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!

• 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 was 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.

More chronic infection + "dirty auscultation" (multi focal, diffuse abnormal noises, wheezing...)

• BRONCHITIS?
• Doxycycline 100mg 1 tab daily
• Not better?  Think about TB...
• (See 31-TB Protocol)