Difficulty breathing

URI

Forum Crew Member
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Hi guys,
Im new to the forums, and fairly new to EMS as well so please bear with me if my questions seem a little elementary, but this is how we learn.

Anyway I'm still a basic but I have only the NREMT- P practical before I'm a medic. I volunteer for a local FD where we only serve 6k people in a rural area so don't we respond to that many calls.

I was on a call the other night where my rescue lieutenant needed man power so I told him I would meet him on scene with my pov.
6-8 min. into pt. care I arrive on scene to find them already loaded up in the ambulance.

It's a 31 y/o black female c/o shortness of breath. My Lt. who is a intermediate already had her on a NBR 15 lpm.
Pt. A&Ox3, speaking 5-7 words sentences but with mild distress, no audible wheezes, lungs sounds clear, maybe some slight rhonchi at the bases. Skin: (nail beds) seemed pink, warm, and dry. tears from distress.
She has a dry cough

VITALS: hr.88, b/p 160/92, RR 24 labored on expiration.
A: NKDA
M: Albuterol - for asthma sense she was 12
Erythromycin- for a recent upper respiratory infection 2 wks. prior.
And some form of contraceptive.

she has been a febrile, however has difficulty breathing for the past 5 weeks but got worse tonight.

Never had to be hospitalized or intubated in the past.

She reports she took her prescribed albuterol but quickly developed chest pain and her breathing became even more labored.

My question: My Lt. wanted to know my thoughts on this pt. and what would be my tx. I was considering doing a duel neb. my initial thought process was her condition was due to the changes in weather, and this was a typical asthma attack. But then second guessed myself due to her hx. of her upper respiratory infection. With the above mentioned, about her prescribed Albutrol making it condition worse, would a duel neb. cause more harm?

We decided she was in fairly stable condition with the NRB, but again this is for educational purposes so please bear with me.
 

Aidey

Community Leader Emeritus
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The NRB was likely highly unnecessary. And it is duo neb, not duel neb. As for the rest, someone with more sleep will need to respond.
 

usalsfyre

You have my stapler
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Dry cough and expiratory difficulty is suggestive of asthma. That said, a neb probably would have been indicated for either. Have you considered the fact the URI exacterbated the asthma? Remember our patients rarely fall neatly on one protocol page.
 
OP
OP
URI

URI

Forum Crew Member
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Duo neb: thanks Aidey

Usalsfyer: that makes perfect sense. I know for a fact I have read the signs & symptoms for asthma, and have been on calls where we've treated asthma pts. But until it's your turn...
I appreciate it. Part of my issue was she stated that the Albuterol she took prior to our arrival seemed to give her chest pain, and made her breathing more labored.
 
OP
OP
URI

URI

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Unfortunately we didn't put her on capnography, but you do bring up an interesting point. And I'll certainly have one for my next respiratory pt.

Her spo2 was 97% on a NRB 15lpm. I showed up late in the call so I never did get a room air sat.
 

AnthonyM83

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I hear what you're saying.

I don't know this if this was the case, but you'll learn the patient might tell you a piece of information that seems to suggest a zebra (or some alternative vague dx), but everything else is pointing to a horse. While you don't completely disregard that information, you sometimes decide to treat the horse, anyway... and it works.

Ex: Patient reports a tightness in throat for last day tell you it's making him short of breath. States no heart problems.
+Swallowing, +Increased pedal edema, +Transient Short Wheezes, +Dyspnea on Exertion, +Orthopnea, +Paroxysmal Nocturnal Dyspnea, +Prescribed Lasix with increased dose, +HTN/HighCholesterol, +Overweight, +Elderly, +NoAllergies/NewFoods/NewMeds/NewEnvironment

You could get caught up in the potential anaphylaxis or treat as potential CHF exacerbation. Quick consult with medical control, treat with Albuterol which produced rales. Treat rales with NTG. Patient reports marked relief from dyspnea.


In like, the patient might tell you her home albuterol made it worse, but you MIGHT try nebulizer anyway, and it makes her feel better... OR you might not, judgement call based on specific situation. If the overall big picture points to something with one small thing out of place, it might still be that same big picture...(sometimes not)
 
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JPINFV

Gadfly
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Black female with SOB? Sarcoidosis. :D (Ok... real life isn't like Step 1).

Any history of sputum production? Chills? Has the difficulty breathing been the same over the past 5 weeks prior to tonight? Anything make it better? Anything make it worse? Sick contacts?
 

18G

Paramedic
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That case doesn't sound like an asthma exacerbation to me. Her lungs were clear and no wheezes were heard. And only a "might" be rhonchi. She is not tachycardic and only mildly tachpneic. The RR of 24 is more than likely from anxiety more than compensatory from a disorder of respiration. And with a true asthma exacerbation your gonna see a HR greater than 88 99% of the time. Honestly, I'm surprised its only 88 given the fact she is crying and worked up. How about the dry cough? This is a common finding with asthma. Has the cough became more frequent? Remained the same? New onset? Has she used her inhaler over the past five weeks? How did it make her feel then? Did it help? Make her feel worse like this episode? Is she a smoker?

How has her emotional state been over the past few weeks? Any depression, anxiety or panic disorder? Depression and anxiety can make a person feel very SOB.

On a call like this you need to mentally list all differentials and rule them out one by one.

So here we list these at least:

Asthma
Pulmonary embolism
Psychological etiology
Pneumonia
Cardiac etiology (ie tachyarrhythmia, CHF)
Allergic reaction or inhaled irritant.

Duoneb is albuterol and ipratropium. Based on the information posted I don't see indication for either of these medications.

Capnography is an awesome tool and can help figuring out what is wrong in a case like this. I would have got a room air SpO2 and backed off the NRB. Chances are the patient didn't need any oxygen at all.

Perhaps just some reassurance and coaching.
 
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Aidey

Community Leader Emeritus
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Duo neb: thanks Aidey

Usalsfyer: that makes perfect sense. I know for a fact I have read the signs & symptoms for asthma, and have been on calls where we've treated asthma pts. But until it's your turn...
I appreciate it. Part of my issue was she stated that the Albuterol she took prior to our arrival seemed to give her chest pain, and made her breathing more labored.

Didn't you have to have a certain number of respiratory pts to pass your paramedic internship?
 
OP
OP
URI

URI

Forum Crew Member
37
2
8
I hear what you're saying.

I don't know this if this was the case, but you'll learn the patient might tell you a piece of information that seems to suggest a zebra (or some alternative vague dx), but everything else is pointing to a horse. While you don't completely disregard that information, you sometimes decide to treat the horse, anyway... and it works.

Ex: Patient reports a tightness in throat for last day tell you it's making him short of breath. States no heart problems.
+Swallowing, +Increased pedal edema, +Transient Short Wheezes, +Dyspnea on Exertion, +Orthopnea, +Paroxysmal Nocturnal Dyspnea, +Prescribed Lasix with increased dose, +HTN/HighCholesterol, +Overweight, +Elderly, +NoAllergies/NewFoods/NewMeds/NewEnvironment

You could get caught up in the potential anaphylaxis or treat as potential CHF exacerbation. Quick consult with medical control, treat with Albuterol which produced rales. Treat rales with NTG. Patient reports marked relief from dyspnea.


In like, the patient might tell you her home albuterol made it worse, but you MIGHT try nebulizer anyway, and it makes her feel better... OR you might not, judgement call based on specific situation. If the overall big picture points to something with one small thing out of place, it might still be that same big picture...(sometimes not)

I will keep this in mind for the future. A lot of this clinical judgement comes from simply running calls, and I welcome everyone's constructive criticism. Thank you
 
OP
OP
URI

URI

Forum Crew Member
37
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8
Black female with SOB? Sarcoidosis. :D (Ok... real life isn't like Step 1).

Any history of sputum production? Chills? Has the difficulty breathing been the same over the past 5 weeks prior to tonight? Anything make it better? Anything make it worse? Sick contacts?

When asked she stated she had some yellow sputum approx. 5 weeks prior, she was seen and they diagnosed her with asthma, with bronchiolitis. But since then she had self diagnosed URIs with sinus infections. Yet she was a-febrile.


I'll be the first to admit I should have gotten a better history of the present illness. I was more focused on the acute setting which is I'm sure a common rookie mistake.
 
OP
OP
URI

URI

Forum Crew Member
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8
That case doesn't sound like an asthma exacerbation to me. Her lungs were clear and no wheezes were heard. And only a "might" be rhonchi. She is not tachycardic and only mildly tachpneic. The RR of 24 is more than likely from anxiety more than compensatory from a disorder of respiration. And with a true asthma exacerbation your gonna see a HR greater than 88 99% of the time. Honestly, I'm surprised its only 88 given the fact she is crying and worked up. How about the dry cough? This is a common finding with asthma. Has the cough became more frequent? Remained the same? New onset? Has she used her inhaler over the past five weeks? How did it make her feel then? Did it help? Make her feel worse like this episode? Is she a smoker?

How has her emotional state been over the past few weeks? Any depression, anxiety or panic disorder? Depression and anxiety can make a person feel very SOB.

On a call like this you need to mentally list all differentials and rule them out one by one.

So here we list these at least:

Asthma
Pulmonary embolism
Psychological etiology
Pneumonia
Cardiac etiology (ie tachyarrhythmia, CHF)
Allergic reaction or inhaled irritant.

Duoneb is albuterol and ipratropium. Based on the information posted I don't see indication for either of these medications.

Capnography is an awesome tool and can help figuring out what is wrong in a case like this. I would have got a room air SpO2 and backed off the NRB. Chances are the patient didn't need any oxygen at all.

Perhaps just some reassurance and coaching.

She did appear to be anxious. When I first got on scene she had the NRB and was being coached with her breathing. My interpretation was she was anxious due to the dyspnea not the other way around. She had a prolonged exploratory phase, but no audible wheezes. She was coughing every 3-5 sentences, with dryness. I didn't ask about the history if her cough only that it has lasted for the past 5 wks. and is worse tonight- then stated her Albuterol made her breathing worse.

Thank you for the deferential diagnosis,
again this is all educational. .
 
OP
OP
URI

URI

Forum Crew Member
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Didn't you have to have a certain number of respiratory pts to pass your paramedic internship?

It was based more on getting certain skills completed, opposed to the types of pts.
IVs = 60
Med pushes= 15
ET= 10.
You get the point..
Its kind of easy when someone else is directing care.

I'm just going to have to learn from the forums, keep my eyes and ears open, and get a damn good history while doing research.
 
OP
OP
URI

URI

Forum Crew Member
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8
When asked she stated she had some yellow sputum approx. 5 weeks prior, she was seen and they diagnosed her with asthma, with bronchiolitis. But since then she had self diagnosed URIs with sinus infections. Yet she was a-febrile

Sorry, I need to elaborate, her self diagnosed URI was seen at a walk in clinic 2 weeks prior.
 
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