Take my breath away

Terrified that a 4 am dyspnea page will leave you more short of breath than your patient? Take 10 minutes to work through this module and leverage your AMBOSS resources!

You’re an intern cross-covering overnight for the general internal medicine service. You’ve just settled into the work room and are preparing to catch up on your admission notes with a bag of salty carbs in hand…when your pager goes off.

Click the pager icon to reveal the message.

Why do I always have this black cloud on call? you wonder. You call back the listed extension, but the phone just rings...and rings. Nobody answers. Now you have a decision to make.

Question: How urgently should you assess the patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• Right now
• Once you finish your snack
• Once you’ve caught up on the admission notes

You’re on your way to see the patient. While taking the elevator up to the patient’s floor, you have a minute to collect your thoughts.

Question: What information is most crucial to know, and how are you going to find it?

Read on to see the bits of information you should collect quickly, as well as how to find them.

Signout sheet review

Hopefully your signout sheet is still in your pocket, instead of dropped somewhere in the hallway. If so, whip it out so you can find out the following information about the patient:

• Age
• Code status
• Admission diagnosis or reason for hospitalization
• Past medical history, procedures, and interventions
• Medications
• Allergies
• Recent remarkable labs

More information, please...

• If you can’t find this information on your signout sheet, then pull up the patient's electronic health record, either on your phone or on a computer on wheels (“cow”), which you can bring into the patient's room.

• And, thinking ahead, once you find the patient’s nurse, you’ll also want to get a quick report about:

  • Onset and progression of symptoms
  • Other associated symptoms

You arrive at the nurse’s station, but it's deserted—a potluck is happening in the break room. It's somebody’s birthday, and there are so many delicious-smelling dishes that you immediately feel a cephalic phase rise in your gastric acid secretion. You look for the patient’s nurse and hope beyond hope that there will still be some food left when you’re done taking care of the patient.

Question: When you find the patient’s nurse, what do you do?

Make your choice, then click on the explanation bubble to reveal the answer.

• Get a quick report about the patient’s symptoms, then encourage the nurse to go enjoy the potluck.
• Ask the nurse to come with you to the patient’s bedside and to give you a quick report as you go.

  When the situation may be critical, don’t assess the patient alone. Bring the nurse (or other staff) along so you have backup if you need to call for help and another set of hands in case you need to start an intervention (e.g., ECG, oxygen therapy).

You and the nurse arrive at the patient's room.

Question: Which of the following can you immediately assess from the doorway?

Make your choices, then click on the explanation bubbles for more information.

• Position of the patient
• Mental status
• Respiratory rate and pattern
• Signs of respiratory distress
• Signs of increased work of breathing
• Vital signs
• Presence of ongoing oxygen therapy

That's right—all of the above!

You can learn a lot in just a few seconds, so gather up those visual details and auditory clues! Then use your immediate impression of how sick the patient is to prioritize initial management.

“Two roads diverged in a yellow wood…”

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module:

• Option 1: Impending respiratory failure
• Option 2: Shortness of breath with stable vital signs

Your patient's still breathing. Now you can breathe again too...and hopefully enjoy some leftover food from the potluck!

• You did a great job:
  • Establishing the context to quickly triage a potentially critically ill patient
  • Recognizing when to call for help (Option 1)
  • Prioritizing initial management over diagnostics (Option 1)
  • Expanding your assessment when emergency treatment wasn't required (Option 2)
  • Using a focused history and physical to identify life-threatening causes of dyspnea (Option 2)
  • Ordering basic tests appropriate for most patients with undifferentiated dyspnea (Option 2)
• Of course, the differential for dyspnea is broad, and further management will depend on the diagnosis. Try these flowcharts as a starting point.

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with dyspnea!

Personal story from an AMBOSS clinician

I had just started my early morning Saturday call shift when I was called STAT to the ICU for a respiratory emergency. Upon arrival, I saw two respiratory therapists and two nurses attempting bag-valve-mask ventilation on a young woman with an obvious head and neck deformity (her neck was flexed over 60° anteriorly and 45° laterally). The patient was diaphoretic, deeply cyanotic, and struggling to sit up. The monitor was alarming for tachycardia (heart rate 165 beats/minute), the blood pressure cuff was cycling without reading, the pulse oximeter had no waveform, and capnography was only intermittently displaying an end-tidal CO₂ (EtCO₂) of 10 mm Hg.

Within seconds, the patient became unresponsive, and the ECG rapidly progressed from tachycardia to coarse ventricular fibrillation to asystole. A code was called and CPR started. Bag-valve-mask ventilation was difficult even with two providers and an oral airway in place. An anesthesiologist arrived quickly and was able to intubate the patient's trachea, but ventilation was still difficult. Peak pressures over 60 cm H₂O produced only minimal chest rise and tidal volume return. The patient remained in asystole despite high-quality ACLS, and resuscitation efforts were terminated after 15 minutes.

The sentinel event report included the following:

• The patient had been admitted with community-acquired pneumonia less than 20 hours prior to the code.
• She had a history of ankylosing spondylitis, and during treatment of pneumonia one year earlier, intubation was difficult and weaning her from ventilation took 8 weeks.
• Her family was eager to avoid another intubation, though the patient had full code status.
• Throughout the night, frequent escalation of oxygen therapy for intermittent hypoxia was necessary: low-flow nasal cannula oxygen, then face-mask oxygen, then high-flow nasal cannula (HFNC), and finally BiPAP one hour before the code.
  • After each escalation, oxygen saturation improved to 100%.
  • Until shortly before the code, end-tidal CO₂ was detectable and 20–25 mm Hg.
  • One blood gas was obtained while the patient was on HFNC at 60 L/minute: pH 7.40, PaO₂105 mm Hg, and PaCO₂43 mm Hg.
  • The covering team, wanting to honor the family's wishes, felt these findings indicated acceptable oxygenation and ventilation and opted not to proceed with intubation or noninvasive mechanical ventilation.
• The cross-covering team had left one note, which did not mention the progressive tachypnea, tachycardia, and hypertension or the nurse's notation that the patient was “struggling to breathe.”
• Autopsy results were consistent with diffuse ARDS.
• Conclusion of the investigation: Earlier intervention (i.e., intubation and high PEEP, low tidal volume ventilation) might have prevented the cardiac arrest.

The lesson I learned: Do not be fooled by reassuring oxygen saturations or isolated ABG results if a patient has evidence of progressive respiratory failure. Believe your eyes! There is no substitute for your examination when determining if the work of breathing is unacceptably high and the patient is at risk for respiratory failure.