Respiratory Distress

Respiratory Distress is a topic covered in the 5-Minute Emergency Consult.

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Basics

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–Barré 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


Pregnancy Considerations
  • Pulmonary emboli; including thromboembolic, amniotic fluid emboli, and septic emboli from septic abortion or postpartum uterine infection
  • Peripartum dilated cardiomyopathy

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Basics

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–Barré 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


Pregnancy Considerations
  • Pulmonary emboli; including thromboembolic, amniotic fluid emboli, and septic emboli from septic abortion or postpartum uterine infection
  • Peripartum dilated cardiomyopathy

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