HOW TO APPROACH A PATIENT WITH RESPIRATORY DISCOMFORT

[00:00] Hello guys, welcome again to Intellect Medigos, where learning is made easy. I'm Dr. Chirag Madan, working as an intensivist ICU consultant at Apollo Hospital, New Delhi. First of all, I would like to thank all of you guys for the love and support and the feedback you have shown through a previous video.

[00:20] mainly the last two videos. One was on how to read a chest X-ray, the other on the lung sounds. Thank you so much guys. And also I like to tell you all that I have got so many requests about the ECG interpretation. So there is my video on this channel with the name of how to read...

[00:40] ECG. That is a 10 minute video which has gained 2.9 million views all because of you guys. So go check this link in the description below. And also there's a link shown over here. So coming on to today's video. So now in today's video we have shown a pro-order

[01:00] to a patient with respiratory discomfort or respiratory distress. So let's begin.

[01:20] is 120 per minute. The blood pressure is 100 by 60 millimeters of mercury. Respiratory rate of a patient is 25 per minute and the patient is somewhat drowsy. So how will you approach this patient? Pause this video and think about the management how will you approach.

[01:40] Seriously, pause this video and think about it.

[02:00] fluids. Second, patient is tachypneic and they seem to have respiratory distress. So obviously attach oxygen. And third is give the nebulizers. So this is a universal thing which I have seen for so many years. But this is a very, very, very bad management of the patient. Very bad.

[02:20] Why? All because you have given let's say 500 ml bolus, saline because you have seen tachycardia and low BP. But after giving you bolus of 500 ml, I give you a history. The patient is CKD and has not been dilated for past 3 days. So congratulations, patient is already fluid overload.

[02:40] fluid and this distress is because of Fluidovolo and you have also given 500 ml to it. So secondly, now you have given nebulizers, you have waited for next 5-10 minutes till there is a respiratory discomfort. After 10 minutes I give you a history that patient has a trauma of hedonic anemic.

[03:00] So yeah, so it could be your pneumothorax and your nebulizers will not work. So this is the importance of having a good history. So whenever you have to approach a patient, have a good detailed history. But if patient doesn't have a good history,

[03:20] give you time, I mean the condition of the patient as in this case I mean there is a tachycardia, VP is low and obviously the sensorium is also drowsy. So in these kind of situation you can't go for a detailed history, you just need to have a brief history. So you can remember this brief history by a mnemonic sample.

[03:40] Sample S stands for Sin and Symptom. So you have seen the sin in the patient. In symptoms you can go for asking whether there is any cough, fever or sputar production. So that means you are thinking in terms of pneumonia, consolidation. Nowadays, a very important thing to ask is about the COVID. I mean any

[04:00] contact with a recent contact with a COVID patient or any COVID immunization. Third, you ask about chest pain or angina so as to rule out any cardiac pathology. Then fourth, you ask about the dyspnea or breathlessness, whether it is at rest, whether it is during exertion or lying down.

[04:20] down or sitting position. So these symptoms also help you make a diagnosis. So this is very very important. So you have asked the basic symptoms right so as to rule out some of the differential diagnosis. Next comes the A which stands for Allergies.

[04:40] this patient has taken Augmentin for some reason, I mean for UTI or some kind of fever. So obviously this presentation could be anaphylaxis and when the BP is going down, the patient is hypertensive, that means patient is going into shock, that means anaphylactic shock. So until an analysis, you do not go for the drug of trans-

[05:00] that is adrenaline, I mean all the efforts are useless, giving fluids, giving oxygen, giving nebulizers, this will not work at all. So again, the importance of history. Now next comes the medication, the third, medications, the patient is on. So if the.

[05:20] relative gives the history that patient is on is a has a history of COPD or asthma and usually takes MDI and for the past five days the or three days patient is not taking that MDI that those inhalers so for sure this could be exacerbation of COPD or asthma right now

[05:40] Now the other thing is P. P stands for past medical history. So in this you need to ask again the cardiac, any cardiac, previous cardiac diseases, any renal kidney disease, any liver disease, any surgical, any bleeding history, any history of cardiac disease.

[06:00] previous treatments. So this is past medical history. And then L stands for last meal time. Now why does last meal time have importance over here? Because in these kinds of situations where patient is drowsy on the verge, these conditions are called as peri-arrest. So patient is not yet arrested.

[06:20] is near about. So in these kind of periocidal scenario, patient is actually drowsy right now and can be unresponsive in next few minutes. So whenever the patient becomes unresponsive, the first and foremost thing which happens is the blunting of the reflexes, the pharyngeal and laryngeal reflexes. That means

[06:40] Patient is at risk of aspiration. So you need to have that history also. And the last E stands for previous events. So this is how you have a brief history. But again, if patient is deteriorating and I mean let's say patient is becoming more drowsy, there is more distress, the BP is falling.

[07:00] Obviously, many a times what happens in the ICU in the emergencies, we have to skip this. We have to skip the history part and directly we have to approach, we have to go for the next thing which is the examination part. So next important thing after the history comes examination.

[07:20] Now, first and foremost thing is you have to have a general survey. So whether the patient is looking toxic or normal, whether the patient is lying on the bed comfortably or is not comfortable, then the belt of the patient, whether the patient is thin belt, average belt or obese patient because this also matters.

[07:40] Now, a main examination, if you talk about examination and we are talking about respiratory system, the first and foremost is the inspection. So from a distance you see the movement of the chest and compare right and the left side. So let's say the left side of the patient is not moving, then that goes in favour

[08:00] of either pneumothorax or pleural effusion or any other pathology. So that is actually helping you to come to a diagnosis or narrow down all the differential diagnosis. Coming on to the next step of examination that is palpation. Now in palpation you palpate the patient and you see the temperature.

[08:20] Second, you would see any kind of tenderness which goes in favour of your refracture. It could be musculoskeletal also, but refracture, that has an importance because in trauma patients, they can be refractured, which can cause lung contusion, pneumothorax, hemothorax.

[08:40] palpation could be your palpation of the trachea. So after inspection, palpation is also important. But again, if patient is deteriorated, you directly go on to the next step. That is percussion. In percussion, you have to percuss both the sides and they could be normal or resonant. And then if it is hyper-researched,

[09:00] or the other term used is tympanic which is going in favour of pneumothorax. Then there could be dullness while doing a percussion. So this dullness could be woody or stony. But frankly speaking it is very difficult to differentiate between a stony and a woody dullness.

[09:20] But as far as your medical examination is concerned, your woody dullness goes in favour of consolidation, your stony dullness goes in favour of pleural diffusion. So this is the third part, that is the percussion. Now comes the fourth, which is very important, that is the auscultation part, which I have

[09:40] uploaded a video recently about lung sounds. So how do you hear these kind of sounds? You can have the link in that description box below and the link over here as well.

[10:00] you have to have a detailed examination from head to toe, having the CNS examination, the respiratory examination, the cardiac examination, everything. Now we have talked about the history, the examination of a patient. And now comes the investigation, which is very, very important. I mean, and whenever you have these kind of patients, the first test you need

[10:20] to check or you need to do is blood sugar. Then comes the importance of ABG. I mean, we are talking about respiratory system, the patient is in distress. So obviously you send an ABG, that is, arterial blood gas analysis. And you can read about the interpretation of an ABG with the link in the description below and also over here.

[10:40] I will upload the second part of this video soon. Next, coming on to the other investigation is chest X-ray. But if you are suspecting a pneumothorax, that will not give you time. I mean tension pneumothorax. So if you are ordering an X-ray, you are getting an X-ray done, then do it.

[11:00] the reporting of the X-ray or the uploading of the film. So nowadays what we used to do in our ICUs, in our emergency is ultrasound. So that is called a spocus, point of care ultrasound. So in that we can see the pneumothorax, the pleural diffusion, the consolidation, pulmonary edema, having a B line of breath.

[11:20] early B lines. So this is a very very important investigation or you can say equipment the ultrasound. Now after the X-ray and ultrasound comes the importance of ECG to rule out any cardiac pathology and if you think this is a cardiac origin and obviously you are getting any kind of

[11:40] ST elevation. In the ECG obviously you have to send the cardiac biomarkers as well. And coming on to the next investigation is the HRCT test. If your X-ray is inconclusive and you are still thinking this is a respiratory pathology, obviously you have to go for CT test. Now apart from all these investigations, you need to send

[12:00] then the routine investigation according to your hospital protocol. So the CBC that is complete blood count, the KFT that is kidney function test or renal function test and a lefties that is liver function test. So these are the investigation which we normally send for these kind of patients. So we have completed the history, the examination of patients.

[12:20] investigation, the investigation now comes the most important part that is the treatment part.

[12:40] having a pneumothorax. That is a use. You are wasting the precious time of the patient. So, if there is a pneumothorax and that to attention pneumothorax, obviously you have to decompress it. So, previously we used to decompress using a needle in the second intercostal space, that too in the mid-clavicular line. But in 2018, that too in

[13:00] in the next class.

[13:20] anterior to the mid axillary line. So this is for the tension pneumothorax. Let us say patient has a pulmonary edema. So this could be either cardiac origin or non-cardiac origin. In cases of fluid overload, you have to give a diuretic. Next come the other pathology which could be fluid refusion. That means there is a fluid accumulation in the air.

[13:40] inside the prual cavity, you can find the link in the description below. I have a video on that and the link over here as well. So if this is contributing to the respiratory distress of a patient, obviously you have to tap it, you have to remove that. That video also I have discussed how much is the maximum

[14:00] amount which you can remove from the fluid cavity, I mean the maximum fluid which can be removed. If at all you increase that amount what can happen, what is the complication for that? You can go and check that video. Okay, coming on to the other pathology which could be asthma or a COPD, excess starvation of COPD or asthma.

[14:20] So in these kind of patients, obviously you have to give bronchodilators and IV or injectables of steroids. So this is how we proceed and this is how we manage. I mean, be it any patient, again, the same thing, be it cardiac, respiratory, abdominal, any or GEO, grandiogrammetry.

[14:40] Any patient, you have to follow this. History, examination, investigation and then the treatment. Don't directly jump onto the treatment. If at all you don't have time, still you have to do a basic examination of a patient. So that you don't waste and you don't put unnecessary efforts into the management of the patient.

[15:00] That was all about it, about how to approach a patient with respiratory distress If you like this video, do hit the like button and do share with your friends and colleagues And do not forget to subscribe to the channel for the latest updates And I would like to have your comments, your feedback on this video because this acts as a benefit

[15:20] as a fuel to the motivation to upload more and more videos. So that's it. Thank you so much guys for watching this video. Take care. Bye.

[15:40] You