Approach to Adult Patients with Acute Dyspnea

The Predictive Role of Lactate in the Emergency Department in Patients with Severe Dyspnea

Objective

An accurate identification of patients at the need for prioritized diagnostics and care are crucial in the emergency department (ED). Blood gas (BG) analysis is a widely available laboratory test, which allows to measure vital parameters, including markers of ventilation and perfusion. The aim of our analysis was to assess whether blood gas parameters in patients with dyspnea at an increased risk of respiratory failure admitted to the ED can predict short-term outcomes.

Methods

The study group eventually consisted of 108 patients, with available BG analysis. The clinical and laboratory parameters were retrospectively evaluated, and three groups were distinguished-arterial blood gas (ABG), venous blood gas (VBG), and mixed blood gas. The primary endpoint was short-term, all-cause mortality during the follow-up of median (quartile 1-quartile 3) 2 (1-4) months. The independent risk factors for mortality that could be obtained from blood gas sampling were evaluated.

Results

The short-term mortality was 35.2% (38/108). Patients who died were more frequently initially assigned to the red triage risk group, more burdened with comorbidities, and the median SpO2 on admission was significantly lower than in patients who survived the follow-up period. In the multivariable analysis, lactate was the strongest independent predictor of death, with 1 mmol/L increasing all-cause mortality by 58% in ABG (95% CI: 1.01-2.47), by 80% in VBG (95% CI: 1.13-2.88), and by 68% in the mixed blood gas analysis (95% CI: 1.22-2.31), what remained significant in VBG and mixed group after correction for base excess. In each group, pH, pO2, and pCO2 did not predict short-term mortality.

Conclusions

In patients admitted to the ED due to dyspnea, at risk of respiratory failure, lactate levels in arterial, venous, and mixed blood samples are independent predictors of short-term mortality.

Ultrasound on the Frontlines: Empowering Paramedics with Lung Ultrasound for Dyspnea Diagnosis in Adults-A Pilot Study

Lung transthoracic ultrasound (LUS) is an accessible and widely applicable method of rapidly imaging certain pathologies in the thorax. LUS proves to be an optimal tool in respiratory emergency medicine, applicable in various clinical settings. However, despite the rapid development of bedside ultrasonography, or point-of-care (POCUS) ultrasound, there remains a scarcity of knowledge about the use of LUS in pre-hospital settings. Therefore, our aim was to assess the usefulness of LUS as an additional tool in diagnosing dyspnea when performed by experienced paramedics in real-life, pre-hospital settings. Participants were recruited consecutively among patients who called for an emergency due to dyspnea in the Warsaw region of Poland. All the enrolled patients were admitted to the Emergency Department (ED). In the prehospital setting, a paramedic experienced in LUS conducted an ultrasonographic examination of the thorax, including Bedside Lung Ultrasound in Emergency (BLUE) and extended Focused Assessment with Sonography for Trauma (eFAST) protocols. The paramedic's diagnosis was compared to the ED diagnosis, and if available, to the final diagnosis established on the day of discharge from the hospital. We enrolled 44 patients in the study, comprising 22 (50%) men and (50%) women with a median age of 76 (IQR: 69.75-84.5) years. The LUS performed by paramedic was concordant with the discharge diagnosis in 90.91% of cases, where the final diagnosis was established on the day of discharge from the hospital. In cases where the patient was treated only in the ED, the pre-hospital LUS was concordant with the ED diagnosis in 88.64% of cases. The mean time of the LUS examination was 63.66 s (SD: 19.22). The inter-rater agreement between the pre-hospital diagnosis and ER diagnosis based on pre-hospital LUS and complete ER evaluation was estimated at k = 0.822 (SE: 0.07; 95%CI: 0.68, 0.96), indicating strong agreement, and between the pre-hospital diagnosis based on LUS and final discharge diagnosis, it was estimated at k = 0.934 (SE: 0.03; 95%CI: 0.88, 0.99), indicating almost perfect agreement. In conclusion, paramedic-acquired LUS seems to be a useful tool in the pre-hospital differential diagnosis of dyspnea in adults.

COVID-19 and pulmonary Tubercuiosis coinfection: three case reports from Iran

Tubercuiosis is still a significant problem worldwide. Until the COVID-19 pandemic, tuberculosis was the leading cause of mortality from a single infectious agent. Pulmonary Tubercuiosis patients are more tending to be co-infected with COVID-19 notably when they have a history of exposure. There are some case reports relating to pulmonary TB and COVID-19 coinfection but the information about TB and COVID-19 was still little. We report three coinfected patients. Case one and two were both middle-aged Iranian mans with history of opium addiction, case one presented with dyspnea and weakness and case two presented with progressive weakness. Case three was a healthy young man with history of progressive dyspnea, productive cough and hemoptysis. Case one and case three were improved. In conclusion, COVID-19 is still an important issue and can coexist with other lung infections such as Pulmonary Tubercuiosis, so we should be aware of the advancement of the Tubercuiosis epidemic after the COVID-19 pandemic.

Associations between biomarkers of multimorbidity burden and mortality risk among patients with acute dyspnea

The patients' burden of comorbidities is a cornerstone in risk assessment, clinical management and follow-up. The aim of this study was to evaluate if biomarkers associated with comorbidity burden can predict outcome in acute dyspnea patients. We included 774 patients with dyspnea admitted to an emergency department and measured 80 cardiovascular protein biomarkers in serum collected at admission. The number of comorbidities for each patient were added, and a multimorbidity score was created. Eleven of the 80 biomarkers were independently associated with the multimorbidity score and their standardized and weighted values were summed into a biomarker score of multimorbidities. The biomarker score and the multimorbidity score, expressed per standard deviation increment, respectively, were related to all-cause mortality using Cox Proportional Hazards Model. During long-term follow-up (2.4 ± 1.5 years) 45% of the patients died and during short-term follow-up (90 days) 12% died. Through long-term follow-up, in fully adjusted models, the HR (95% CI) for mortality concerning the biomarker score was 1.59 (95% CI 1348-1871) and 1.18 (95% CI 1035-1346) for the multimorbidity score. For short-term follow-up, in the fully adjusted model, the biomarker score was strongly related to 90-day mortality (HR 1.98, 95% CI 1428-2743), whereas the multimorbidity score was not significant. Our main findings suggest that the biomarker score is superior to the multimorbidity score in predicting long and short-term mortality. Measurement of the biomarker score may serve as a biological fingerprint of the multimorbidity score at the emergency department and, therefore, be helpful for risk prediction, treatment decisions and need of follow-up both in hospital and after discharge from the emergency department.

High-Altitude Pulmonary Edema in Ohio at an Elevation of 339 Meters

Background

HAPE (High-Altitude Pulmonary Edema) is a life-threatening form of high-altitude illness caused by noncardiogenic pulmonary edema. It has been most commonly reported in individuals who live at lower elevations and travel to elevations above 2500 m, typically in those who do so without any acclimatization. It can also occur in residents of high altitudes who descend to lower altitudes and then return to their native altitude without acclimatization. HAPE is more common in individuals with a history of prior HAPE, very rapid rates of ascent, upper respiratory illness, extreme exertion and cold environmental temperatures, Down’s Syndrome, obesity and congenital pulmonary anomalies.

Case Presentation

Our case discusses a patient presenting to an emergency department in Ohio with severe respiratory distress, hypoxia and a radiograph that showed pulmonary edema without cardiomegaly. Additional history revealed the patient had recently returned from Breckenridge, Colorado (an elevation of approximately 2926 m). The diagnosis of HAPE was recognized and he was appropriately treated. He was educated and will not be returning to high altitude without acclimatization in the future.

Conclusion

Upon literature review, there has never been a prior documented case of a patient in Ohio with HAPE. Providers must consider altitude illness when evaluating travelers from high altitude destinations, even when traveling to a very low altitude like Ohio, as symptoms may be unresolved by descent alone. This case emphasizes the importance of obtaining relevant historical data including a travel history. It also emphasizes the importance of avoiding early closure of the diagnostic process by only considering common conditions. Finally, the case emphasizes the potential danger of anchoring bias to previously encountered conditions.

CORT-AHF Study: Effect on Outcomes of Systemic Corticosteroid Therapy During Early Management Acute Heart Failure

OBJECTIVES

This study investigated whether systemic corticosteroids (new onset) administered to patients with acute heart failure (AHF) have any association with outcomes, with differentiated analyses for patients with and without chronic obstructive pulmonary disease (COPD) as a comorbidity.

BACKGROUND

Patients with undiagnosed dyspnea frequently receive corticosteroids in emergency departments while determining a final diagnosis, but their effect on the outcomes of patients with AHF without overt COPD exacerbation is unknown.

METHODS

We selected patients with AHF from the EAHFE (Epidemiology of Acute Heart Failure in the Emergency Departments) registry, recording key data (new-onset corticosteroid therapy, COPD condition). Patients with and without COPD were analyzed separately. We calculated unadjusted and adjusted ratios for corticosteroid-treated compared with corticosteroid-untreated patients for 2 coprimary endpoints: 90-day all-cause mortality (from index episode) and 90-day post-discharge combined endpoint (all-cause mortality or readmission for AHF), with intermediate time-point estimations. Other secondary endpoints were calculated, and some sensitive and stratified analyses were performed.

RESULTS

We analyzed 11,356 patients: 8,635 without COPD (841 corticosteroid-treated, 9.7%) and 2,721 with COPD (753 corticosteroid-treated, 27.7%). There were several differences between treated and untreated patients, essentially because corticosteroid-treated patients were sicker. Although unadjusted outcomes were worse in corticosteroid-treated patients, especially in patients without COPD, these differences disappeared after adjustment: hazard ratios for 90-day mortality (without/with COPD) were 0.91 (95% confidence interval (CI): 0.76 to 1.10)/0.99 (95% CI: 0.78 to 1.26), and 1.09 (95% CI: 0.93 to 1.28)/1.02 (95% CI: 0.86 to 1.21) for the post-discharge combined endpoint. Analyses of intermediate time-point coprimary endpoints and secondary outcomes rendered similar estimations. Sensitivity and stratified analysis did not significantly modify these results.

CONCLUSIONS

There is no evidence of harm related to the new onset of systemic corticosteroid therapy during an episode of AHF, either in patients with or without concomitant COPD.

Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis

Background

Emergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each.

Methods

This was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression.

Results

Initial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage.

Conclusions

Despite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints—all subject to limited guidance by the ESI algorithm—were particularly under-appreciated.

An Observational Study of Dyspnea in Emergency Departments: The Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM)

OBJECTIVES

The objective was to describe the epidemiology of dyspnea presenting to emergency departments (EDs) in the Asia-Pacific region, to understand how it is investigated and treated and its outcome.

METHODS

Prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong, and Malaysia of adult patients presenting to the ED with dyspnea as a main symptom. Data were collected over three 72-hour periods and included demographics, comorbidities, mode of arrival, usual medications, prehospital treatment, initial assessment, ED investigations, treatment in the ED, ED diagnosis, disposition from ED, in-hospital outcome, and final hospital diagnosis. The primary outcomes of interest are the epidemiology, investigation, treatment, and outcome of patients presenting to ED with dyspnea.

RESULTS

A total of 3,044 patients were studied. Patients with dyspnea made up 5.2% (3,105/60,059, 95% confidence interval [CI] = 5.0% to 5.4%) of ED presentations, 11.4% of ward admissions (1,956/17,184, 95% CI = 10.9% to 11.9%), and 19.9% of intensive care unit (ICU) admissions (104/523, 95% CI = 16.7% to 23.5%). The most common diagnoses were lower respiratory tract infection (20.2%), heart failure (14.9%), chronic obstructive pulmonary disease (13.6%), and asthma (12.7%). Hospital ward admission was required for 64% of patients (95% CI = 62% to 66%) with 3.3% (95% CI = 2.8% to 4.1%) requiring ICU admission. In-hospital mortality was 6% (95% CI = 5.0% to 7.2%).

CONCLUSION

Dyspnea is a common symptom in ED patients contributing substantially to ED, hospital, and ICU workload. It is also associated with significant mortality. There are a wide variety of causes however chronic disease accounts for a large proportion.