Transcript Dyspnea

In the name of GOD
History and
Physical Examinations
Hassan Ghobadi MD
Assistant Professor of Internal Medicine
Ardabil University of Medical Science
MEDICAL INTERVIEW
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CHIEF COMPLAINT AND PRESENT ILLNESS
MAJOR PULMONARY SYMPTOMS
FAMILY AND SOCIAL HISTORIES
PAST HISTORY
SYSTEMS REVIEW
QUESTIONNAIRES
PHYSICAL EXAMINATION
Symptoms & Signs
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Dyspnea (Breathlessness)
Cough
Chest pain
Hemoptysis
Palpable mass
Audible wheeze
An abnormal chest finding on imaging
History and Physical Examinations
Dyspnea
( Breathlessness )
Dyspnea
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Unpleasant sensation of breathing.
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Dyspnea implies that the awareness is disproportionate
to the stimulus and, the sensation is abnormally
uncomfortable.
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The sensation experienced by normal subjects during
physical exertion is described as “ shortness of
breath," not as dyspnea .
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Many patients describe their breathing discomfort as:
"breathlessness," "tightness," "choking," "inability to
take a deep breath," "suffocating," and simply "can't get
enough air.
Dyspnea
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Dyspnea occurs in healthy subjects under
stress (e.g., exercise, altitude).
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In patients with an underlying disorder it
may occur with little or no exertion.
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Dyspnea is a term used to characterize a
subjective experience of breathing
discomfort
Mechanisms of Dyspnea
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There are no known specialized dyspnea receptors.
The mechanisms of dyspnea are incompletely understood .
Mechanisms are multifactorial.
Interactions between the efferent motor output from the brain
to the ventilatory muscles and the afferent.
Disorders of the ventilatory pump are associated with
increased work of breathing or a sense of an increased effort
to breathe
A discrepancy or mismatch between the feed-forward
message to the ventilatory muscles and the feedback from
receptors that monitor the response of the ventilatory pump
increases the intensity of dyspnea.
Mechanisms of Dyspnea
Dyspnea may occur when there is :
1- Increased central respiratory drive secondary
to hypoxia, hypercapnia, or other afferent
input;
2- Augmented requirement for the respiratory
drive to overcome mechanical constraints or
weakness; and
3- Altered central perception.
Mechanisms of Dyspnea
Pathophysiology of Dyspnea
Pathophysiology of Dyspnea
Intensity of Dyspnea
Clinicians generally rely on a combination of patients'
reports and physiologic measurements (e.g., FEV1)
to evaluate dyspnea
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Modified Borg scale
Visual analogue scale
Chronic Respiratory Disease Questionnaire
Diseases Causing Dyspnea
1- Mechanical Interference with Ventilation
Obstruction to airflow (central or peripheral)
Asthma, emphysema, bronchitis,
Endobronchial tumor ,Tracheal or laryngeal stenosis
Resistance to expansion of the lungs ("stiff lungs")
Interstitial fibrosis of any cause , Left ventricular failure ,
Lymphangitic tumor
Resistance to expansion of the chest wall or diaphragm
Pleural thickening or "peel" (e.g., empyema)
Kyphoscoliosis , Obesity ,
Abdominal mass (e.g., tumor, pregnancy)
Diseases Causing Dyspnea
2 - Weakness of the Respiratory Pump
Absolute
Prior poliomyelitis, Neuromuscular disease (e.g.,
Guillain-Barré syndrome, muscular dystrophy,
systemic lupus erythematosus, hyperthyroidism)
Relative
(i.e., muscles at a mechanical disadventage )
Hyperinflation (e.g., asthma, emphysema) ,
Pleural effusion ,Pneumothorax
Diseases Causing Dyspnea
3 - Increased Respiratory Drive
a- Hypoxemia of any cause
b- Metabolic acidosis
Renal disease (failure or tubular acidosis)
Decreased effective hemoglobin
(e.g., anemia, hemoglobinopathy)
Decreased cardiac output
c- Stimulation of intrapulmonary receptors
infiltrative lung disease, pulmonary
hypertension, pulmonary edema
Diseases Causing Dyspnea
4 -Increased Wasted Ventilation
Capillary destruction
(e.g., emphysema, interstitial lung disease)
Large-vessel obstruction
(e.g., pulmonary emboli, pulmonary vasculitis)
Diseases Causing Dyspnea
5 - Psychological Dysfunction
Bodily preoccupation ( somatization)
Anxiety ( hyperventilation syndrome)
Depression
Involvement in litigation
( alleged respiratory injury)
Respiratory System Dyspnea
1- Controller
Acute hypoxemia and hypercapnia, bronchospasm (asthma),
interstitial edema, pulmonary embolism, High altitude, high
progesterone states (pregnancy), drugs (aspirin).
2- Ventilatory Pump
Increased airway resistance (e.g., asthma, emphysema, chronic
bronchitis, bronchiectasis).
increased airway resistance and work of breathing
(kyphoscoliosis, Guillain-Barré syndrome, pleural effusions).
3- Gas Exchanger
Pneumonia, pulmonary edema, ILD, Pulmonary vascular
disease.
Cardiovascular System Dyspnea
1- High Cardiac Output
Anemia, Left-to-right intracardiac shunts, obesity
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2- Normal Cardiac Output
Deconditioning, Diastolic dys., Pericardial disease
3- Low Cardiac Output
coronary artery disease, cardiomyopathies
Approach to Dyspnea
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HISTORY.
A comprehensive medical history is important for a diagnosis
of dyspnea
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PHYSICAL EXAMINATION.
Pattern of breathing , body habitus (e.g., cachexia, obesity),
posture (e.g., leaning forward on elbows as in COPD),
skeletal deformity, Cough on deep inspiration or expiration
suggests asthma or interstitial lung disease
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DATABASE.
Anemia , Polycythemia , chest radiography, spirometry, and
possibly electrocardiography
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SPECIAL STUDIE.
Pulmonary function tests , Pulse oximetry , Spiral CT scanning ,
Gallium CT scanning , cardiac catheterization .
Approach to Dyspnea
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Orthopnea is a common indicator of congestive heart failure,
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mechanical impairment of the diaphragm associated with obesity,
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Asthma triggered by esophageal reflux.
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Nocturnal dyspnea suggests congestive heart failure or asthma.
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Acute, intermittent episodes of dyspnea are more likely to reflect
episodes of myocardial ischemia, bronchospasm, or pulmonary
embolism,
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Chronic persistent dyspnea is typical of COPD and interstitial lung
disease.
Approach
to
Dyspnea
Severity of dyspnea
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Inability of the patient to speak in full sentences
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Evidence for increased work of breathing (supraclavicular
retractions, use of accessory muscles of ventilation, and the tripod
position) is indicative of disorders of the ventilatory pump.
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When measuring the vital signs, an accurate assessment of the
respiratory rate should be obtained and examination for a pulsus
paradoxus ; if it is >10 mm Hg, consider the presence of COPD.
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During the general examination, signs of anemia (pale
conjunctivae), cyanosis, and cirrhosis (spider angiomata,
gynecomastia) should be sought.
Dyspnea: Treatment
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Correct the underlying problem responsible for the symptom
and its complications .
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If this is not possible, one attempts to lessen the intensity of
the symptom and its effect on the patient's quality of life .
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Supplemental O2 should be administered if the resting O2
saturation is < 90% .
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For patients with COPD, pulmonary rehabilitation programs
have demonstrated positive effects on dyspnea, exercise
capacity, and rates of hospitalization .
Dyspnea: Treatment (1)
Reduce Sense of Effort and
“ Improve Respiratory Muscle Function “
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Energy conservation (e.g., pacing)
Breathing strategies (e.g., pursed-lip breathing)
Position (e.g., leaning forward)
Correct obesity or malnutrition
Inspiratory muscle exercise
Respiratory muscle rest (e.g., cuirass, nasal
ventilation, transtracheal oxygen)
Medications (e.g., theophylline)
Dyspnea: Treatment (2)
Decrease Respiratory Drive
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Oxygen
Opiates and sedatives
Exercise conditioning
Vagal nerve section (not done)
Carotid body resection (not done)
Dyspnea: Treatment (3)
Alter Central Nervous System Function
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Education
Psychological interventions (e.g., coping
strategies, psychotherapy, group support)
Opiates and sedatives
Dyspnea: Treatment (4)
Exercise Training (Pulmonary Rehabilitation)
Enhance self-esteem and self-confidence in
ability to perform
Improve efficiency of movement
Desensitization to dyspnea
(i.e., from repeated exercise)
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