefotaxime
  • Fuoroquinolones: Lévofloxacine
  • bacteriological samples

3- acute decompensation of COPD :

  • Tableau VII. – Main causes of acute decompensation outbreaks of & rsquo; chronic respiratory failure.

    elderly, IRC

  • factor décompensant
  • polypnoea, print, respiration abdominothoracique, sibilants
  • Signes d’ICD, right gallop
  • Signs of hypoxemia – hypercapnie .
  • Radio thorax, gasometry

Treatment :

  • β2-mimetic aerosols
  • anticholinergic
  • Mechanical ventilation
  • Trt of the cause

4- OAP :

  • Liquid d & rsquo; plasma-derived diffuses into extravascular spaces lung
  • L & rsquo; edema pulmonary capillary hypertension (OAP cardiogénique)
  • L & rsquo; edema by alveolo-capillary membrane (lesional edema)

OAP lesional

  • Increase in the permeability coefficient alveolo-capillary membrane.
  • Pulmonary capillary wedge pressure is normal or low. The liquid d & rsquo; edema has a very high protein content similar to that of plasma.
  • acute respiratory failure with subsequent possible evolution towards interstitial fibrosis : the acute respiratory distress syndrome.

etiologies :

  • infectious, influenza, septicémies, septic shock…
  • toxic, inhalation of toxic gases, ventilation with pure oxygen, inhalation of gastric fluid (syndrome de Mendelsohn).

Evolution :

  • 3 phases :
  • with sudden onset pulmonary edema
  • 2nd phase with inflammatory lesions, edema, constitution de membranes hyalines
  • 3th is the chronic pulmonary fibrosis.
  • The consequence = major gas exchange disorder, refractory hypoxemia by shunting
  • no ventilation and perfusion maintained.

OAP cardiogénique

  • sudden or chronic elevated pulmonary capillary wedge pressure.
  • Dyspnea effort, night orthopnoea, dry cough, productive, frothy, pink salmon
  • crackles, bases, "Tide", galloping left
  • RT: bilateral alveolar opacities in "butterfly wings", cardiomegaly
  • ECG: causal heart disease

3 phases

  • single venous hypertension
  • Stade d & rsquo; interstitial edema
  • Alveolar edema

etiologies :

  • left ventricular failure
  • mechanical barrier without left ventricular failure

Treatment :

  • diuretics : furosemide (Lasilix) / Bolus IV 40-80mg
  • nitrates : Di nitrate d’isosorbide, glyceryl trinitrate (Risordan, Lenitral) 1-Bmg puis perfusion 3-10mg/h

monitoring PA :

  • Tonicardiaques: Dobutamine
  • Ventilation non invasive
  • Treatment of the cause (IDM, rhythm disorder…)
Risk factor

5- Pulmonary embolism :

  • difficult diagnosis
  • Contributing factors (DVT antecedent, surgery, he tement, cancer…)
  • sudden onset
  • Dyspnea, tho pain, hémoptysies
  • RT: pulmonary infarction, ECG (CPA)
  • gasometry: hypoxémie-hypocapnie
  • D-dimer, echo + cardiography, chest CT angiography, angiography, scintigraphy

Symptom / sign

Treatment :

  • Anti coagulation curative dose : HBPM / Unfractionated heparin: massive forms
  • Thrombolyse: embolie massive, State of shock, Acute pulmonary heart
  • surgical embolectomy

6- Pneumothorax :

  • Post traumatic or spontaneous
  • Dyspnea + chest pain inspiration
  • tympany
  • Emphysema subcutaneous
  • Radio
  • Exsufflation, drainage

7- Tuberculosis :

  • Contage
  • Impaired general condition
  • d & rsquo signs impregnation, night sweats
  • Adénopathies
  • Radio: outpouring, cave, miliary, ADP
  • IDR + Research BK
  • TB treatment

8- lung cancer :

  • Impaired general condition
  • hepatocellular carcinoma
  • Radio + scanner
  • Surgery, chemotherapy

9- metabolic :

  • metabolic acidosis: DKA. Acute renal failure…
  • etiological treatment

10- neuromuscular :

  • Polyradiculonévrite aigue PRN, myasthénie…
  • specific treatment
  • Mechanical ventilation

11- intra bronchial foreign body :

  • young child
  • Context
  • of suffocation, penetration syndrome
  • Radio + scanner
  • bronchoscopy

12- laryngeal edema :

  • Angioedema
  • Anaphylactic shock
  • Traumatic
  • Adrenaline, corticosteroids

13- other diagnoses :

  • Strangulation, submersion, drowning…
  • Intoxication

14- CO poisoning :

  • Carbon monoxide
  • odorless, colorless, tasteless
  • Frequent and serious
  • Ie cause of poisoning deaths
  • L & rsquo; hemoglobin has an affinity 230 times greater for CO for the & rsquo; oxygen

pathophysiology :

  • hypoxia, secondary to the formation of carboxyhemoglobin (HbCO)
  • independent cellular toxicity of & rsquo; hypoxemia immunological and inflammatory components

initial signs : headaches, nausea, vomiting, consciousness disorders, memory, dizziness, fatigue

Signs of gravity : coma, calm hypertonic, trismus, convulsions

vegetative signs : hyperthermia, sweats and pink coloring "cochineal" of integument

  • HTA, Rhabdomyolysis and acute renal failure, respiratory distress
  • ECG : tachycardia, arrhythmias, disorders repoiarisation, myocardial infarction
  • Collective character and Seasonal
  • Laboratory diagnosis:
  • Oxycarbonémie (mi/100ml) > 0,2ml/100mii
  • Assay carboxyHb > 5%
  • CPK, Troponine: MYOC ischemia, muscular
  • creatinine: IRA
  • Hyperleucocytose
  • normal blood gas

Supports CO

  • The CO of the half-life is 320 minute air, 90 minute FiO2 100%, and 23 minutes in a hyperbaric chamber to 3 atmospheres
  • Oxygen Therapy FiO2 100%
  • Normobaric at high concentration mask
  • 12 L / min for 6 hours
  • Indications: absence of symptoms and COHb < 15%
  • hyperbaric oxygen Therapy:
  • Indications :
  • Loss of even brief knowledge, disturbance of consciousness, convulsions, neurological signs, pregnancy, child, cardio preexisting lung disease, change of & rsquo; ECG
  • HbCO > 15% with symptoms
  • HbCO > 25% even without symptoms
  • Cons-indications: undrained bronchospasm major pneumothorax

WE- Treatment :

Symptomatic treatment :

  • Sitting
  • Oxygé nothérapie(Sa02>90%)
  • intravenously
  • Airway
  • Extraction of the toxic atmosphere
  • ICU admission (signs of severity)

ventilatory support :

  • Indications : refractory hypoxemia, respiratory exhaustion, consciousness disorders
  • conventional mechanical ventilation : Tracheal intubation after sedation
  • Ventilation non invasive VNI: Masque facial, requires awareness and patient cooperation (OAP, BPCO, pneumonia, immunosuppressed)

VII- Conclusion :

  • Acute Dyspnea is a common reason for emergency consultation
  • The diagnosis is mainly based on clinical examination and simple diagnostic tests
  • Early etiological diagnosis allows you to start appropriate treatment, pledge of better prognosis

Dr FOUGHALI's course – Faculty of Constantine