Author:
Christopher JamesWatson
Michael N.Cocchi
Description
Respiratory distress is the physical manifestation of a patient's difficulty with breathing and is a common complaint in the ED
Etiology
- Upper airway obstruction:
- Anaphylaxis
- Epiglottitis
- Laryngotracheobronchitis (croup)
- Foreign body
- Angioedema
- Abscess/fluid collection:
- Retropharyngeal abscess
- Ludwig angina
- Peritonsillar abscess
- Cardiovascular:
- Pulmonary edema/CHF
- Dysrhythmias
- Myocardial ischemia
- Pulmonary embolus
- Pericarditis
- Cardiac tamponade
- Cardiomyopathy
- Valvular disease
- Air embolism
- Pulmonary:
- Asthma
- Chronic obstructive pulmonary disease (COPD)/emphysema
- Pneumonia
- Malignancy/SVC syndrome
- Viral infection (influenza, RSV, etc.)
- Acute respiratory distress syndrome (ARDS)
- Pleural effusion
- Hydrothorax/chylothorax
- Aspiration
- Bronchiolitis
- Bioweapons (anthrax, plague, tularemia, hemorrhagic viruses)
- Trauma:
- Pneumothorax
- Tension pneumothorax
- Hemothorax
- Rib contusion/fractures
- Pulmonary contusion
- High cervical spinal injury
- Fat embolism with long-bone fractures
- Neuromuscular:
- Guillain-Barre syndrome
- Myasthenia gravis
- Metabolic/systemic/toxic:
- Anemia
- Acidosis
- Hyperthyroidism
- Sepsis
- Septic emboli (IV drug use or indwelling lines)
- Overdose (opiates, sedatives, ethanol, salicylate)
- Sympathomimetic (cocaine, amphetamine, pheochromocytoma)
- Obesity (deconditioning, restrictive disease)
- Inhalation injury (smoke, carbon monoxide)
- Psychogenic:
- Anxiety disorder
- Hyperventilation syndrome
Pediatric Considerations |
- Respiratory failure is a common cause of cardiac arrest in pediatric patients
- Bronchiolitis:
- <2 yr old
- Respiratory distress, fine rales, congestion
- Nasal suction and high-flow O2
- Asthma:
- ≥2 yr old
- Respiratory distress, wheezing
- Albuterol/ipratropium nebulizers, steroids, O2
- Croup syndromes include:
- 6 mo-6 yr old
- Respiratory distress, barking cough, stridor
- Systemic steroids
- Racemic epinephrine if stridorous at rest
- Foreign body:
- Young children, often <3 yr old
- Possible respiratory distress, stridor
- Upright and lateral decubitus CXRs
- Utilize specialists to retrieve object given risk of worsening obstruction
- Epiglottitis:
- Highest incidence between 2-4 yr
- Abrupt onset respiratory distress and stridor
- Tripod position with poor secretion control, agitation
- Emergently to OR for airway management; IV antibiotics
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Pregnancy Prophylaxis |
- Pulmonary emboli; including thromboembolic, amniotic fluid emboli, and septic emboli from septic abortion or postpartum uterine infection
- Peripartum dilated cardiomyopathy
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Signs and Symptoms
- Hypoxemic respiratory failure:
- Tachypnea, tachycardia, agitation, low SpO2/PaO2, low PaCO2, cyanosis, accessory muscle use
- Eventually induces fatigue and subsequent hypercarbia, as below
- Hypercarbic respiratory failure:
- Bradypnea, bradycardia, lethargy, obtundation, high PaCO2
- Signs of upper airway compromise:
- Stridor, wheezing, hoarse voice, poor control of secretions, increased work of breathing/accessory muscle usage
- Signs of lower airway compromise:
- Wheezing, rales, rhonchi, productive cough (purulence, froth, blood), loss of breath sounds, tracheal deviation, increased work of breathing, accessory muscle usage
History
- Known cardiopulmonary, oncologic, renal, neurologic, hepatic, autoimmune, psychiatric, toxicologic illnesses
- Recent fever or upper respiratory tract infection, cough, sputum production, sore throat, systemic disease, trauma
- Recent travel or sick contacts
- Infectious risk factors
- Immune status
- Constitutional symptoms
Physical Exam
- Observe: Respiratory rate, mental status, level of distress, work of breathing/use of accessory muscles, jugular venous distention, skin color
- Palpate: Distal pulses, chest wall, peripheral edema
- Percuss: Lungs for dullness or resonance, abdominal distention, or hepatomegaly
- Auscultate: Air movement, rales/rhonchi/wheezes, upper airway stridor, cardiac murmurs/rubs/gallops
Pediatric Considerations |
- Evaluate retractions, behavior, respiratory rate, breath sounds, and skin color
- Signs of distress in neonates: Weak cry, expiratory grunting, nasal flaring, tachypnea and tachycardia, retractions, and cyanosis
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Essential Workup
- Pulse oximetry
- Cardiac telemetry and BP monitoring
- CXR
- ECG if suspected cardiac etiology
Diagnostic Tests & Interpretation
Lab
- ABG for severity and acid-base determination
- CBC
- Basic metabolic panel
- Per context, consider:
- Cultures for fever or sepsis
- B-type natriuretic peptide (BNP)
- D-dimer
- Troponin
- Viral testing, including influenza
- Toxicology screen
- Urinary output monitoring for pulmonary edema
Imaging
- CXR for:
- Pneumonia
- Pneumothorax
- Hyperinflation
- Atelectasis
- Pulmonary edema
- Abscess/cavitary lesions/other infiltrates
- Tuberculosis
- Lung US:
- Pneumothorax
- Pleural effusion
- Pulmonary edema
- Rib fractures
- Echocardiography:
- Pericardial effusion/tamponade
- Global contractility and dilatation of LV/RV
- Gross wall motion abnormality
- Flail valve
- Neck CT or radiographs to assess epiglottis, soft-tissue spaces, presence of foreign body
- CT angiography or ventilation/perfusion scan for pulmonary embolus
Pediatric Considerations |
- Chest/neck radiograph may show foreign body or “steeple sign” in croup syndromes
- Chest fluoroscopy may be used to assess inspiratory and expiratory excursions if foreign body is suspected
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Diagnostic Procedures/Surgery
- Fiberoptic laryngoscopy to assess epiglottis, vocal cords, and pharyngeal space
- Bronchoscopy for foreign body in trachea or bronchus
- Consider pulmonary artery (Swan-Ganz) catheter for severe CHF, ARDS, pulmonary edema
Differential Diagnosis
See Etiology
Prehospital
- Assume a position of comfort for patient
- High-flow oxygen:
- Nasal cannula, face mask, face tent
- Bag-valve mask (BMV) ventilation if obtunded
- Airway adjunct devices (oral or nasal) to maintain airway patency if tolerated
- Intubation for severe respiratory distress
- Needle decompression if suspected tension pneumothorax
Initial Stabilization/Therapy
- ABCs
- Ensure patent airway; noninvasive positive pressure ventilation (NIV), BVM, or endotracheal intubation for severe distress or respiratory arrest
- IV fluids if hypotensive
- 100% oxygen by face mask:
- Use cautiously in patients with COPD or chronic CO2 retention
- Monitor BP, heart rate, respirations, pulse oximetry
- Advanced cardiac life support for dysrhythmias or arrest
ED Treatment/Procedures
- Treat underlying etiology as appropriate
- Respiratory isolation precautions as indicated
- Heart failure; cardiogenic pulmonary edema:
- Asthma, bronchiolitis, COPD:
- Albuterol/Ipratropium nebulizers
- Steroids
- Magnesium for severe asthma
- Antibiotics for infection
- Antiviral for influenza
- NIV or intubation if severe
- ARDS:
- Mechanical ventilation with lung-protective ventilation strategy (low tidal volumes of 6 mL/kg, target plateau pressure <30 cm H2O)
- Pneumonia:
- Antibiotics
- Consider risk factors for resistant organisms
- Pneumothorax:
- Immediate decompression if suspected tension pneumothorax
- Tube thoracostomy (see Pneumothorax)
- Pleural effusion:
- Determine etiology
- Diagnostic and therapeutic thoracentesis
- Croup:
- Cool, misted air or oxygen
- Steroids
- Racemic epinephrine
- Antibiotics for bacterial infection
- Epiglottitis:
- Immediate airway stabilization with intubation or tracheostomy in OR if possible
- Antibiotics, cover Haemophilus influenzae
- Anaphylaxis, angioedema:
- IV steroids
- H1/H2-blockers
- SQ/IV epinephrine
- Early intubation
- Consider C1 esterase inhibitor or fresh frozen plasma for hereditary angioedema
- Abscess:
- Drainage
- IV antibiotics
- ENT consult as indicated
- Cardiac:
- Treat dysrhythmias or ischemia
- Anticoagulation or thrombolysis for PE
- Pericardiocentesis for tamponade
- NSAIDs for pericarditis
- Neuromuscular:
- NIV or intubation as needed
- Pyridostigmine bromide or neostigmine for myasthenia gravis
- Plasmapheresis or IVIG for Guillain-Barre syndrome
- Metabolic/toxic:
- Psychogenic:
Pediatric Considerations |
- Transtracheal jet ventilation if unable to intubate (cricothyrotomy not recommended in children <10 yr)
- Bronchiolitis:
- Bronchodilators
- Antivirals for respiratory syncytial virus
- Antibiotics for infection
- Spasmodic croup:
- Very sensitive to misted air
- Bacterial croup (laryngotracheobronchitis):
- Cover Staphylococcus aureus
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Pregnancy Prophylaxis |
- Supportive care, oxygen therapy for amniotic fluid embolism
- Heparin for PE
- IV antibiotics for septic embolism
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Medication
Refer to specific etiologies
Disposition
Admission Criteria
- Continued supplemental oxygen requirement
- Cardiac or hemodynamic instability:
- Requiring IV therapy or hydration
- Requiring close airway observation or repeated treatments
- Respiratory isolation
- As required by underlying cause or significant comorbid disease
Discharge Criteria
- Correction of underlying disease
- Stable airway
- Acute supplemental oxygen not required
Issues for Referral
Refer to specific etiologies