Transcript Dyspnoea
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