(Last Updated On: 3 March 2020)

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:

• 

  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:

• 

  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

CO support

• 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