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Common Examples of Labored Breathing
Asthma
Asthma is an allergic disorder affecting bronchi and bronchioles. Smooth muscle constricts and glands of the bronchi secrete increased amounts of mucous. Air enters the alveoli but leaves with difficulty. The result is wheezing. Wheezing is not critical unless the patient is using accessory muscles to force air out of the lungs. Occasionally in a tiring patient, wheezes diminish and little air is moved, heralding respiratory failure and requiring endotracheal intubation and mechanical ventilation. Tests reflecting the patient’s respiratory status are pulse oximetry and peak flow.
Blood gases are usually not required (they show a partial respiratory alkalosis—CO2 is blown off ). However, if done, a normal CO2 in a tiring asthmatic indicates impending respiratory failure. A peak flow of less than 200 L/min after several nebulizer treatments is usually an indication for hospitalization (normal peak flow is over 400 liters per minute).
Treatment:
1. oxygen by cannula or mask,
2. nebulizer therapy: a predominantly beta-2 agent such as albuterol (Ventolin), an anticholinergic bronchodilator such as ipratropium (Atrovent), combinations, or a more beta-2 selective agent such as levalbuterol (Xopinex) is administered,
3. an intravenous steroid such as methylprednisolone (Solu-Medrol) 125 mg is given. In addition to having delayed long-acting anti-inflammatory effects, steroids act synergistically with beta-2 aerosols to abort some of the bronchospasm of asthma.
It is important to remember that, from a vital sign standpoint, a person may have a normal respiratory rate, not be wheezing and be in severe respiratory failure, as signaled by use of accessory muscles, sweating, tiring, deterioration of mental status and movement of little air. In this case endotracheal intubation is required.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) refers to two disease entities sharing characteristics of long term obstruction to air flow: chronic bronchitis and emphysema. Smoking is often a component in both diseases. In bronchitis, the bronchial mucosa is swollen and red, mucous is secreted by the glands, and the sputum may be green or yellow. In emphysema air is trapped in the alveoli because of long-term irritation
of the bronchi, and mucous and pus accumulate. When pressure in the alveoli exceeds the elastic limit, they become permanently ballooned-out and nonelastic. This produces the barrel-chested person sometimes requiring use of accessory muscles of respiration to breathe. Wheezes are often heard in both situations. Pulse oximentry usually shows chronic hypoxemia. A peak flow is less useful than in asthma, and is usually measured against the patient’s baseline.
Treatment:
1. low-flow oxygen at 2 L/min (high-flow may abolish the hypoxic ventilatory drive and lead to respiratory arrest), or 28% by Venturi mask,
2. bronchospasm is treated with a beta-agonist such as albuterol 2.5 mg, levalbuterol (Xopinex), or an anticholinergic agent such as iprotropium (Atrovent) 500 µg in 2 ml normal saline by nebulizer,
3. inflammation is treated with a steroid such as methylprednisolone 125 mg IV,
4. an antibiotic (amoxicillin or trimethoprim-sulfamethoxazole) is administered since the exacerbation is usually the result of an infection, and
5. stopping smoking helps dramatically.
Pneumonia
Signs and symptoms of pneumonia are fever, chills, cough, production of rust-colored sputum, chest pain, tachypnea, dyspnea, decreased breath sounds and rales. The CBC shows a leukocytosis and a chest x-ray usually reveals an infiltrate.
Treatment: viruses require no therapy. A bacterial infection is treated with an appropriate antibiotic based on gram stain or probable etiology.
Pulmonary Edema
Acute pulmonary edema is a life-threatening sequel of congestive heart failure, often triggered by failure to take appropriate medication and sometimes by an acute myocardial infarction. Because of inadequate pumping action of the left ventricle, fluid backs up in the lungs. Cough, orthopnea and chest pain are common symptoms. Anxiety, dyspnea, tachypnea, rales, wheezes, tachycardia with an S-3 gallop rhythm, jugular venous distention (JVD), peripheral edema and diaphoresis may be present. Blood gases show
hypoxia and sometimes hypercapnia. A chest x-ray reveals diffuse infiltrates in both lungs.
Treatment:
1. upright position,
2. high flow oxygen by mask,
3. a diuretic such as furosemide 80 mg IV to remove fluid,
4. nitroglycerine (NTG) 10 µg per minute by intravenous infusion for vasodilation, reducing preload (and some afterload),
5. morphine, 2 mg IV, although controversial, slightly reduces afterload, cardiac work and produces a sedative effect,
6. a systolic pressure <100 mmHg may require the administration of
dopamine (5 µg/kg/min).
7. severe hypertension not responding to NTG may require nitroprusside 0.5 µg/kg/min. Intubation is frequently required. Firstline therapy may be remembered by the mnemonic: L (lasix), M (morphine), N (nitrates), O (oxygen), P (position).
Pulmonary Embolism/Infarction
In pulmonary embolism, a clot from a pelvic or deep leg vein detaches and travels to the lung. The clot impacts in a branch of the pulmonary artery causing chest pain, dyspnea, tachypnea and sometimes syncope, anxiety, cough and hemoptysis. A large embolus occluding a major branch of the pulmonary artery (infarction) may cause shock and even death. Predisposing factors include a previous pulmonary embolism, deep vein thrombosis (DVT), CHF, MI, obesity, recent surgery, immobilization, trauma, pregnancy
and malignancy. Diagnosis is made by lung scan (normal ventilation, with perfusion defects), or a spiral CT scan. If results are equivocal, a pulmonary angiogram is done. Doppler studies of the leg are often positive.
Treatment:
1. oxygen by cannula or mask to maintain an oxygen saturation at 95%,
2. heparin 10,000 unit IV bolus and 1000 units per hour, or low molecular weight heparin such as enoxaparin (Lovenox) at 1 mg/ kg subq q 12 hours,
3. IV normal saline,
4. dopamine (5 µg/kg/min) may be required for hypotension. Long term therapy includes an oral anticoagulant such as warfarin (Coumadin).
Note: pulmonary embolism is one of the more missed diagnoses. An increased respiratory rate with some hypoxia is almost always present.
Pneumothorax
A pneumothorax is air between visceral and parietal pleurae. It occurs from rupture of a pulmonary bleb in the lung of the asthmatic/COPDer, in the trauma patient (particularly knife or bullet wound) and sometimes in cancer patients. Symptoms are sharp chest pain and cough. Occasionally dyspnea is present. Unless the pneumothorax is quite small, breath sounds are decreased on one side. A chest x-ray is usually diagnostic. Occasionally, air may compress the mediastinum and vena cavae, resulting in severe respiratory distress, tachycardia and hypotension (tension pneumothorax).
Treatment:
close observation for a small nontraumatic pneumothorax. A greater than 20% pneumothorax usually requires a chest tube (tube thoracostomy). For tension pneumothorax, a 14/16-gauge needle/catheter is inserted in the second interspace, midclavicular line, followed by tube thoracostomy.
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