Dyspnea

[Mateo_1387]

I am not quite convinced this is just COPD. I know there is a reference for pneumonia, but Pulmonary Edema is what is on my mind when I read this scenario.

So, I am curious, is this a true call Bieber? If so, we you able to do capnography (I ask because I see an EKG, yet no capnography though you indicate it as being shark fin like). Did you actually use percussion?

This is basically going to be a bunch of rambling. But...

A patient presents with a medical history of both COPD and Congestive Heart Failure. It was mentioned that he does not have peripheral edema, which its absence is not an indicator that the problem is not pulmonary edema, as there are many causes. Since the patient presents with nocturnal dyspnea, his blood pressure is high, JVD present, I just get the feeling that that there is a pulmonary edema component. Now, I know it is not much evidence for pulmonary edema, yet I get the feel that it is. Actually, I really think that it could be a combination of both problems. Though, I do lean towards the pulmonary edema.

Of course, I am basing a lot of this off the idea that you did not use percussion and capnography, though I would expect a loss of plateau for a COPD patient, especially with advanced disease.

So, I'll jump on a limb and go down the pulmonary edema route. At a minimum, I'd use Nitroglycerin and CPAP.

I enjoy the scenario, even though I am going off into left field from the rest of y'all.

Matty

*EDIT* I just realized after this quick rambling of a post that I am now one of the Elites. Thanks to the person that thought I was worthy of it, I'm honored.

Edited May 27, 2012 by Mateo_1387

[J306]

I agree with pulmonary edema and administration of Nitro along with CPAP. Nitro will also be helpful for treating the patient's HTN.

[Kiwiology]

Sublingual GTN won't have any effect on his hypertension

It could be CHF but I am not convinced

For now I'll hold off on anaesthetising, paralysing and intubating him to try 0.8mg of SL GTN

We don't have CPAP so it's not an option here, it'd have to be a tightly fitted bag mask and PEEP of 10

My guess is he's not going to tolerate somebody shoving a bag mask over his gob nor can we reasonably expect the ambo to tolerate doing it for thirty minutes until we reach hospital so I think intubating him is going to be the end point of this bloke anyway regardless of what is done beforehand

[nypamedic43]

As chbare stated, we can inline the neb treatment. I would do the CPAP and a NTG sublingual and call med control about some Lasix. NTG and Lasix are in our protocol but with the absence of peripheral edema and still tight lung sounds I would ask the Doc about the Lasix. I would be still trying to get a line in him, but he doesnt need the fluid, so it will a KVO rate. Once I've gotten that done, I'll worry about the PSVT and see what happens with him as the CPAP starts to work. His work of breathing should greatly diminish once he stops fighting the machine.

If this is pulmonary edema, and the wheezes being heard get to sounding like rales, the CPAP is whats gonna push the fluid out, and he SHOULD stabilize.

Then again I could be off in the ditch too lol

[DwayneEMTP]

I think that pulmonary edema is intuitive in this patient, but I don't see the signs of it. By the time that we're detecting wheezes we should be able to also pick ups crackles, yet they've not been reported in any region so far.

I'm not really concerned about his hypertension where it is now, but Kiwi, why do you say that the Nitro will have no effect on that?

And I think that I did address the tachycardia, but only briefly. I guess we'll have to wait for Biebs to come back and expound...

Though I'm confident that Kiwi is right, that he's likely going to end up intubated, I'd still like to try and avoid it if possible, and the CPAP gives us a good option for doing so.

[chbare]

Unfortunately, a bag mask with a PEEP valve will not provide PEEP to a spontaneously breathing patient. However, a simple modification will provide PEEP. Place the patient on nasal cannula at 15 LPM then get a good face seal with the bag mask that has an attached PEEP valve. This will actually provide CPAP.

From emcrit:

http://emcrit.org/misc/bvm-preoxygenation-and-reoxygenation

To be clear, I used PEEP and CPAP interchangeably in the above post since both are physiological analogues; however, the common terminology is CPAP when discussing a spontaneously breathing patient.

[DwayneEMTP]

...As chbare stated, we can inline the neb treatment. I would do the CPAP and a NTG sublingual and call med control about some Lasix...

How come? What information are you going to give the doc to get him to approve the Lasix?

...I would be still trying to get a line in him, but he doesnt need the fluid...

What makes you say that?

I'm kind of onboard with pulmonary edema but I'm also pretty confident that Biebs would recognize that if he heard it.

Also we've got an elderly nursing home patient, tight lungs, hypertension, tachycardia, a captured run of PSVT..other than the distended neck veins, which may resolve to something liver related (I think), I think that there's a fair chance that this guy is going to get some fluid..And I'm really not looking at Lasix for him.

But as always I tend to go looking for zebras, so my guess is that this is exactly what it appears to be..

[chbare]

Also, many people with acutely decompensated CHF are not fluid overloaded. This has become such an issue in my area, companies now have guidelines that require providers to calculate serum osmolarity to see if they can consider administering furosemide.

Edited May 27, 2012 by chbare

[nypamedic43]

I dont think he needs the Lasix but its part of our protocol and I would have to ask to NOT give it. In this case I would tell the Doc whats going on, how the patient is presenting to me and ask if he wants me to give it. If not, I'm cool with that. A KVO rate on the IV will get him some fluid, however I dont want to make the problem worse by hosing in fluid just because I can, for which the ED will be giving triple the Lasix that I would to help get rid of it....

[chbare]

If we can get labs, we can appreciate a bigger picture. This patient may in fact benefit from fluid administeration.