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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.