So when someone comes in respiratory distress,
the examination, you wanna look at the patient.
You can gather so much information
just by looking at the patient from the door.
You wanna listen,
you wanna take a listen to your lungs,
that can give you a clue
as to what's going on with the patient.
If you hear wheezing,
that's potentially obstructive lung disease or asthma.
If you hear rales or crackles,
that's more likely to be CHF
and you wanna go ahead and feel the patient's chest.
You can do tactile fremitus [and nagothane 00:00:33.05]
And the key thing in patients with respiratory distress
is you're going to be treating them and examining them
potentially all at the same time.
So when someone comes in with severe respiratory distress,
often times, our treatment and our exam, and our history
are all taking place at the same time
'cause we're moving very quickly
to rapidly treat and assess the patient.
Now, a key thing with respiratory distress
is you always wanna be reassessing your patient.
So you always wanna be going back to your patient
after you've given them a certain treatment,
after you’ve given them nebulizer treatments, or diuretics,
or started them on non-invasive ventilation,
and you always wanna be going back and reassessing your patient.
Your further physical exam,
we wanna focus on the respiratory rate.
when someone is having significant respiratory distress
the respiratory rate will be elevated.
Sometimes, you wanna go ahead
and you wanna make sure you're focusing on that
and that you’re counting the respiratory rate
and seeing what it is.
Often times, it will be obvious
that the patient's respiratory rate is elevated.
You want your patient to be on a pulse oximeter,
you wanna be able to measure their oxygen saturation
and generally, peripheral pulse oximeters
are non-invasive pulse oximeters,
do a pretty good job
of measuring the patient's oxygenation.
You also wanna think about the patient's position.
So often times, our instincts
are for people to be lying flat in bed
or flat on the stretcher,
but for the most part,
if someone's in severe respiratory distress,
you want to sit them up in bed.
And the reason that you wanna sit them up in bed
is because when you’re sitting up,
you're able to take deeper inhalations
and you're able to recruit more of your lung volume.
When your laying down flat,
you’re not able to do that.
The other thing that happens
when you sit people up,
especially if they have some fluid in their lungs,
is the fluid goes to the bottom of their lungs,
and then they are able to utilize,
again, larger portions of their lung volume
and they are able to fill their lungs with more fluid.
So gravity is your friend.
Go ahead and sit those patients up,
the fluid will go down,
they're gonna be able to breathe better in that situation.
Lastly is listening.
You wanna definitely take a listen to the lungs,
you wanna see if you hear wheezes,
if you hear crackles.
If you hear crackles,
how far up those go.
Rhonchi or the other thing
that you can sometimes hear
and all of those things will point you in a direction
as to what you think is the most likely etiology
of the shortness of breath for a patient.
So in respiratory distress
the physical exam can provide you
with lots of clues to the etiology
of a patient's shortness of breath.
Go ahead and utilize that exam.
And much of that important information on the physical exam
can actually be gathered in the first few seconds
simply by walking in the room and looking at your patient.
Looking at your patient,
you could see if they are in respiratory distress,
you can touch them very quickly
and see if they are cool and clammy
or if they're warm and red.
Also, there's lots of information that you can just get
in those first few seconds.
Make sure that you utilize
those first few moments
to take a look at your patient.
So like I said, any situations
we're gonna be doing lots of stuff at the same time.
We’re gonna be examining our patient,
we're gonna be intervening on their shortness of breath,
we're gonna be reassessing them.
And then we're also gonna be thinking about
what initial test we wanna get.
So we're gonna start out
by talking about some blood tests
that you are gonna wanna get.
When thinking about shortness of breath,
we wanna focus on the blood gas.
And when we're talking about a blood gas,
for the most part in the Emergency Department,
we utilize venous blood gases.
Historically, we use to get arterial blood gases,
so we use to take blood from the artery
and send that to the lab to analyze it.
The advantage of taking an arterial blood gas
over a venous blood gas
is that an arterial gas
can help you further assess oxygenation.
Like I said, for the most part,
our peripheral pulse oximeters
that go on a patient’s finger,
do a pretty good job of assessing the oxygenation.
So for the most part in the ED,
we send a venous blood gas,
and the venous blood gas
can take a pretty good look at ventilation.
So when we're talking about ventilation,
we're talking about whether or not
that person is able to adequately
expire their carbon dioxide.
And when we're looking at a venous blood gas
and arterial blood gas,
they actually correlate pretty closely together.
The other problem with an arterial blood gas
is that they can be challenging to get.
For the most part,
arterial blood gases were obtained
from the radial artery,
which is the artery in the wrist.
Now, that's historically can be painful for patient.
So we know that patients
report a lot of pain with that procedure.
we do the venous blood gas instead.
And we can just send the venous blood gas off
with the rest of the labs that are sent off.
We wanna think about cardiac testing,
so shortness of breath is sometimes due to problems in the lungs.
But sometimes, it’s due to a problem with the heart.
So we wanna think about sending off troponin testing.
And then other basic lab test
can give you additional information as well.
So thinking about basic blood tests,
you can find out if the patient is anemic,
because anemia can cause shortness of breath.
You can find out if there's kidney failure.
The next step is thinking about imaging.
So in imaging,
we think about getting a chest x-ray.
The chest x-ray can give you lots of information.
It can take at the lung fields,
you could see if there's a pneumonia and pneumothorax,
if there's fluid in the lungs,
and it can give you a lot of information
about what's going inside the patient's lungs.
if your chest x-ray is potentially
not very revealing or you’re not sure.
You can move on and you can get a chest CT
after you get some additional information.
A chest CT scan gives you the advantage
of taking a closer look at the patient's lung fields.
The other thing that it can do
is if you administer IV contrast with the chest CT,
you can take a look at the vessels in the lungs
and see if there's a blood clot there.
Lastly, thinking about additional cardiac testing,
the EKG is something that you can get
that will look for ischemia.
So you can look and you could see
if there's any evidence
that the patient's having a heart attack,
or a myocardial infarction.
You could also look for arrhythmias.
Arrhythmias sometimes also can make people feel short of breath
such as arterial fibrillation or arterial flutter.
And then an echocardiogram.
In the Emergency Department,
we utilize bedside point of care ultrasound quite a lot,
and an echocardiogram
is something that can be obtained easily and quickly.
Studies have shown that in the Emergency Department,
emergency medicine physicians are good at figuring out
if the patient has a good EF,
a medium EF or a low EF.
So we're good at kind of approximating that
and as technology just keeps getting better,
and we are training our residents,
I think that this scale will only get utilized more and more
over the upcoming years.