Dyspnea

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Dyspnea

• Jin Yu-hua
• Dept. of Geriatrics

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Definition

• Dyspnea is defined as an awareness of difficulty
  in breathing.
• Most patients suffer from actual difficulty, some
  patients just taste an awareness of
  hyperventilation(????).

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How to describe these sensations

• Cannot get enough air
• Air does not go all the way down
• Smothering feeling in the chest
• Tightness in the chest
• Fatigue in the chest

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Definition

• Dilatation of nares(????), cyanosis(??), use of
  accessory muscles of respiration
• Abnormalities of respiratory rate,depth or rhythm

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Etiology

• Respiratory disease
• Cardic disease
• Toxic
• Nero-Psychogenic
• Haematological disease
• Increase of abdominal pressure (massive
  ascites(??), pregnancy(??) etc)

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• Normal person may experience the physiologic
  dyspnea during heavy exercise
• Environment short of oxygen

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Respiratory dyspnea

• Respiratory dyspnea is caused by abnormal
  ventilation and gas exchange.
• Reduction in ventilatory capacity,
  hypercapnia(??????) and hypoxemia(????) resulting
  from respiratory disease.
• Three clinical types inspiratory dyspnea,
  expiratory dyspnea, mixed dyspnea.

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Inspiratory dyspnea

• Clinical characteristics visible indrawing over
  the sternal notch, the supraclavicular spaces,
  the intercostal spaces and the epigastrium in the
  inspiration(???).
• Accompanied by a coarse, low pitched inspiratory
  wheezing and dry cough.
• Stenosis and obstruction of larynx, trachea, and
  bronchi

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Expiratory dyspnea

• Clinical characteristics expiration is prolonged
  and laboured with wheezing.
• Cause the decrease of lung elasticity and spasm
  narrowing of the bronchioles and smaller bronchi.
• Familiar diseases emphysema(???), bronchial
  asthma(?????) and chronic asthmatic
  bronchitis(???).

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Mixed dyspnea

• Clinical characteristics breathing is difficult
  during both inspiration and expiration.
  Respiratory frequency increase and respiration
  superficial.
• Cause decrease of ventilators and gas exchange
  capacity
• Familiar diseases severe pneumonia(??),
  pulmonary fibrosis(????), massive
  atelectasis(?????) etc

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Cardiac dyspnea

• Cardiac dyspnea is usually attributable to
  pulmonary vascular congestion resulting from the
  left and/or right heart failure.
• Dyspnea is the primary symptom of left heart
  failure.

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Left heart failure

• Basal diseases
• Coronary heart disease
• Hypertensive heart disease
• Rheumatic heart disease
• Congenital heart disease

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Left heart failure

• Mechanism
• Lung congestion decrease gas dispersion
• Alveoli are stiff and more work is needed to
  overcome elastic recoil
• The high alveolar pressure stimulate stretch
  receptor
• High pulmonary circulation pressure stimulate
  respiratory nerve center

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Left heart failure

• Clinical representation
• Exhausted dyspnea(???????)
• Orthopnea(????)
• Paroxysmal nocturnal dyspnea(?????????)

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Exhausted dyspnea

• Difficulty in breathing when the patient is in
  activity relived when he relax.
• Doing exercise impel more blood into pulmonary
  circulation.
• More oxygen is needed for body demand, especially
  the heart.

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Functional classification

• Class ? no limitation Ordinary physical
  activity does
• Class ? slight limitation of physical activity
• Class ? Marked limitation of physical activity
• Class ? inability to carry or any physical
  activity without discomfort

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Orthopnea

• Difficulty in breathing in the supine position
• relived by sitting up
• Reduce the degree of pulmonary congestion by
  pooling blood in the lower extremities
• Improve the diaphragmatic movement
• Increase vital capacity

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Paroxysmal nocturnal dyspnea

• The patient awakes short of breath at night, but
  often obtain relief by sitting up for a period of
  time.
• Physical examination moist rales at the both
  lung bases, tachycardia, wheezing and
  bronchospasm (cardiac asthma?????).

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Paroxysmal nocturnal dyspnea

• Reason
• Supine posture for sleep impel more blood into
  pulmonary circulation, and decrease vital
  capacity.
• Vagus excitement cause coronary artery
  constriction and bronchioles spasm.

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Right heart failure

• Basal diseases
• Acute cor pulmonale(???) which caused by
  pulmonary embolism(???)
• Chronic cor pulmonale which caused by chronic
  obstructive pulmonary disease(???)

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Right heart failure

• Mechanism
• The pressure of right atria and superior vena
  cava is the natural stimulus of respiratory
  center.
• Hypoxemia and the accumulation of the acid
  metabolites stimulate respiratory center.
• The restriction of the respiratory movement
  caused by enlargement of liver,ascites and
  pleural effusion.

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Biventricular failure

• Left heart failure plus right heart failure
  may cause severe dyspnea?

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Toxic dyspnea

• In the metabolic acidosis (uremia??? and
• diabetic acidosis???????), the acid
  metabolites stimulate the respiratory center,
  causing deep and regular respiration (Kussmanul)
  with snoring.

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Toxic dyspnea

• The overdose of morphine and pentobarbital
• can depress respiratory center causing slow
• respiration or Cheyne-Stokess respiration.

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Neuro-Psychogenic dyspnea

• The respiratory center loses the blood
• supply or is compressed while patient
• suffering from cerebro vascular disease.
• The respiration becomes deep, slow and
• irregular.

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Nero-Psychogenic dyspnea

• Patient suffer from hysteria will be seen
• repetitive deep, signing respiration with
• numbness of extremities or lips, cheiropedal
• spasm.

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Haematologicl dyspnea

• The decrease of oxygen-carrying capacity and
  oxygen content develop abnormal respiration and
  increase heart rate, such as severe anemia,
  carbon monoxide.
• Hypotension can stimulate respiration when
  patient suffer from shock.

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Accompanying symptoms

• Paroxysmal dyspnea with wheezing, It is
  present in bronchial asthma and cardiac asthma.
  Paroxysmal severe dyspnea is often seen in acute
  larynx edema(?????), spontaneous
  pneumothorax(?????), massive pulmonary embolism.

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Accompanying symptoms

• Dyspnea with chest pain. It is frequently
  observed in lobar pneumonia(?????), pulmonary
  infarction(???), spontaneous pneumothorax, acute
  exudative pleurisy(????????), acute myocardial
  infarction(??????), and bronchial
  carcinoma(?????).

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Accompanying symptoms

• Dyspnea with fever. It is commonly noted in
  pneumonia, lung abscess(???), pulmonary
  tuberculosis(???), pleurisy, acute
  pericarditis(?????), and nervous system diseases.

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Accompanying symptoms

• Dyspnea with cough and purulent sputum. It is
  often present in chronic bronchitis, obstructive
  pulmonary emphysema with infection, purulent
  pneumonia, and lung abscess Dyspnea with large
  amount of foamy sputum is often seen in acute
  left ventricular heart failure and
  organophosphorus poisoning(?????).

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Accompanying symptoms

• Dyspnea with coma. It suggests cerebral
  hemorrhage(???), pneumonia with shock, uremia,
  diabetic ketoacidosis(????????), and acute
  poisoning.

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