Approach to Dyspnea

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Approach to Dyspnea

• Dr. Ghulam Hussain Baloch
• Associate Professor of Medicine
• LUMHS, Jamshoro

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Definition

• 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

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DyspneaDefinitions

• Dyspnea of exertion (DOE)
• Exertion-induced SOB
• Orthopnea
• Recumbent-induced SOB
• Paroxysmal nocturnal dyspnea (PND)
• Sudden SOB after recumbent

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PND (Cardiac Asthma)

• Sever breathness at night relieved when patient
  sits up

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Case 1

• 73 y/o F presents to the ED with complaints of
  SOB for the last 2 days

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Case 2

• 28 year male presented with high grade fever,
  cough on examination bronchial breathing
• Diagnosis
• Investigation Mangement

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DyspneaRapid Assessment

• ABCs
• Mental status
• Presence of cyanosis

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DyspneaInitial Interventions

• IV assess
• Pulse oximetry supplemental O2
• Cardiac monitor

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What Are the Indications for Airway Management?

• Secure maintain patency
• Protection
• AMS or altered gag
• C-spine
• Oxygenation
• Ventilation
• Treatment Suction, medications

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DyspneaHistory

• 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?

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DyspneaHistory

• Has there been similar episodes?
• Are there associated symptoms?
• What is the past medical Hx?
• Smoking Hx?
• Medications?

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Cause

• Acute
• Bronchial asthma
• Pneumonia
• Pneumothorax
• thromboembolic disease
• Cardiac
• Pulmonary oedema
• Non cardiac pulmonary oedema
• psychogenic

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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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DyspneaEtiologies
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DyspneaEtiologies Pulmonary Causes
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DyspneaCommon Pulmonary Causes

• Obstructive lung disease
• Asthma/COPD
• Pneumonia
• Pulmonary embolism
• Pneumothorax

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DyspneaCommon Pulmonary Causes

• Obstructive lung disease
• Asthma/COPD
• Pneumonia
• Pulmonary embolism
• Pneumothorax

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DyspneaEtiologies Nonpulmonary Causes
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DyspneaCommon Cardiac Causes

• Acute coronary syndromes
• CHF
• Dysrhythmias
• Valvular heart disease

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DyspneaCommon Cardiac Causes

• Acute coronary syndromes
• CHF
• Dysrhythmias
• Valvular heart disease

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DyspneaCommon Miscellaneous Causes

• Metabolic acidemias
• Severe anemia
• Pregnancy
• Hyperventilation syndrome

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DyspneaPhysical Examination Vital Signs

• BP
• ? if dyspnea significant
• ? life-threatening problem
• Pulse
• Usually ?
• Bradycardia - severe hypoxemia
• Respiratory rate
• Sensitive indicator of respiratory distress
• DANGER gt 35-40 bpm or lt 10-12 bpm

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DyspneaPhysical Examination Observation

• Ability to speak
• Patient position
• Cyanosis
• Central vs. peripheral (acrocyanosis)
• Mental status
• Altered MS - hypoxemia/hypercapnia

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DyspneaPhysical 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
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DyspneaPhysical Examination Pulmonary

• Inspection
• Use of accessory muscles
• Splinting
• Intercostal retractions
• Percussion
• Hyper-resonance vs. dullness
• Unilateral vs. bilateral

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DyspneaPhysical Examination Pulmonary

• Auscultation
• Air entry
• Stridor upper airway obstruction
• Breath sounds
• Normal
• Abnormal
• Wheezing, rales, rhonchi, etc.
• Unilateral vs. bilateral

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DyspneaPhysical Examination Cardiac

• Neck
• ? JVD
• Auscultation
• Abnormal S2 splitting
• Present of S3 and/or S4
• Rubs
• Murmurs

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What does clubbing suggest? Chronic Hypoxemia
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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

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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

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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

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3. Acute Pulmonary edema

• Previous H/O Heart Disease
• Hyperthyroidism
• Rheumatic Heart disease (ms)
• Sign of LVF
• Tachycardia
• Pulses alternan
• Basal criptation
• ECG change
• X-ray Chest ( cardiomegaly)
• Echo

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Pulmonary Embolism

1. History of prolonged remobilization
2. pelvic surgery
3. contraceptive pills
4. cyanosis
5. ECG
6. x-ray chest
7. ABG
8. ECHO
9. PIQ study

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Case 1History

• 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

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Case 1Physical 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

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Case 1

• What are likely etiologies for this patients
  dyspnea?
• Heart failure
• ? ACS

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DyspneaDiagnostic Adjuncts

• What study will most patients with dyspnea get?
• CXR
• Indicated in most cases of dyspnea, especially
  new-onset

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Case 1
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DyspneaDiagnostic Adjuncts

• What other non-laboratory study would you like?
• ECG
• Indicated if cardiac etiology suspected or
  cardiac history

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Case 1
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DyspneaDiagnostic Adjuncts

• What lab tests might be useful in dyspnea workup?
• ABG
• If any question about ventilatory or acid-base
  status
• Beware of interpretation of (Aa)O2
• Troponin
• How would it be helpful in our patient?
• B-type natriuretic protein (BNP)
• Laboratory studies based on suspected etiology of
  dyspnea

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DyspneaTreatment

• Cornerstone of Rx
• Assuring oxygenation/ventilation
• Supplemental O2
• PaO2 gt 60 mm Hg SpO2 gt 90
• Specific Rx depends on working diagnosis

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DyspneaSpecial Considerations Pediatrics

• Common upper airway problems
• Infection
• Croup
• Retropharyngeal abscess
• Epiglottitis
• Foreign body aspiration

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DyspneaSpecial Considerations Pediatrics

• Common lower airway problems
• Anaphylaxis
• Asthma
• Bronchiolitis
• Bronchopulmonary dysplasia
• Cystic fibrosis
• Foreign body aspiration
• Pneumonia

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DyspneaSpecial Considerations Pregnant Patient

• Venous thrombosis/pulmonary embolism
• 3/1000 pregnancis
• Risk continues to the postpartum period
• Heparin outpatient treatment of choice
• Asthma
• Rule of 1/3
• Rx same as non-pregnant patient
• Pulmonary edema
• Preeclampsia
• Postpartum cardiomyopathy

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CaseConclusion

• Diagnosis CHF subacute MI
• Treatment
• IV nitroglycerin
• IV furosemide
• Reassessment much improved