Respiratory emergencies

Case 1
• A 55 year old male presented with acutely worsening shortness of
breath over 24 hours. He has a history of multiple similar
presentations over the last 6 months. He continues to smoke 5
cigarettes a day despite being asked to stop.
• O/E
• RR – 24/min, SpO2 on room air – 78%, BP – 120/70, PR = 96/min
• RS examination – reduced breath sounds bilaterally, rhonchi
Q1. What is the most likely diagnosis?
• Exacerbation of bronchial asthma
• Acute LVF
• Pulmonary embolism
• Exacerbation of COPD
Differential History Examination Initial investigations
Acute heart failure Acute onset shortness LV gallop, bilateral basal ECG and Echo
of breath, orthopnoea, crepitations ABG
wheezing

MS with pulmonary Past rheumatic fever Typical murmur of MS

edema
Bronchial asthma Past history of asthma, Bilateral diffuse ronchi Clinical
prominent wheezing ABG

COPD Past history, smoker, Bilateral diffuse rhonchi ABG

cough with sputum with superadded
production crepitations
Hyperinflated chest

Pneumothorax Pleuritic chest pain Tracheal deviation to

the opposite side
Absent breath sounds,
hyper-resonant
percussion note

Pulmonary embolism Risk factors, pleuritic Clear chest, loud P2 ECG

chest pain
Acidosis Features of uremia Clear chest Renal function test
Oliguria
What would you do next?
• Start high flow oxygen via facemask
• Request an urgent inward CXR
• IV furosemide 80mg stat dose
• Nebulization with salbutamol and ipratropium bromide
• Oxygen via venturi mask to maintain minimum saturation of 88%
Initial management
• Start the patient on oxygen – target saturation -88-92%
• Start nebulization with 5mg of salbutamol and 0.5mg of ipratropium
bromide
• Start the patient on intravenous hydrocortisone (100mg 6 hourly) or on
oral prednisolone (40-50mg)
• Start intravenous antibiotics – in patients who have significant increase in
dyspnea, cough, sputum production and require mechanical ventilation
• Co-amoxiclav or a macrolide can be used as initial therapy, but antibiotics
with pseudomonal cover are required if the patient has had recurrent
exacerbations in the past
• The patient does not improve with this initial management. He is
more drowsy (but rousable) on examination
• RR = 12/min, Saturation – 91%, BP -110/70, PR – 100/min, bounding
What would you do next?
• Increase FiO2 to 60% via venturi mask
• Back to back nebulization with salbutamol
• Intravenous aminophylline bolus
• Intravenous MgSO4
• BiPAP
Case 2
• A 25 year old female presents with wheezing for 4 hours duration.
She is a diagnosed patient with asthma, with very poor control due to
non compliance with medication
• SpO2 – 90% on room air, PR – 100/min, BP – 120/90, no murmurs
• RS – widespread rhonchi
What is the next step in the management?
• Start back to back nebulization with salbutamol
• High flow oxygen via facemask
• Start empirical antibiotics
• IV hydrocortisone
• IV aminophylline
Management of acute severe asthma
• Immediately start the patient on oxygen (facemask or non-
rebreathing mask with reservoir bag for high flow oxygen)
• Start oxygen driven nebulization with 5mg salbutamol – this can be
repeated if the patient does not show an adequate response (15-20
minutes) or even back to back if required
• Start ipratropium bromide 0.5mg via oxygen driven nebulization
• Start IV hydrocortisone 100mg stat and every 6 hours or prednisolone
40mg daily
• Monitor the patient’s clinical parameters and saturation
• Despite showing initial improvement, the patient rapidly deteriorates
after 2 hours of admission
• Saturation – 80% on FiO2 – 60%, BP – 80/40, PR – 100 min
• RS, reduced breath sounds on the L/S
• CXR
What will you do now?
• Monitor the patient
• Admit to ICU for invasive ventilation
• BiPAP
• Needle decompression on the left hemithorax
• Needle decompression followed by IC tube insertion
Case 3
• A 60 year old female presented with a 4 day history of worsening
shortness of breath and R/S pleuritic type chest pain. She also has a
history of loss of weight for 3 months and anaemia for 6 months.
Previous investigations for anaemia included an UGIE which was
normal, and an inconclusive colonoscopy due to poor bowel
preparation
• Examination
• Pale, SpO2 – 91% on room air, PR – 110/min, BP – 150/90, no
murmurs
• RS – clear lungs
What investigation will you perform next?
• CXR
• Echocardiogram
• V/Q scan
• CTPA
• D – dimer
Management
• Stable – anticoagulation with heparin
Final diagnosis
Case 4
• A 50 year old male presents with fever for 3 days, cough and
worsening shortness of breath
• On admission, the patient is tachypnoeic
• SpO2 – 88% on room air, RR – 30, PR – 100/min, BP – 90/60
• RS – crackles bilaterally, up to midzones
• FBC – WBC – 9000, Neutrophils – 8000, Lymphocytes – 800, Hb – 11,
platelets – 150,000
• CRP – 90, D – dimer - 2000
What is the differential diagnosis?
• Think
What will you do next?
• Confirm diagnosis – investigations
• Oxygen
• NIV
• Steroids
• Dexamethasone reduced deaths by one-third in ventilated patients (rate
ratio 0.65 [95% confidence interval 0.48 to 0.88]; p=0.0003) and by one
fifth in other patients receiving oxygen only (0.80 [0.67 to 0.96]; p=0.0021).
There was no benefit among those patients who did not require respiratory
support (1.22 [0.86 to 1.75; p=0.14).
• Antivirals – Remdesivir – evidence of clinical improvement
• Thromboprophylaxis