05. Hypoxia and Dyspnea

7/28/2019 05. Hypoxia and Dyspnea

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Hypoxia and Dyspnea

Intern Bootcamp Lecture Series

Anne HumlJuly 15th and July 17th, 2008


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Definitions

DYSPNEA:

An abnormally uncomfortable awareness ofbreathing.

HYPOXIA:

Deficiency of oxygen-as measured by SpO2.


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Differential Diagnosis-context is inpatient with shortness of breath

or change in pulse ox.

Pulmonary Pathology

Pulmonary edema

Pneumonia

COPD/AsthmaOSA

Pulmonary embolism

PneumothoraxPlueral effusion

Etc, etc.

Extra-pulmonary Insult

CNS (hemorrhage, ischemia, drugs,tumor)

Cardiac(MI, arrythmia, HF,

pericardial process)

Abdominal (ascites, hernia)

Hematologic (anemia, sickle celldisease)

Renal (acidemia)

Psychiatric (anxiety)


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Determining the Cause

1. Before entering thepatients floor/room

2. While at the bedside

3. Diagnostictools/interpretation


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The Signout

What is the patient admitted for?

What are the co-morbidities? Pertinent medications?

Pertinent lab values?


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At the Bedside

Review flow sheet-ask the RN/assistant for statvital signs

Review recently given medications

Take a very focused history

Examine the patient

Provide immediate supportive measures


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Diagnostic Interventions

Think back to the differential: PULMONARYVS. EXTRAPULMONARY

CXR is it the lungs?

ECG is it the heart?

ABG what is the imbalance?

LABSr/o other causes.


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The Next Step

Intensification of oxygen delivery

Medications-IV, PO, inhaled

Intervention

Further imaging

Transfer

Call for reinforcement

F/U important studies

Documentation


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Case #1

75 yo male with history of a fib, CAD with ICM and OA presented to UHwith a 1 day h/o hematemesis. He underwent EGD on arrival to UH whichrevealed a peptic ulcer with a clot. His H/H was 7 and 23 respectively andthe Cherniak team had ordered 2 units of PRBC to be infused during theevening. At 11 pm, the RN on Lk 50 pages to report that the patients pulseox is 89% on 2L NC.

On review of the RECS information, you note that the patients EF on a TTEdone 1 year ago is 40%. His coumadin and ibuprofen are on hold as well asthe remainder of his home PO regimen as he is NPO. He is receiving IV PPIas well as IVF and the plan is to check serial h/h after transfusion and

advance the diet if his HCT stabilizes and there is no further evidence forbleeding.


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On arrival at the bedside

VS stat: afeb, HR 99, R 23, BP 155/90 (baselinewas 130/80) and he is 89% on 2Lwhichresponded to increased of 35% VM at 92%

Exam: pt. using some intercostal muscles forrespiration, diffuse crackles bilaterally.


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CXR


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What is your impression?

What can you expect to learn from anyadditional data obtained?

What is the next step?


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Case #2

A 93 yo female with h/o recent CVA resulting in PEG tube placement andchronic foley due to neurogenic bladder presented to the hospital from herNH where she is undergoing rehab with altered mental status. She is on theCarpenter medicine service being treated with IV antibiotics while cultures arepending. Her MS had improved after IVF administered and IV antibioticscommenced. At 9 PM on hospital day #3, you are notified by the RN on Lk

65 that the patient is requiring 6L oxygen by NC to maintain sats at 90% andher temp at 8 PM was 38.5.

On your way from T3 to examine the pt, you review her signout. You notethat she has just been transitioned to oral bactrim for her UTI and the socialworker is planning on d/c in the morning to Judson Park nursing home. Sheunderwent modified barium swallow that morning.


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On arrival at the bedside, no repeat vital signsare available.

You step into the room to exam the patient andnote that she is extremely somnolent, difficult toarouse and A&O x2.

What do you do next?


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CXR


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What is your interpretation?



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Case #3

A 56 yo female with history of breast cancer is admitted to T6with newly diagnosed brain mets. She is awaiting surgicalintervention for brain lesion by neurosurgery. You are on theRatnoff team and called by the T6 nurse that the patients HR is

increased to 122-130 and that her oxygen requirements haveincreased over the past 4 hours.

On review of your signout, you note that her brain surgery isscheduled for 2 days from today. She has been started on highdose steroids and today, she was given PRN ativan for anxiety

due to her upcoming surgery. She is also on tamoxifen, SQheparin and a PPI.


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As you approach her room, you note that herstat VS are: afeb, HR 129, BP 134/88, R 19.

You enter the room and observe a slightlydistressed female. Upon questioning, she statesthat she is anxious about her surgery. Her

breathing feels somewhat different than earlierin the day, and it hurts to take a deep breath.She states, perhaps, I am just anxious.


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CXR


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You increase supplemental oxygen and obtainABG to confirm hypoxia as well as ECG due totachycardia.

What is your biggest concern?

What is the appropriate course of action?

What do you anticipate the findings ofsubsequent studies to be?


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Case #4

A 77 yo male is admitted to the hospital by aprivate doctor to the Hellerstein service forwork-up of palpitaions/syncope. On hospital

day #2, no underlying etiology of his symptomshave surfaced. Since he was admitted on aFriday night, he is awaiting a TTE on Monday

morning, then d/c is planned. You are called bythe T5 nurse for a HR 130 and a new oxygenrequirement of 2L NC.


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As you approach the room, the patient isundergoing a 12 lead ECG and the telemetrystrip is thrown over the chart box at the door.

You note that his BP is 110/70, HR 150 andSpO2 on 2L NC is 95%.

Pt. states that he is feeling OK, some flutteringin chest. On exam, he is irreg/irreg.


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ECG


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CXR


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What is next step in management?

What do you think other studies will show?


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Case #5

79 yo male with h/o tobacco abuse who has not seen adoctor in over 15 years presented to the hospital with acellulitis of his LE. He initially had a leukocytosis and

was being given morphine for pain control. You are called by the Lk 20 RN that the patient is not

arousable. He was visited by his girlfriend approx. 4hrs ago and at that time, she requested that he have his

IV morphine. The nurse went to hang his PM dose ofvancomycin and found him to be extremely lethargic.


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On your way to Lk 20, you furiously shufflethrough your pockets for the Wearn signout.You note that the patient is on IV antibiotics, a

nicotine patch and newly initiated HCTZ forhypertension. He has an order for PRNalbuterol.

On arrival, the patient is difficult to arouse, afeb,oxygen sats on RA are 88%, his BP is stable.Lungs with diminished breath sounds bilaterally.


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Last CXR


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You obtain an ABG and note that his pCO2 ishigh and his pO2 is marginal.


What are your options for reducing pCO2?

Why did his pCO2 climb?


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References

Braunwald, et al. Harrisons Principles of InternalMedicine. New York, McGraw-Hill, 2001.

Dr. Chandrasekhars online chest x ray atlas:

www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/atlas/cxratlas_f.htm - 2k -

05. Hypoxia and Dyspnea

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