Shortness of Breath: Quick Decision Making

[DISCLAIMER- This piece is not medical advise. It is intended as teaching for medical residents.]

Let's simplify a very complex problem according to the relatively few quick-acting things you can do for someone who is short of breath in the hospital.

While you're thinking of what to do, pull up the most recent CXR and if it is more than 12 hrs old, consider ordering a second one.

1- Suction. Mucus plugging can happen soon after repositioning and not be evident on imaging. Chest PT and suctioning are rarely harmful.

2- Ipratropium/albuterol nebulizer. Very commonly helpful, sometimes resolves the problem. Wheezes on exam, history of asthma/reactive airways/COPD, hyperinflated chest x-ray make this a sure bet. Duonebs are very well tolerated. 

Potential Harm:

Albuterol can drive rapid afib, delirium and anxiety. If either has been a problem, you can just give ipratropium. Trying to force a delirious patient to keep a mask on their face is a bad idea. For upper airway issues, particularly tracheobronchomalacia, nebs can be an irritant. Lastly, nebs can give false reassurance- a desperate patient wants to believe that all they need is a quick breathing treatment and can be quick to report improvement. Keep in mind that they are a temporary solution, and further work is needed to root out the underlying problem.

3- Lasix. CHF is very common, even in older patients without a formal diagnosis. Take a moment to look for CHF in the history, lasix in the home med list, congestion on the most recent imaging, how much fluid they got recently (especially maintenance fluids), BNP, extremity or sacral edema. Lasix acts quickly, causes lasting improvement, and is relatively harmless. And it provides some diagnostic utility. Don't forget to aggressively treat other drivers of CHF like hypertension in flash pulmonary edema and rapid A fib. 

Potential Harm:

Watch the kidneys (keeping in mind that volume overload can cause AKI as well).

4- Naloxone. If the patient is somnolent, naloxone is almost always a good idea. It is well tolerated, fast acting, and diagnostic. Even if a patient isn't on opioid meds, they sometimes are using their own surreptitiously. 

Potential Harm:

Almost none. In cancer patients with lots of pain, especially if on comfort focused care, naloxone is very uncomfortable.

5- Steroids. Most COPD/asthma patients are already on steroids, but if not, this can be helpful.

Potential Harm:

Hyperactive delirium, possibly fluid retention in CHF, though a few doses overnight is unlikely to cause a problem.

6- Noninvasive ventilation. For alert patients who have failed the above, BIPAP is generally well tolerated. Sometimes it makes sense to trial it on the sooner side so that a patient can get acquainted with having a mask over their face before they start to get frantic or delirious and try to pull the mask off. Checking pH and pCO2 is helpful, and a VBG is less painful than an ABG for this.

Potential Harm:

Hypotension due to increased intrathoracic pressure, aspiration in obtunded patients, unnecessary ICU transfer.

7- Foley or straight cath. Particularly in patients with multifactorial dyspnea (some CHF, some COPD, some anxiety), you are looking for every little bit that can help. Urinary retention is common, and some patients can have more than 1.5L of urine in their bladder.

Potential Harm:

Catheter associated UTI.

8- Thoracentesis (or paracentesis). Check the x-ray and breath sounds for signs of pleural effusion, pneumothorax, hemothorax. If it's easy to visualize fluid, then it'll probably feel a lot better when it's drained. Urinary retention or ascites with distended abdomen can cause a restrictive deficit.

Potential Harm:

All the harms of an invasive procedure. 

9- Morphine. 0.5 mg IV morphine, or 0.5mg IV lorazepam can be very helpful for patients in distress. We worry about respiratory suppression, but a small dose is unlikely to tip someone over the edge. For the occasional patient whose anxiety is compromising ventilation, a small dose of sedation can break a feedback loop. Remember that pure anxiety is a diagnosis of exclusion (but some anxiety always accompanies dyspnea.)

Potential Harm:

Respiratory depression, delirium.

10- Pain. Shallow breathing with atelectasis from splinting can cause tachypnea and/or hypoxia (as well as fever and look like pneumonia on chest x-ray). Patients are not usually dyspneic. Treating pain can help, though keep in mind that PE's and pericarditis hurt.

Important considerations, though unlikely to improve quickly

- Broaden antibiotics. Patients with worsening symptoms and pneumonia deserve broader coverage. Think of fungi, legionella, and multi drug resistant organisms. 

- Acute coronary syndrome. Dyspnea is often an angina equivalent, and patients with lung disease often have comorbid coronary disease. An EKG and troponin are almost never a mistake.

- Pulmonary embolism. PE is very common in COPD exacerbations. Use the Wells criteria to identify high risk patients, apply the PERC rule, and correct D-dimer for age [upper limit of normal = age/50 in mg/L FEU, age x 10 in mcg/L DDU].

- Pericardial effusion. Review CT chest, echocardiogram. Check pulsus paradoxus.


Please email criticism/questions/suggestions to astupple at gmail so I can update this post.