I- Introduction:
- AD is a common medical emergency, one of the main causes of emergency consultation
- Multiple etiologies, some can be life-threatening
- The dg is based on clinical examination and simple paraclinical examinations
- Recognize major respiratory, cardiovascular or metabolic emergencies that require immediate dg and urgent treatment
II- Definitions:
- Dyspnea is a painful subjective sensation, a gene during breathing, felt like shortness of breath, lack of air, choking
- Acute – symptomatology< 2 semaines 2=””></ 2 semaines>
- Polypnea (tachypnea) – rapid breathing EN – 20/min, shallow
- Orthopnea – Decubitus D that forces the patient to breathe while sitting
III- Pathophysiology:
- Complex, imperfectly known
- Perception in the muscles respi periph, inadequacy tension (CNS) and length
- Disbalance between activation of central inhalecommand (activator signal) and ventilatory movement (inhibitory mechanisms)
- Signals R chest wall, pulmonary, bronchial, VAS, central chemoR and periph
- Integration into the brainstem, central cortex
IV- Diagnostic approach:
1- Interrogation:
- Major importance
- May be enough on its own to make the diagnosis
- Age and sex
- Pathological history
- Clinical characteristics of dyspnea
- Cardiovascular history:

HTA, coronary artery disease (angor, IDM, bypass)
Diffuse Atherosclerosis (stroke, Arteritis Ml)
Risk factors for MTE (ATCD, surgery, bed rest, neoplasia)
- Pleuropulmonary history: Signs of COPD, occupational exposure (asbestos, silica, aerosols), medications, smoking (20 PA)
- Immunodepression (HIV, hemopathy, chemo) swallowing disorders, context
- Clinical features:
- Intensity
- Continuous, intermittent, rest, activity
- Installation mode, spontaneous, brutal, progressive
- Conditions of appearance: schedule, season, triggers
- Rhythm, time (inspiratory, expiratory)
- Change by position
- Aggravation at night
- Seniority
- Accompanying signs
2- Physical review:
- Simple gestures
- Signs of gravity
- Makes dg, the most likely cause
A- Pleuropulmonary review:
- Inspection
- Rhythm, chest deformity, abnormal movements
- Chest dilation (COPD, asthma, emphysema)
- Decrease in the expansion of a hemithorax
- Neck inspection, over-sternal hollow, over-clavicular (drawing, mass, turgescence)
- Inspiratory contraction of SCM muscle
- Thoraco-abdominal swing, thoracic paradoxical movement
- Flapping the wings of the nose
- Cyanosis
- Physical examination of the chest
- Percussion: unilateral tympanism, dullness
- Auscultation: asymmetry, decreased vesicular murmurs, crackling rails, sibilant rattles, stridor, pleural friction

B- Cardiovascular review:
- Signs of heart failure: jugular turgescence, Hepatujug reflux, painful HPM, inf limb edema, PA measurement
- Auscultation: galloping noise, breath, arrhythmia, pericardial friction
C- Clinical review:
- The rest of the exam must be complete
- Infectious syndrome, signs of anemia, neck and thyroid palpation, cervical lymph node areas
3- Additional reviews:
- Useful, confirm the dgou assess the impact of the causal disease
- 3 simple exams: Rxthorax- ECG -gasmetry
- Other context functions, clinical examination, and simple exam results
A- Thorax X-ray:
- Orients the etiological dg
- Interpretation large radiological sd (Interstitial alveolar, bronchial, vascular, pleural,,,)
- Chest distension (Asthma, IRsC)
- Heart size
B- Arterial gas:
- Two situations: hypoxemia with hypercapnia, hypoxemia without hypercapnia
- Hypoxemia-hypocapnia – shunt effect
- EP, asthma, OAP, bacterial lung disease
- Hypercapnia
C- Electrocardiogram:
- Heart causes
- Myocardial ischemia, rhythm disorder, Hypertrophy, signs of EP (AD deviation, S1Q3, BBD…)
D- Echocardiography:
- Non-invasive, heart cause
- Valvulopathy, hypokinesis, hypertensive heart disease, pericardial effusion, signs of PE (acute pulmonary heart
E- Other reviews:
- D-dimers
- Inflammation markers (CRP, PCT)
- Cardiac enzymes (Tropo, myoglobin, CPK, transaminases)
- Type B (BNP) and NT-proBNP natriuretic peptide
- Chest scanner
- Pulmonary ultrasound
V- Etiological Diagnosis:
1- Acute asthma:
- Dgfacile to history
- Young, Nocturnal Wheezing Seizures, Stress or Spring, Personal or Family Allergy ATCD, Childhood Asthma, Bronchiolitis)
- Sibilants, expiratory braking
- RT (chest distension, triggering factor)
- Signs of severity, threat syndrome
- Severe acute asthma
Etiological treatment
- Acute asthma:
2-mimetic aerosols: Salbutamol-terbutaline (Ventoline-Bricanyl)
Anticholinergics: Atrovent – Ipratropium Bromide Nebulization 5mg/0.5mg20min, 3 times/h then every 4h Corticosteroids: Solumédrol 2mg/kg, Hydrocortisone 15 mg/kg
2- Bronchopneumonia:
-
Table III. – Clinical manifestations of hypoxia and hypercapnia. AEG, fever, chills, tachypnea, tachycardia
- Cough, purulent sputum, tho pain
- Mateity, Crepe, tubal breath
- Systeria opacity, pleurisy, bilateral images
- Levies
Treatment:
Probabilistic early antibiotic therapy
- fMactamine, clavAmoxicillin acid
- C3G: Cefotaxim
- Fuoroquinolones: Levofloxacin
- Bacteriological samples
3- Acute DEcompensations of COPD:
-
Table VII. – Main causes of acute flare-ups of decompensation of chronic respiratory failure. Elderly subject, IRC
- Decompensating factor
- Polypnea, drawing, abdominothoracic breathing, sibilants
- ICD signs, right gallop
- Signs of hypoxemia – hypercapnia.
- Chest radio, gasmetry
Treatment:
- 2-mimetic aerosols
- Anticholinergic
- Mechanical ventilation
- Trt of the cause
4- OAP:
- Plasma liquid diffused in extravascular spaces of the lung
- Pulmonary hair hyperpression edema (cardiogenic OAP)
- Edema by alteration of the alveolo-capillary membrane (lesional edema)
OAP Lesional
- Increased permeability coefficient by alteration of the alveolo-capillary membrane.
- Pulmonary hair pressure is normal or low. The edema liquid has a very high protein content close to that of plasma.
- Acute respiratory insufficiency with possible subsequent progression to interstitial fibrosis: acute respiratory distress syndrome.
Etiologies:
- Infectious, flu, sepsis, septic shock…
- Toxic, inhalation of toxic gases, ventilation of pure oxygen, inhalation of gastric fluid (Mendelsohn syndrome).
Evolution:
- 3 phases:
- Brutal start with pulmonary edema
- 2nd phase with inflammatory lesions, edema, hyaline membrane constitution
- 3rd is chronic pulmonary fibrosis.
- The consequence – major gas exchange disorder, shunt-refractory hypoxemia by shunt effect
- Zero ventilation and sustained infusion.
Cardiogenic OAP
- Sudden or chronic elevation of pulmonary hair pressure.
- Stress dyspnea, nocturnal orthopnea, dry cough, productive, frothy, salmon pink
- Crackling rails, bases, “rising tide,” left gallop
- RT: bilateral alveolar opacities in “butterfly wings”, cardiomegaly
- ECG: causal heart disease
3 phases
- Simple venous hypertension
- Interstitial edema stadium
- Alveolar pulmonary edema
Etiologies:
- Left ventricular insufficiency
-
Mechanical obstacle without left ventricular insufficiency
Treatment:
- Diuretics: Furosemide (Lasilix) / Bolus IV 40-80mg
- Nitrous derivatives: Isosorbide di nitrate, trinitrine (Risordan, Lenitral) 1-Bmg then infusion 3-10mg/h
PA surveillance:
- Tonicardiaques: Dobutamine
- Non-invasive ventilation
- Treatment of the cause (IDM, rhythm disorder…)

5- Pulmonary embolism:
- Difficult diagnosis
- Favourable factors (DVT history, surgery, bed rest, cancer…)
- Brutal start
- Dyspnea, pain tho, hemoptysis
- RT: pulmonary infarction, ECG (CPA)
- Gasoline: hypoxemia-hypocapnia
- D-dimers, echo – heartwriting, thoracic angioscanner, angiography, scan

Treatment:
- Anticoagulation with curative dose: HBPM / Non-split heparin: massive forms
- Thrombolysis: massive embolism, shock, acute pulmonary heart
- Surgical embolectomy
6- Pneumothorax:
- Traumatic or spontaneous post
- Dyspnea – Inspiration chest pain
- Tympanism
- Emphysema under the skin
- Radio
- Exsufflation, drainage
7- Tuberculosis:
- Contage
- Alteration of the general condition
- Signs of impregnation, night sweats
- Adenopathies
- Radio: effusion, cave, miliaire, ADP
- IDR – BK research
- Tuberculosis treatment
8- Lung cancer:
- Alteration of the general condition
- Primary cancer
- Radio – scanner
- Surgery, chemotherapy
9- Metabolic:
- Metabolic acidosis: diabetic ketoacidosis. Acute kidney failure…
- Etiological treatment
10- Neuromuscular:
- Acute PRN polyradiculonéuritis, myasthenia…
- Specific treatment
- Mechanical ventilation
11- Intra bronchial foreign body:
- Young child
- Context
- Suffocation access, penetration syndrome
- Radio – scanner
- Bronchoscopy
12- Laryngé edema:
- Quincke’s edema
- Anaphylactic shock
- Traumatic
- Adrenaline, corticosteroids
13- Other diagnoses:
- Strangulation, submersion, drowning…
- Intoxication
14- CO poisoning:
- Carbon monoxide
- Odorless, colourless, insipid gas
- Frequent and serious
- The cause of death from poisoning
- Hemoglobin has a 230 times stronger affinity for CO than for oxygen
Pathophysiology:
- Hypoxia, secondary to carboxyhemoglobin (HbCO) formation
- Cell toxicity independent of hypoxemia immunological and inflammatory components
Initial signs: headache, nausea, vomiting, impaired consciousness, memory, dizziness, fatigue
Signs of gravity: deep coma, hypertonic calm, trismus, convulsions
Vegetative signs: hyperthermia, sweating and pink “cochineal” gingling of teguments
- HTA, rhabdomyolysis and then acute kidney failure, respiratory distress
- ECG: tachycardia, rhythm disorders, repoiarization disorders, myocardial infarction
- Collective character and season
- Biological diagnosis:
- Oxycarbonemia (mi/100ml) – 0.2ml/100mii
- CarboxyHb dosage – 5%
- CPK, Troponine: myocischemia, muscular
- Creatinine: IRA
- Hyperleucocytosis
- Normal gasmetry
- The half-life of co is 320 minutes in ambient air, 90 minutes in FiO2 100%, and 23 minutes in a hyperbaric chamber with 3 atmospheres
- FiO2 Oxygen Therapy 100%
- Normobare with high concentration mask
- 12 L/min for 6 hours
- Indications: no symptoms and HbCO< 15%></ 15%>
- Hyperbaric oxygen therapy:
- Indications:
- Even brief loss of consciousness, consciousness disorder, convulsions, neurological sign, pregnancy, child, pre-existing cardio pulmonary pathology, modification of ECG
- HbCO – 15% with symptoms
- HbCO – 25% even without symptoms
- Contraindications: pneumothorax not dreused major bronchospasm
VI- Treatment:
Symptomatic treatment:
- Sitting
- Oxygé notherapy (Sa02-90%)
- Venous pathway
- Airway freedom
- Extracting the toxic atmosphere
- Admission to resuscitation (signs of severity)
Ventilatory assistance:
- Indications: refractory hypoxemia, respiratory exhaustion, consciousness disorders
- Conventional mechanical ventilation: tracheal intubation after sedation
- Non-invasive NIV ventilation: Facial mask, requires patient awareness and cooperation (OAP, COPD, pneumonia, immunosuppressed)
VII- Conclusion:
- Acute dyspnea is a common reason for emergency consultation
- Diagnosis is essentially based on clinical examination and simple paraclinical examinations
- Early etiological diagnosis allows the start of appropriate treatment, a guarantee of better prognosis
Dr. FOUGHALI Course – Constantine Faculty
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