Shortness of Breath

Differential Diagnosis

  • Respiratory
    • Airway problems
    • Obstruction (FB aspiration)
    • Obstructive lung disease: COPD, Asthma
    • Restrictive lung disease
    • Infectious (pneumonia, TB, pleurisy)
    • Pulmonary edema
    • Pulmonary effusions
    • PE (see chest pain notes)
    • Pneumothorax
  • Cardiovascular
    • CHF
    • MI
    • Pericardial effusion
    • Anemia
  • Metabolic
    • Acid-base imbalance
  • MSK

History

  • Onset, Duration/Frequency, Severity
  • Symptoms associated? Chest pain, fever/chills, B symptoms, edema
  • PMHx, Rx, Smoking/Drugs/EtOH
  • Specifics: Well’s criteria met?



 

Physical exam

  • Vitals
  • Full respiratory exam (WOB?)
  • CVS exam

Investigations

  • Imaging
    • CXR (PA and lat)
    • VQ or spiral CT if mod-high probability PE
  • Blood work
    • CBCD, Lytes, BUN Cr
    • D dimmer if low probability PE
  • ABG

Pneumonia Severity Index

Used for scoring patients with pneumonia in order to determine course in hospital.  Older patients, those with multiple medical problems, or those with hypoxia are likely to be admitted, while younger more healthy patients can usually be treated on antibiotics as an outpatient.

*If patient scores ≤ 90 points – may be treated as a outpatient

*If patient scores >90 pointes – admit to hospital and may even consider IV antibiotics

Systemic Inflammatory Response Syndrome (SIRS)

2 or more of the following criteria must be met:

  • Heart rate > 90 beats per minute
  • Body temperature < 36 or > 38°C
  • Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 < 32 mm Hg
  • White blood cell count < 4000 cells/mm3 or > 12000 cells/mm3 or the presence of > 10% immature neutrophils

Should SIRS criteria be met and an infection source be identified (blood culture or tissue specimen) then the patient has sepsis.

Pediatric airway versus adult airway

  • Infant larynx:
    • Found more superiorly
    • Shorter, floppier epiglottis
    • Vocal cords slanted
    • Larynx cone-shaped (narrowest area is the subglottic cricoid ring)
    • Softer, more pliable
  • Larger tongue
  • Larger head
  • May be obligate nose breather (<3 months)

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