Download Dyspnoea

Approach to Dyspnea
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
LUMHS, Jamshoro
Definition
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Awareness of his own breath
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Hyperventilation
Signing breath
In ability to take deep breath
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Orthopnea dyspnea on recumbence
Dyspnea
Definitions
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Dyspnea of exertion (DOE)
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Orthopnea
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Exertion-induced SOB
Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND)
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Sudden SOB after recumbent
PND (Cardiac Asthma)
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Sever breathness at night relieved when
patient sits up
Case 1
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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
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ABC’s
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Mental status
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Presence of cyanosis
Dyspnea
Initial Interventions
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IV assess
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Pulse oximetry; supplemental O2
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Cardiac monitor
What Are the Indications for Airway
Management?
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Secure & maintain patency
Protection
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AMS or altered gag
C-spine
Oxygenation
Ventilation
Treatment – Suction, medications
Dyspnea
History
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Prolonged questioning can be counterproductive
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Yes/No questions if significantly dyspneic
Unlike pain, severity of dyspnea = severity of disease
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What does patient mean by SOB?
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How long has SOB been present?
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Is it sudden or gradual
Does anything make it better or worse?
Dyspnea
History
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Has there been similar episodes?
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Are there associated symptoms?
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What is the past medical Hx?
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Smoking Hx?
Medications?
Cause
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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
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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
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Obstructive lung disease
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Asthma/COPD
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Pneumonia
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Pulmonary embolism
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Pneumothorax
Dyspnea
Common Pulmonary Causes
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Obstructive lung disease
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Asthma/COPD
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Pneumonia
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Pulmonary embolism
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Pneumothorax
Dyspnea
Etiologies: Nonpulmonary Causes
Dyspnea
Common Cardiac Causes
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Acute coronary syndromes
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CHF
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Dysrhythmias
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Valvular heart disease
Dyspnea
Common Cardiac Causes
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Acute coronary syndromes
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CHF
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Dysrhythmias
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Valvular heart disease
Dyspnea
Common Miscellaneous Causes
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Metabolic acidemias
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Severe anemia
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Pregnancy
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Hyperventilation syndrome
Dyspnea
Physical Examination: Vital Signs
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BP
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Pulse
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 if dyspnea significant
 = life-threatening problem
Usually 
Bradycardia - severe hypoxemia
Respiratory rate
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Sensitive indicator of respiratory distress
DANGER = > 35-40 bpm or < 10-12 bpm
Dyspnea
Physical Examination: Observation
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Ability to speak
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Patient position
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Cyanosis
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Central vs. peripheral (acrocyanosis)
Mental status
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Altered MS - hypoxemia/hypercapnia
Dyspnea
Physical Examination
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Pulmonary
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Use of accessory muscles
Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor
Cardiac
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Check neck for presence of JVD
Signs of severe
respiratory
distress
Dyspnea
Physical Examination: Pulmonary
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Inspection
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Use of accessory muscles
Splinting
Intercostal retractions
Percussion
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Hyper-resonance vs. dullness
Unilateral vs. bilateral
Dyspnea
Physical Examination: Pulmonary
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Auscultation
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Air entry
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Stridor = upper airway obstruction
Breath sounds
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Normal
Abnormal
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Wheezing, rales, rhonchi, etc.
Unilateral vs. bilateral
Dyspnea
Physical Examination: Cardiac
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Neck
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? JVD
Auscultation
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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
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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
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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
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What are likely etiologies for this patient’s
dyspnea?
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Heart failure
? ACS
Dyspnea
Diagnostic Adjuncts
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What study will most patient’s with dyspnea
get?
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CXR
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Indicated in most cases of dyspnea, especially newonset
Case 1
Dyspnea
Diagnostic Adjuncts
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What other non-laboratory study would you
like?
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ECG
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Indicated if cardiac etiology suspected or cardiac history
Case 1
Dyspnea
Diagnostic Adjuncts
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What lab tests might be useful in dyspnea
workup?
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ABG
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Troponin
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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
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Cornerstone of Rx
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Assuring oxygenation/ventilation
Supplemental O2
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PaO2 > 60 mm Hg; SpO2 > 90%
Specific Rx depends on working diagnosis
Dyspnea
Special Considerations: Pediatrics
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Common upper airway problems
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Infection
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Croup
Retropharyngeal abscess
Epiglottitis
Foreign body aspiration
Dyspnea
Special Considerations: Pediatrics
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Common lower airway problems
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Anaphylaxis
Asthma
Bronchiolitis
Bronchopulmonary dysplasia
Cystic fibrosis
Foreign body aspiration
Pneumonia
Dyspnea
Special Considerations: Pregnant Patient
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Venous thrombosis/pulmonary embolism
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Asthma
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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
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Preeclampsia
Postpartum cardiomyopathy
Case
Conclusion
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Diagnosis = CHF & subacute MI
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Treatment
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IV nitroglycerin
IV furosemide
Reassessment – much improved