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52 JULY 2016 | EMSWORLD.com alveoli lose their elasticity and the ability to exchange oxygen and CO 2 , which results in prolonged respiration, decreased oxygen saturations and CO 2 retention. Chronic bronchitis is a type of COPD that causes inflammation of the bronchial tubes, which produces the classic triad of a chronic cough, increased mucus production and shortness of breath. Some of the most difficult breath sounds to assess occur in patients with COPD. Due to the destruction of the alveoli, breath sounds are generally decreased. Additionally, wheezing, rales and rhonchi can also be pres- ent, especially if associated with pneumonia. During COPD exacerbations, patients try to manage the increased workload of breath- ing by assuming a tripod position, utilizing their accessory muscles and breathing with pursed lips. As compensatory mechanisms fail, increased respiratory effort and CO 2 retention can quickly exhaust a patient, causing a decreased level of consciousness. Look for a history of increasing respira- tory distress, typically preceded by infec- tions such as pneumonia or upper respira- tory infections, or by exposure to irritants such as air pollution or chemicals. Differential diagnosis: CHF, pulmonary embolus, pneumonia. CHF—For the purposes of this article we will focus on left heart failure, as left ventricular failure (LVF) can cause severe respiratory distress. Conditions such as myocardial infarction or cardiomyopathy can damage the left ventricle enough so that a person's ejection fraction is significantly reduced. This reduction causes blood to back up into the pulmonary circulation, causing the pulmonary venous pressures to increase. The elevated pressure causes capillaries to leak fluid into the alveoli and interstitial space. Dyspnea on exertion and weight gain may indicate f luid retention in CHF; that and orthopnea are early signs of LVF. They are typically pre- ceded by increased sodium intake, infec- tions and noncompliance with medica- tions. 4 Symptoms may progress gradually over hours or days. In contrast, flash pulmo- nary edema occurs rapidly, often becoming extremely severe in minutes. It is often a result of severe hypertension, myocardial infarction or mitral valve dysfunction. Signs of right heart failure may be pres- ent: JVD, HJR, weight gain due to f luid retention, pedal edema. Differential diagnosis: pneumonia, pul - monary embolus, COPD. Asthma—Asthma is characterized by bronchoconstriction, inflammation of the airways and increased mucus production. As with emphysema, asthma patients have difficulty getting air out. Patients can quick- ly become exhausted due to the increased workload of breathing and retention of CO 2 . History will include a rapid onset of wheezing and SOB, which may be preceded by a recent upper respiratory infection or exposure to irritants (chemicals, tobacco smoke, air pollution, etc.). Exercise, stress and noncompliance with medications may also cause exacerbations. Differential diagnosis: COPD, CHF, pul- monary embolus, pneumonia. Pneumonia—Pneumonia is an infection of the lung characterized by a productive cough, fever and malaise. Risk factors include weakened immune systems due to chemotherapy or HIV/AIDS, chronic ill- nesses such as COPD, asthma and diabetes, and age over 65. Look for recent upper respiratory infec- tion or flu, productive cough, dyspnea on exertion, fever/chills and general malaise. Differential diagnosis: COPD, CHF, asthma. Conclusion One of the more difficult aspects of con- ducting a prehospital history and physical exam is deciding which questions need to be asked and what elements of the exam should be done. In each article of this series, we have detailed a his- tory and physical exam based on the body system correlat- ing with the chief complaint. Paramedics are encouraged to develop their own pattern recognition in medicine. Pat - tern recognition is the ability to see the similarities between several cases with the same diagnoses and medical con- ditions in order to more rapidly diagnose future similar cases. Over time, using final hospital diagnoses to reinforce correct deci- sions (or alternatively correct false diagnos- tic impressions), the skilled paramedic will gain clinical acumen that will help improve the accuracy of their prehospital diagnosis and assist in determining what clues to look for in their history and physical examina- tions. With this information in hand, let's take another look at the hypoxic elderly female patient from our opening. The patient A one-sided swollen leg can indicate DVT, which would raise the likelihood that pulmonary embolism is the cause of the dyspnea. Ken Scheppke