Dyspnea in a Man Who Was Stuck in a Bathroom for 24 Hours

Joshua J. Solano, MD

Disclosures

November 04, 2020

Discussion

Respiratory distress is a common complaint in the ED, especially among older adults, and accounts for 4 million visits each year in the United States.[1] Rapid treatment of patients with acute dyspnea in the ED relies on an organized evaluation that starts with airway, breathing, and circulation. At the same time, pertinent information is gathered and therapeutic interventions are applied. Dyspnea can be categorized based on the oxygen level of the patient.

This patient presents with dyspnea and significant hypoxia after he had been on the floor for approximately 24 hours. The differential diagnosis for acute dyspnea with hypoxia in adults is broad. It most commonly includes viral or bacterial pneumonia, pulmonary embolism, pulmonary edema, acute respiratory distress syndrome, asthma exacerbation, congestive heart failure exacerbation, and chronic obstructive pulmonary disease (COPD) exacerbation. Other less common but important considerations include pneumothorax, pleural effusion, foreign body aspiration, anaphylaxis, angioedema, neurologic disorders, and epiglottitis.

Causes of acute dyspnea without hypoxia include pericardial effusion, metabolic acidosis from multiple etiologies (eg, rhabdomyolysis, diabetic ketoacidosis, aspirin toxicity, sepsis), severe anemia, neurologic conditions, panic attacks, vocal cord paralysis, and acute myocardial infarction. Chronic dyspnea with hypoxia can result from tumors or malignancy, COPD, bronchiectasis, tuberculosis, idiopathic pulmonary fibrosis, and pulmonary arterial hypertension.

At times, the evaluation may be limited by the lack of a previous medical history, because the patient has not sought proper medical care in the past and is acutely ill at the initial presentation. This situation makes the assessment of acute dyspnea in the ED challenging.

In general, the workup includes a chest radiograph, a complete blood cell count, a basic metabolic panel, an ECG, and other tests depending on the circumstances, such as CT angiography of the chest, ventilation-perfusion scanning, arterial blood gas measurement, ultrasonography, measurement of troponin levels, and measurement of BNP and N-terminal pro b-type natriuretic peptide (NT-proBNP) levels.

Ultrasonography has become a helpful adjunctive test in the care of patients with acute dyspnea owing to its ability to rapidly detect life-threatening conditions.[2] The evaluation of the heart and lungs is key. This patient's echocardiogram reveals a significantly reduced ejection fraction without pericardial effusion (see Figures 7 and 8).

Figure 7.

Figure 8.

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