Download Dyspnoea - Spire Healthcare

Managing the breathless
patient
Dr Dean Creer
Consultant Physician
Royal Free Hospital NHS Foundation Trust
Introduction
 Breathing discomfort is one of the most common and
distressing symptoms experienced by patients.
 There are no symptom-specific data about the prevalence of
this problem, the epidemiology of cardiac and pulmonary
diseases indicates that the magnitude of the problem is large.
 Cardiac disease is the leading cause of death
 Asthma and COPD patients seek help for relief of breathlessness
Respiratory system
dyspnoea includes
disorders of
 the central controller
 the ventilatory pump
 the gas exchanger
An Official American Thoracic Society Statement:
Update on the Mechanisms, Assessment, and Management of Dyspnea 2011
www.thoracic.org/statements/resources/other/update-on-mamd.pdf
Common causes of chronic dyspnoea:
the ATS top 5(6)
The majority of patients with chronic
dyspnoea of unclear etiology have:
 Asthma
 Chronic obstructive pulmonary disease (COPD)
 Interstitial lung disease
 Myocardial dysfunction
 Obesity/deconditioning
An adult with the symptom
of breathlessness comes
to you for help...
 Assume any patient seeking help for breathlessness has an
acute component, even where there is a pre-existing
diagnosis of a chronic condition.
 Breathlessness is subjective and relative: compared to when,
to whom?
 Because breathlessness is subjective, diagnosing the
cause(s) of new or gradually deteriorating breathlessness is
often not easy.
 Taking a good history and thorough examination are the first
and most important things you can do.
 Check blood pressure
 Measure oxygen saturation
 Measure pulse rate
 Manually confirm the rate and rhythm
 Measure respiratory rate
 Measure PEFR
 Other admission criteria
Check blood pressure
 Relative hypotension for that patient or values < 90/60
(know normal BP for that patient).
Measure oxygen saturation and
pulse (pulse oximeter)
whilst manually confirming the rate
and rhythm
 Oxygen saturation < 92%.
 Pulse rate < 60 bpm (bradycardia) or > 100 bpm
(tachycardia) or if the rhythm is rapid and irregular.
Pulse oximetry is a simple and discriminating test for respiratory failure
(irrespective of the cause, which may be cardiac)
and should be done first because patients with new or worsening respiratory
failure always need admission.
Respiratory Rate
 Consider admission if respiratory rate is above 30 breaths per
minute.
 Respiratory rate is an underused reliable measure of how sick a
patient is.
 It is easy to do and low tech.
 The cut-offs are:
 > 24 bpm: predicts ICU risk
 >20 bpm: flag in early warning systems and
 >30 bpm: used by CURB-65 used to predict mortality in pneumonia.
Measure Peak Expiratory Flow
using a peak flow meter
 All people with a life-threatening asthma exacerbation
(PEFR < 33% best or predicted and/or saturation < 92%).
 People with a severe asthma exacerbation (PEFR usually 33–
50% best or predicted) who do not rapidly respond to initial
treatment or who have a factor that warrants a lower threshold
for admission.
 People with a moderate asthma exacerbation (PEFR usually
>50% best or predicted) who have a factor that warrants a lower
threshold for admission.
Consider admission to hospital
also for these indicators:
 New confusion, increased confusion or increased drowsiness, either
observed or reported by carers
 Central chest pain
 Suspected unstable arrhythmia
 Stridor and breathing effort without air movement (suspect upper
airway obstruction)
 Unilateral tracheal deviation, unilateral breath sounds (suspect tension
 pneumothorax)
 Heart failure (confirmed or not) and extensive oedema or tachycardia
or cardiac shock
Consider admission to hospital
also for these indicators:
 Consider PE as a cause of otherwise unexplained
recent onset breathlessness and refer for urgent
(same day) assessment in hospital, including
CTPA.
 COPD exacerbation: follow guidance by NICE
 Heart failure: follow NICE guidance.
 If the patient has a firm diagnosis based on an echo and
specialist opinion, modify treatment involving community or
hospital heart failure teams where helpful.
 If they do not have a firm diagnosis, refer to a one-stop
Taking a good history is the next
and most important thing you can
do
 This sequence will be governed to some extent by how much
you know the patient and/or their family, tailor it to the
individual.
 Take a detailed history to start ruling out/in common physical
causes: COPD, asthma, heart failure, anaemia,
obesity, anxiety and to narrow down your hypothesis.
 Ask the patient what they want out of the consultation, listen
to their story including any history of cardiac, pulmonary
disease or trauma.
 Listen to their breathing, examine them, and take evidencebased measurements.
History
 Attention to the quality of the breathing discomfort often
provides clues to the underlying diagnosis:
 Chest tightness may be indicative of bronchospasm
 A sensation of rapid, shallow breathing may correspond to
interstitial disease
 A sense of heavy breathing is typical of deconditioning
 Exercise induced symptoms
 Cardiac: develop within 50-100M
 EIA: precipitated by more intense activity
Triggers
 Specific, reproducible inciting events such as exposure to fumes
or cold air (Asthma)
History
 Social History
 Smoking history
 Pets (Birds)
 Occupational history (Asbestosis/HSP).
 PMH
 Cardiopulmonary disease
 Atopy/Allergy
 Rheumatological, etc
 FHx
 Drug History
 Beta blockers/Amiodorone/Nitro/MXT
Smoking history
 Ask all chronically breathless patients about their
smoking history
 Calculate pack years. (Ask Advise Act)
 The prevalence of smoking in people with chronic
respiratory problems is often much higher than the
average prevalence.
 Published figures suggest it could be as high as
 over 40% of people with COPD
 about two thirds of people with idiopathic pulmonary fibrosis
 over a third of people with asthma.
Examination
 Assess the general condition and appearance:
 Do they appear anxious, tense, are they pale or clammy?
 Are they chatting normally?
 Look carefully at their hands (nicotine stains, anaemia,
clubbing).
 Observe breathing pattern including use of accessory
muscles
 Assess airway patency and listen to the patient’s lungs
 Check if they have raised JVP
 See if they have ankle oedema
 Listen for murmurs eg aortic stenosis, especially in elderly
 Take their temperature (only if you think necessary)
 Measure BMI
Uncertainty is better than the wrong dx!
 It is OK to be unsure of the diagnosis and to use
more than one consultation to make the right
diagnosis
 It is better to be unsure than to make the wrong
diagnosis and have to correct it later.
 The IMPRESS algorithm encourages the clinician
to ask themselves whenever they see the patient if
this is the right diagnosis.
Pinning down the diagnosis
 Because there are many clinical causes of
breathlessness.
 Common things do occur commonly, but there may
be an alternative explanation or additional
explanations.
 Two-thirds of breathlessness is cardiac or
pulmonary.
 Start with diagnosing/excluding common causes
 asthma, COPD, heart failure, obesity and anaemia
 Anxiety may also be a cause or co-exist.
 COPD, heart failure and anxiety are all
underdiagnosed in primary care.
List of further tests in breathlessness that
should be carried out to confirm a
diagnosis or to provide further information
 Routine blood tests
 U&E, eGFR, TFT, LFT, fasting lipids, fasting glucose, HbA1c,
FBC, serum bicarbonate to pick up chronic respiratory failure
 (calcium and thyroid function tests)
 Urinalysis
 looking for proteinuria or haematuria
 Natiuretic peptides
 BNP <100 pg/ml or NTproBNP <400 pg/ml, heart failure unlikely
 If BNP is above these levels then refer immediately to the rapid
access HF clinic.
 Triage according to levels
Pulmonary Function Testing
Initial assessment
 Spirometry
 Pulse oximetry
 Ambulatory pulse oximetry
 normal pace over approximately 200M
 and/or up two to three flights of stairs.
Who to refer for full PFT’s
 Complete pulmonary function testing is generally
reserved for:
 individuals in whom interstitial fibrosis or ventilatory muscle
weakness are suspected,
 the spirometry results are abnormal,
 or in individuals who have low baseline oxygen saturation
(eg, ≤95 percent)
 or a significant decline in oxygen saturation during
exercise (eg, ≥5 percent).
Who to refer for bronchial
provocation testing
Bronchoprovocation testing is typically
obtained in patients with recurrent,
episodic dyspnoea suggestive of
asthma, who have normal or near
normal spirometry
Imaging: CXR
CXR may provide evidence of
hyperinflation and bullous disease
suggestive of OLD
 CXR may show changes in interstitial
markings consistent with inflammation or
interstitial fluid.
Abnormalities of heart size may indicate
valvular disease or other cardiac
dysfunction.
When to request CT CHEST
usually is not indicated in the initial evaluation of
patients but can be valuable in three circumstances
1. patients with crackles on examination or reduced lung
volumes
2. patients with a smoking history, normal spirometry, and
normal chest radiographs may have emphysema on HRCT
(these patients generally have exercise oxygen
desaturation and a low diffusing capacity)
3. In patients in whom chronic thromboembolic disease is a
consideration due to elevation of pulmonary artery
pressure on an echocardiogram or oxygen desaturation
during exercise
Who to ECHO?
 Patients in whom the heart is enlarged on chest radiograph
 When LVF or pulmonary hypertension are suspected on:




clinical finding
Raised BNP levels,
CXR findings
Oxygen desaturation with exertion.
 Color flow Doppler echocardiography is used for patients in whom
chronic thromboembolic disease, pulmonary hypertension, or
diastolic dysfunction are being considered.
 Nearly 2/3 older adults with unexplained chronic dyspnea after an
initial evaluation have evidence of diastolic dysfunction
Penicka M, et al J Am Coll Cardiol. 2010;55(16):1701.
Potential complexity
 Because of its complexity, a proper assessment of
chronic breathlessness requires a planned and
structured 20-30 minute first appointment.
 Clinicians should work with their local CCG to find
ways to accommodate this
 This is happening in a number of places across the
country
 such as long term condition appointments,
 sometimes initiated under Year of Care programmes.
Thank you
What is it all about?
 The respiratory system is designed to maintain homeostasis
with respect to gas exchange (adequate oxygenation) and the
acid-base status of the organism (adjust PaCO2 to maintain
normal pH).
 Derangements in oxygenation as well as acidaemia lead to
breathing discomfort.
 The development of dyspnoea is complex which is the result of
stimulation of a variety of mechanoreceptors throughout the
upper airway, lungs, and chest wall, and which also account for
the sensations that arise when there is a mechanical load on the
system.
 The origins of dyspnea associated with the inadequate delivery
of oxygen to, or utilization by, peripheral muscles are less well
understood.
Definition of dyspnoea
 A consensus statement of the American Thoracic Society has
defined dyspnoea as:
 "a term used to characterize a subjective experience of
breathing discomfort that is comprised of qualitatively distinct
sensations that vary in intensity.
 The experience derives from interactions among multiple
physiological, psychological, social, and environmental
factors, and may induce secondary physiological and
behavioral responses”
Pathophysiology of dyspnoea
 INCREASED OUTPUT FROM THE RESPIRATORY CENTERS
 Chemoreceptors
 Acute hypercapnia
 Acute hypoxaemia
 STIMULATION OF MECHANORECEPTORS
 Upper airway receptors
 Pulmonary receptors
 Chest wall receptors
 MECHANICAL LOADING OF THE RESPIRATORY SYSTEM
 NEUROMECHANICAL DISSOCIATION
 IMPAIRED OXYGEN DELIVERY OR UTILIZATION
 Anaemia
 Deconditioning
 NEURAL ACTIVATION ASSOCIATED WITH BREATHING DISCOMFORT
Causes may be multifactoral
 The individual with COPD may experience breathlessness
because of:
 Hypoxemia (increased neural input from peripheral
chemoreceptors and output from the respiratory centers)
 Increased airways resistance
 Hyperinflation (mechanical loading)
 Neuromechanical dissociation.
 In the presence of an acute respiratory infection or volume
overload, stimulation of pulmonary receptors may also play a
role
Evaluation of Acute Dyspnoea
 Dyspnoea arising over minutes to hours is due to a small number of
conditions
 They usually have associated symptoms and signs that provide
clues to the diagnosis:




substernal chest pain with cardiac ischemia
fever, cough, and sputum with respiratory infections
urticaria with anaphylaxis
wheezing with acute bronchospasm
 Dyspnoea may be the sole complaint and the physical examination
may reveal few abnormalities (eg, pulmonary embolism,
pneumothorax).
 In these cases, attention to historical information and a review of this
limited differential diagnosis are important.
Evaluation of chronic dyspnoea
 The etiology of dyspnea may prove elusive when it develops
over weeks to months.
 Patients commonly have known cardiopulmonary disease,
but symptoms are out of proportion to demonstrable
physiologic impairments.
 In one study of 85 patients presenting to a pulmonary unit
with a complaint of chronic dyspnea, the initial impression of
the etiology of dyspnea based upon the patient history alone
was correct in only 66 percent of cases
 Thus, a systematic diagnostic approach to these patients is
necessary.
Pratter MR, et al.Arch Intern Med. 1989;149(10):2277.
When to consider CPET?
Cardiopulmonary exercise testing is indicated when:
 the etiology of a patient's dyspnoea remains unclear after the
initial evaluation
 dyspnoea seems out of proportion to the severity of the patient's
known cardiac or pulmonary disease
Cardiopulmonary exercise testing is particularly helpful in:
 establishing the diagnosis of deconditioning
 can yield clues about the presence of hyperventilation
syndromes.
 detects patients with a low threshold for respiratory discomfort;
(these individuals terminate the test at mild workloads because of
dyspnea but have no evidence of cardiopulmonary abnormality)
Pathophysiology: an approach
 Most patients with breathing discomfort can be
categorized into respiratory system or
cardiovascular system.
 Respiratory system dyspnea includes disorders of
 the central controller
 the ventilatory pump
 the gas exchanger
 Cardiovascular system dyspnea includes
 cardiac diseases (eg, acute ischemia, systolic dysfunction,
valvular disorders, pericardial diseases),
 anemia and deconditioning.
Heart Failure
 Heart failure can be a difficult diagnosis.
 So ask yourself the question could this be heart failure?
 If the answer is yes, either measure a natriuretic peptide and
refer to a rapid access one-stop diagnostic clinic
 If the level is above the value that excludes HF, or if there is a
history of previous MI - refer .
 If the patient has a firm diagnosis based on an
echocardiography and specialist opinion, modify treatment
involving community or hospital heart failure teams where
helpful.
Anginal equivalent
 Occasionally breathlessness is an anginal variant
 This diagnosis should be made by the cardiologist
who is seeing the patient within the rapid access
diagnostic clinic.
 Some patients may have anginal symptoms and
shortness of breath, and if anginal symptoms
dominate, referral to a chest pain clinic may be
more appropriate.
Ask about the impact of breathlessness
using a mix of open and closed questions:
“How does your breathing/breathlessness
make you feel?”
“Has your breathlessness been frightening
to you or your family?”
 “What has your breathlessness stopped
you doing that you want to do again, or
would like to do for the first time?”
If there is NO single high
probability cause evident…
 Consider how anxious or depressed the person is
and aim to find out whether the physical problem is
causing the anxiety, or if other life circumstances
are the cause, or a combination of both.
 Short questionnaires validated for use in general
practice include PHQ431 (PHQ)
 HADS is the normal assessment tool in secondary
care.
There are several things that will
put up a BNP or NTproBNP
including:
 left ventricular hypertrophy
 Ischaemia, tachycardia, right ventricular overload
 hypoxaemia [including pulmonary embolism]
 renal dysfunction [GFR < 60 ml/minute]
 sepsis
 COPD
 diabetes
 Cirrhosis
 Age over 70
 Also, it can be lowered by obesity or treatment with
diuretics,ACEi, BBs, ARBs and aldosterone antagonists.
HVS (HyperVentilation Syndrome)
 Characterized by a transient increase in minute ventilation with a wide
range of associated symptoms in the absence of an alternative,
contributory underlying cardiorespiratory diagnosis
 Psychological, neurological, and cardiopulmonary pathologies may all
contribute to a patient’s symptoms.
 There is significant overlap with psychiatric comorbidities (especially
panic and anxiety disorders)
 Physician awareness is key in diagnosing HVS.
 The diagnosis can usually be established by a compelling history,
normal physical exam, and the absence of alternative processes
 Referral to a pulmonologist for specialty testing is only necessary in
complicated diagnostic cases, in patients with multiple comorbidities, or
for patients who are refractory to standard interventions.
 Referral to a psychologist or psychiatrist is also appropriate for many
patients with recurrent episodes.
The best way to treat HVS:
Patients with HVS, who are not felt to have an
underlying anxiety or panic disorder, should be
treated with behavioral therapy focused upon
breathing retraining
The acute management of a hyperventilation
episode should focus on patient reassurance;
paper bag rebreathing should be administered
with caution!
Why not to prescribe!
Beta-blockers
 Show short-term improvement in the frequency of episodes.
 a retrospective study of beta blockers compared to benzodiazepines
and anxiolytics demonstrated no effect of either therapy on subjective complaints,
and dissociation between subjective complaints and measurements of ventilation
Benzodiazepines
 commonly prescribed for patients with overlapping psychological and/or
psychiatric symptoms and HVS.
 limited efficacy data on HVS with or without psychological symptoms.
 One small study demonstrated no efficacy of benzodiazepines compared to
breathing retraining
SSRIs
 beneficial in the treatment of generalized anxiety disorder and PTSD,
 there are no studies of the efficacy of SSRIs in the treatment of HVS
Spirometry nuggets
Airflow obstruction is the main abnormal
finding
 The flow-volume loop can detect upper
and lower airway obstruction.
Postbronchodilator spirometry identifies
reversibility.
 A decrease in FVC can suggest an
underlying "restrictive" abnormality.
Supplemental testing
Maximal inspiratory and expiratory pressures
Maximal voluntary ventilation in one minute
are typically obtained when respiratory muscle
weakness is suspected based on physical
examination and analysis of spirometric and
lung volume results.
Address three dimensions of
history:
 Physical health
 Mental health
 Social context
 Assume that all patients who suffer from chronic breathlessness
are stressed/anxious to some extent.
 Remember some of the anxiety may relate to a failure of
adequate diagnosis and/or treatment of the breathlessness.
 Consider supplementing the history by asking a partner, carer or
relative for their observations.