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Transcript
Approach to Dyspnea
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
LUMHS, Jamshoro
Definition

Awareness of his own breath




Hyperventilation
Signing breath
In ability to take deep breath

Orthopnea dyspnea on recumbence
Dyspnea
Definitions

Dyspnea of exertion (DOE)


Orthopnea


Exertion-induced SOB
Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND)

Sudden SOB after recumbent
PND (Cardiac Asthma)

Sever breathness at night relieved when
patient sits up
Case 1

73 y/o F presents to the ED with complaints
of SOB for the last 2 days
Case 2
28 year male presented with high grade fever,
cough on examination bronchial breathing
a)
Diagnosis
b)
Investigation & Mangement
Dyspnea
Rapid Assessment

ABC’s

Mental status

Presence of cyanosis
Dyspnea
Initial Interventions

IV assess

Pulse oximetry; supplemental O2

Cardiac monitor
What Are the Indications for Airway
Management?


Secure & maintain patency
Protection





AMS or altered gag
C-spine
Oxygenation
Ventilation
Treatment – Suction, medications
Dyspnea
History

Prolonged questioning can be counterproductive


Yes/No questions if significantly dyspneic
Unlike pain, severity of dyspnea = severity of disease

What does patient mean by SOB?

How long has SOB been present?


Is it sudden or gradual
Does anything make it better or worse?
Dyspnea
History

Has there been similar episodes?

Are there associated symptoms?

What is the past medical Hx?


Smoking Hx?
Medications?
Cause









Acute
Bronchial asthma
Pneumonia
Pneumothorax
thromboembolic disease
Cardiac
Pulmonary oedema
Non cardiac pulmonary oedema
psychogenic
Chronic
Pulmonary Cause
1. COPD
 Chronic Bronchial Asthma
 Emphysema Chronic Bronchitis
 2. Restrictive Lung Disease
 Sarcoidosis
 Rheumatoid lung
 fibrosing alveolitis
 Pneumoconosis

Dyspnea
Etiologies
80%
75%
70%
60%
50%
40%
30%
20%
10%
15%
10%
0%
Respiratory
Cardiac
Other
Dyspnea
Etiologies: Pulmonary Causes
Dyspnea
Common Pulmonary Causes

Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax
Dyspnea
Common Pulmonary Causes

Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax
Dyspnea
Etiologies: Nonpulmonary Causes
Dyspnea
Common Cardiac Causes

Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease
Dyspnea
Common Cardiac Causes

Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease
Dyspnea
Common Miscellaneous Causes

Metabolic acidemias

Severe anemia

Pregnancy

Hyperventilation syndrome
Dyspnea
Physical Examination: Vital Signs

BP



Pulse



 if dyspnea significant
 = life-threatening problem
Usually 
Bradycardia - severe hypoxemia
Respiratory rate


Sensitive indicator of respiratory distress
DANGER = > 35-40 bpm or < 10-12 bpm
Dyspnea
Physical Examination: Observation

Ability to speak

Patient position

Cyanosis


Central vs. peripheral (acrocyanosis)
Mental status

Altered MS - hypoxemia/hypercapnia
Dyspnea
Physical Examination

Pulmonary





Use of accessory muscles
Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor
Cardiac

Check neck for presence of JVD
Signs of severe
respiratory
distress
Dyspnea
Physical Examination: Pulmonary

Inspection




Use of accessory muscles
Splinting
Intercostal retractions
Percussion


Hyper-resonance vs. dullness
Unilateral vs. bilateral
Dyspnea
Physical Examination: Pulmonary

Auscultation

Air entry


Stridor = upper airway obstruction
Breath sounds


Normal
Abnormal


Wheezing, rales, rhonchi, etc.
Unilateral vs. bilateral
Dyspnea
Physical Examination: Cardiac

Neck


? JVD
Auscultation




Abnormal S2 splitting
Present of S3 and/or S4
Rubs
Murmurs
What does
clubbing suggest?
Chronic Hypoxemia
Pneumonia
1.Fever with chills
2.Pleuratic chest pain
3. purulent sputum
4. History of upper respiratory symptoms
5.signs of consolidation
6.x-ray chest
7. CBC
8. Blood culture
9. ABG acute bronchial asthma age startedat
childhood
2. Acute Bronchial Asthma
1.Age start in young age
2. Family History
3. H/O Allergic Rhinitis
4.Physical exam
5.barrel shape chest
6.X-ray chest
7. ABG
Pneumothorax
1.Suden chest pain
2. dyspnea,caugh
3. H/O asthma
4.COPD
5.Examination, trachea, shifted to opposite side
absent breath sound
6 x-ray chest
3. Acute Pulmonary edema
Previous H/O Heart Disease
b) Hyperthyroidism
c) Rheumatic Heart disease (ms)
Sign of LVF
a) Tachycardia
b) Pulses alternan
c) Basal criptation
d) ECG change
e) X-ray Chest ( cardiomegaly)
f)
Echo
a)
Pulmonary Embolism
a)
b)
c)
d)
e)
f)
g)
h)
i)
History of prolonged remobilization
pelvic surgery
contraceptive pills
cyanosis
ECG
x-ray chest
ABG
ECHO
PIQ study
Case 1
History







Symptoms started 2 days ago
Onset gradual and progressive
Exertion makes it worse
New onset
(+) chest pain, cough, DOE, PND
No past medical Hx
No medications or smoking Hx
Case 1
Physical Examination







Moderate respiratory distress, talks in partial
sentences, prefers to sit in ED cart
BP = 190/110 mmHg; HR = 118 /min; RR =
36 bpm; afebrile; SpO2 = 85%
HEENT: no angioedema
Lungs: rales & wheezing bilaterally
Cardiac: (+) JVD; (+) S3
Skin: no rashes
Extremities: no edema
Case 1

What are likely etiologies for this patient’s
dyspnea?


Heart failure
? ACS
Dyspnea
Diagnostic Adjuncts

What study will most patient’s with dyspnea
get?

CXR

Indicated in most cases of dyspnea, especially newonset
Case 1
Dyspnea
Diagnostic Adjuncts

What other non-laboratory study would you
like?

ECG

Indicated if cardiac etiology suspected or cardiac history
Case 1
Dyspnea
Diagnostic Adjuncts

What lab tests might be useful in dyspnea
workup?

ABG



Troponin



If any question about ventilatory or acid-base status
Beware of interpretation of (A–a)O2
How would it be helpful in our patient?
B-type natriuretic protein (BNP)
Laboratory studies based on suspected etiology of
dyspnea
Dyspnea
Treatment

Cornerstone of Rx


Assuring oxygenation/ventilation
Supplemental O2


PaO2 > 60 mm Hg; SpO2 > 90%
Specific Rx depends on working diagnosis
Dyspnea
Special Considerations: Pediatrics

Common upper airway problems

Infection




Croup
Retropharyngeal abscess
Epiglottitis
Foreign body aspiration
Dyspnea
Special Considerations: Pediatrics

Common lower airway problems







Anaphylaxis
Asthma
Bronchiolitis
Bronchopulmonary dysplasia
Cystic fibrosis
Foreign body aspiration
Pneumonia
Dyspnea
Special Considerations: Pregnant Patient

Venous thrombosis/pulmonary embolism




Asthma



3/1000 pregnancis
Risk continues to the postpartum period
Heparin outpatient treatment of choice
Rule of 1/3
Rx same as non-pregnant patient
Pulmonary edema


Preeclampsia
Postpartum cardiomyopathy
Case
Conclusion

Diagnosis = CHF & subacute MI

Treatment



IV nitroglycerin
IV furosemide
Reassessment – much improved