12- Dyspnea - Polypnea
Important
- Respiratory rate is an important sign that we should check
for each patient on admission and subsequently at least once a day.
More than 28/minute needs particular attention (or more than 24 if no fever
or no TB).
- Workers should be able at least to
recognize: bronchospasms, crepitations, noise of secretion in upper part of
bronchus, decrease of vesicular murmur, peripheral cyanosis and "hysterical
dyspnea"(see "27-Anxiety").
- If severe dyspnea
and auscultation/cyanosis not clear, treat as PCP and pneumonia (if possible?)
- The "blue nail" (xxx002) (xxx007)
is the best way to evaluate peripheral cyanosis, but in patients with severe
anemia (pale body/conjunctiva/palms), "blue nails" will never occur,
even in severe cyanosis. A patient with polycythemia/dehydration (dark
red face/conjunctiva) will always have "blue nails" even if not
oxygen-deficient.
- Oxygen is toxic for lungs (irritation
which increases coughing and fibrosis). Use only when really necessary
and try not to give more than 2L/min.
Symptomatic
care:
- CYANOSIS (xxx002
xxx007)/DYSPNEA:
- O2, dexamethasone
(4mg=1mL) give 1-4mL IM
- COUGHING AND SPUTUM
- "Normal patient"
- Make secretions more "fluid": acetylcysteine
200mg 1-2 sachets 2-3x/day + good hydration. Don't give too
many anti-tussive drugs (expectorating secretions is good): nothing
or dextromethorphan 1 tab 3x/day... (Codeine
syrup only if suffering)
- Reduce or stop oxygen if possible.
- "Tired dying patient" without hope of improvement:
- "Dry" secretions with Buscopan
1-2 tabs 3-4x/day.
- Strong anti-tussive drugs: codeine syrup1-2
doses 3-4x/day
- BRONCHOSPASM:
- Ventolin 1-2 tabs 3x/day; +/- theophylline 200mg 1-2 tabs 3x/day; +/- dexa (4mg=1mL) give 1-4mL IM; +/- adrenaline 1mL SC
Curative
care:
- Severe dyspnea + Severe peripheral cyanosis (nails) ( xxx002
xxx007)
with symmetrical and/or clean auscultation and/or white sputum.
- PCP?
- Diagnosis: disease is usually considered as an "acute" disease
but in practice, PCP can take a few days before becoming "typical
PCP"... We should start to treat during this few days but decision
is difficult without typical symptoms... and taking a high dose of Bactrim
is difficult as well (especially if the patient is being treated for other
diseases such as TB or toxo!) ... But if we wait too long
before starting, the disease can be easily fatal!
- Treatment
- Trimethoprim 4-5mg/kg/8hours + sulfamethoxazole 25mg/mg/8hours during at least
21 days (see table down). Usually better after 2-3 days.
Sometimes we can observe improvement only after 5 days!!! Five
difficult days for the doctor/nurse who can never be sure of the diagnosis!
|
Treat PCP in practice (patient non allergic sulfa)
|
| |
20-29 kg
|
30-39 kg
|
40-49kg
|
|
BACTRIM (80mg trim+400mg sulfa)
|
2co/ 8hours
|
2.5co/ 8hours
|
3co/ 8hours
|
- If patient is allergic to sulfa: trimethoprim
5mg/kg/8hours + dapsone 100mg/day.
- Prednisone or dexa
is welcome at the beginning of treatment; the dose depends on the degree
of cyanosis/dyspnea
!!! If patients do not take the drugs at exactly 8 hour intervals or
if patients occasionally vomit the drugs, it is better to divide the drugs into
4 equal doses and/or to increase the doses a little bit to avoid a "gap”
or absence of drug coverage in the blood... We had bad experiences in
the past because in our hospice drug distribution is not scheduled at 3 equal
intervals during the day. We must consider the distribution schedule also
when prescribing drugs.
!!! Patient can be so severely ill and taking drugs can be so difficult
that it is often better to interrupt TB treatment when starting PCP treatment...
!!! For us "chronic PCP" does not exist. It is better
to consider that the diagnosis was wrong. It is useless and even dangerous
to administer a high dose of Bactrim to a patient if the lungs are not clearly
better (without corticoids) after one week...!!!
!!! Concurrent treatment of pneumonia with PCP treatment is sometimes
possible... in confusing cases that can be a secure option!!!
If patient has too many pills a day; we sometimes choose to treat him with
trimethoprim + dapsone even if he is not allergic to sulfa... but this alternative
is not recommend for severe cases of PCP...
Acute infection with dyspnea/polypnea
+ focal signs (crepitations, low vesicular murmurs in one lobe, etc) Usually
NO CYANOSIS!
- PNEUMONIA?
- We must treat as pneumonia in acute lungs diseases without cyanosis even
if the auscultation is still symmetrical... asymmetry will come later...
- Treatment: amoxycillin 500mg 1tab 4x/day or (if severe, and feasible give injections
every 8 hours) ampicillin IV 1g/6hours.
|
IF nothing is working in sub-acute context...
(One
of the most difficult challenges for us...)
The patient is going to die from lung disease. Both pneumonia
and PCP treatment are not active... severe dyspnea/polypnea... with
or without symmetrical auscultation... with or without bronchospasm,
with or without cyanosis...
Disease is too acute to be a "normal"
TB and not generalized enough to be milliary TB...
A last challenge is to be made because
in dyspneic context, without morphine, "palliative cares"
is not an operational concept (see "Introduction") and because without a lab, in such context,
hope is always permitted if the patient still has a strong body...
Now, after many bad experiences, our policy is:
- Stop all drugs, including TB treatment
- Lincocin IM 300mg.x2-3 + fluconazole
PO 200mg.x2
- Symptomatic cares as needed, including dexamethasone... (knowing
that dexa is dangerous in CMV infection... emergency is emergency, patient
is already going to die!)
NB Erythromycin
+ fluconazole or even metronidazole
+ fluconazole
can be alternative challenges...
but for us more failure...
|
- More chronic infection + "dirty auscultation"
(multi focal, diffuse abnormal noises, wheezing...)
- BRONCHITIS?
- Doxycycline 100mg 1 tab daily
- Not better? Think about TB...
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