EMS A to Z: The Dyspneic Patient

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn 

Intro: 

Over the last year, EMS systems have experienced a lot of change and challenges. When COVID-19 was first declared a pandemic, we saw an overall decrease in call volumes and ED visits across the nation, as well as changes in our prehospital guidelines and treatments. Working during this pandemic, without a doubt, changed how we think about patient encounters for respiratory complaint. The differential diagnosis for shortness of breath, cough, or fever became much smaller in our minds as everything became “suspected COVID.” 

As we begin widespread vaccination with overall declining case numbers, I wanted to take a few minutes to remind us about some of the other things that can make a patient dyspneic, and some prehospital therapies that we may begin re-employing. Does anyone else miss nebs? I miss nebs. I know that the “data” suggests they aren’t significantly more effective than inhalers, but patients love them, I love them, respiratory therapy may not love them, but that’s ok.  

Let’s go through a few cases to remember our undifferentiated dyspnea differential diagnoses – say that 5 times fast!  

 

Case 1) 

Dispatch: 54M with dyspnea, leg swelling. You arrive to find an age-appropriate, obese appearing male, seated in his dining room, in mild-moderate respiratory distress. On your assessment, you note that he has increased work of breathing, diminished breath sounds with possibly some crackles, and lower extremity edema that goes all the way up under his gym shorts. He tells you none of his pants fit anymore, and he can only wear his house slippers... His vitals are: HR 97, RR 24, BP 170/90, SpO2 88% on RA; improves to 94% on 6L NC. His wife reports a history of hypertension. 

What is your most likely diagnosis, and some others to consider? 

CHF

ACS / arrhythmia 

Pneumonia

COPD/asthma

PE

Pneumothorax

The patient agrees to be transported to the hospital. In the back of the truck, however, he continues to be tachypneic and have increased work of breathing.  

What other therapy / ies can we give him? 

Nitro

ASA

CPAP

Just a quick reminder, nitro works in CHF by dilating blood vessels – predominately veins – and reducing the amount of venous return to the heart, making it easier for the heart to pump out the blood that’ it’s getting. The heart is like a water balloon, if it’s over-filled, some of the elasticity or squeeze is lost. Nitro also lowers BP, so it’s not recommended in patients with hypotension. CPAP works in CHF in a few different ways: first, it stents open alveoli at the end of a breath, to allow better oxygen / CO2 exchange – thereby improving hypoxia and work of breathing. It also increases the intra-thoracic pressure, which decreases blood return to the heart – similar to the nitro that we just mentioned.  

The patient is given sublingual nitro and placed on CPAP. His work of breathing, SpO2, and BP all improve en route to the ED, and he’s ultimately admitted for his likely heart failure.  

 

Case 2)  

Dispatch: 25F with shortness of breath and wheezing. You arrive on scene to find an age-appropriate female in the living room of her apartment in moderate-severe respiratory distress. On your assessment you note tachypnea, increased work of breathing, and diffuse coarse wheezes throughout her lung fields. Her vitals are: HR 130, RR 30, BP 110/70, SpO2 92% on RA. She is speaking in 2–3-word phrases, and says she has asthma, had been doing well until today, when these symptoms developed pretty quickly. She tried her home inhalers without relief.  

What is your most likely differential diagnosis, and some others to consider? 

Asthma

Anaphylaxis

Viral respiratory illness

Pneumonia

PE

Pneumothorax

Arrhythmia 

The patient requests transport to the hospital, and you appropriately start nebulized albuterol / ipratropium in the ambulance, while working on an IV for fluid bolus, solumedrol. I