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P ulmonary dyspnea

APPROACH TO THE DIAGNOSIS OF DYSPNEA. P ulmonary dyspnea. DR.H atice Türker. Sureyyapasa Chest Diseases and Thoracic Surgery e ducation and Research Hospital , Istanbul,. TTD 15.ANNUAL CONGRESS /ANTALYA 13-04-2012. I have no disclosure. PLAN. Pulmon ary D y spne a Definition

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P ulmonary dyspnea

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  1. APPROACH TO THE DIAGNOSIS OF DYSPNEA Pulmonary dyspnea DR.Hatice Türker Sureyyapasa Chest Diseases and Thoracic Surgery education and Research Hospital , Istanbul, TTD 15.ANNUAL CONGRESS /ANTALYA 13-04-2012

  2. I have no disclosure

  3. PLAN Pulmonary Dyspnea Definition Mechanisms Causes of dyspnea Assesment Differential diagnosis Therapy

  4. Dyspnea-increased effort of breathing ‘’Dyspnea’’ Dys:difficult, painful Pneumea:breath

  5. DEFINITION OF DYSPNEA • Patients perceptions: • Unsatisfied inspiration • Chest tightness • Sensation of feeling breathless • Cannot get enough air • Hunger for air • Incomplete exhalation

  6. DEFINITION OF DYSPNEA DEFINITION OF DYSPNEA Clinical :A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. Physiological: The stimulation of pulmonary and extrapulmonary afferent receptors and the transmission of afferent information to the serebral kortex,where the sensation is perceived as uncomfortable or unpleasant Am Respir Crit Care Med.Vol 159,1999 Am Respir Crit Care Med. Vol 185,2012

  7. SUBSTANTIAL EVIDENCE 1-Distinct mechanisms and afferent pathways are reliably associated with different sensory qualities (notably work/effort, tightness, and air hunger/ unsatisfied inspiration) 2-Distinct sensations most often do not occur in isolation 3-Dyspnea sensations also vary in their unpleasantness and in their emotional and behavioral significance. Dyspnea per se can only be perceived by the person experiencing it. Adequate assesment of dyspnea depends on self-report. Am Respir Crit Care Med. Vol 185,2012

  8. CYCLIC EFFECTS OF DYSPNEA SOCIAL ISOLATION IMMOBILITY DEPRESSION LACK OF FITNESS DYSPNEA

  9. Dyspnea Exercise tolerance Quality of life

  10. MECHANISM OF DYSPNEA Comprehensive respiratory medicine,1999

  11. MECHANISM OF DYSPNEA I DON’T BREATH N.Vagus N.Phrenic N.Intercostal Respiratory system motor stimuli muscle stretch musclelength Sensory stimuli Airway receptors, parenchimal receptors, solunum kasları kemoreceptors effort emotions Prof. Dr.Gül Öngen’in izniyle

  12. QUALITIES OF DYSPNEA Arise through cortical motor command Work/effort Stimulation of airway receptors Tightness Imbalance when ventilation increases Hunger for air Am Respir Crit Care Med. Vol 185,2012

  13. CAUSES OF DYSPNEA

  14. ASSESMENT OF DYSPNEA • History • Work/effort • Acute dyspnea • Chronic dyspnea • Associated symptoms • Positionaldyspnea

  15. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea CHARACTERISTICS OF HISTORY Persistance among the day and year and variability Causes triggering or augmenting dyspnea What are the associated symptoms? What is the relationship with position?

  16. CHARACTERISTICS OF HISTORY • Persistance among the day and year and variability • Intermittent • Persistent • Nocturnal • Seasonal • Occupational ( work,home ...etc.)

  17. CHARACTERISTICS OF HISTORY • Intermittent dyspnea • Reversibl causes • Acute bronchoconstriction • Congestive heart failure • Acute pulmonary embolism • Pleural effusion • Persistent dyspnea • Irreversibl causes • COPD • Interstitial • Chronicpulmonary embolism • PAH • Diaphragmatic dysfunction • Chest wall disorders

  18. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea CHARACTERISTICS OF HISTORY • Nocturnal dyspnea • Asthma • Congestive heart failure • Gastroesophageal reflux • Sleep-apnea syndrome • Nasal obstructions

  19. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea DYSPNEA/EFFORT Modified Borg scale(MBS) Visual analog scale(VAS) Modified Medical Research Council(MMRC) Oxygen cost diagram (OCD) Baselinedyspnea index (BDİ) Değişen dispne indeksi (DDİ)

  20. DOMAINS OF DYSPNEA MEASUREMENT

  21. MODIFIED BORG SCALE Borg, 1982 Verbal expression of degree of dyspnea in a nonlinear and numericalway, It’s easier to apply with exercise, It’s appropiate for comparison of persons or groups.

  22. MODIFIED BORG SCALE Score Symptoms

  23. VISUAL ANALOG SCALE What can you do today?  Everything Nothing How severe is your dyspnea today?  Very difficult None How severe is your dyspnea while dressing today?  Very severe No dyspnea 0 cm 10 cm

  24. Modified Medical Research Council scale(MMRC)

  25. OXYGEN COST DIAGRAM It’s a vertical visual analog scale with 13 items designed for assessment of oxygen need during sleep and walking uphill.

  26. Brisk walking uphill medium walking uphill Brisk walking on the level Slow walking uphill Medium walking Bed-making Slow walking on the level Standing Washing yourself Sitting Sleeping 0 OXYGEN COST DIAGRAM

  27. BASALINE DYSPNEA INDEX It’s a versatile scale Functional disability (daytime activities and work performance) Intensity and difficulty of the physical activity Grade of effort Total BDI score: 0-12 Low scores show that dyspnea is severe Mahler DA, Chest 1984;85:751-58

  28. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea ACUTE VE CHRONİC DYSPNEA Acute: dyspnea that develops over hours or days. Chronic: dyspnea that develops over weeks,months or years.

  29. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea CAUSES OF PULMONARY DYSPNEA • Chronic • COPD • Left ventricular failure • Interstitial fibrosis • Asthma • Pleural effusion • Pulmonary embolism • Pulmonary vascular disease • Acute • Pulmonary edema • Asthma • Chest wall travma • Spontan pneumotorax • Pulmonary embolism • Pneumonia • Pleural effusion • Pulmonary hemoraji

  30. DIFFERENTIAL DIAGNOSIS OF DYSPNEA RAPID ONSET CAUSES Acute Dyspnea

  31. + + + • Tracheal tumor • Foreign body Stridor • Acute pulmonary embolism • Myocardial infarction • Aortic dissection • Pericardial effusion • Tamponade • Pulmonary embolism • Effusion • Lobar collapse • Pneumonia Chest pain Pleuritic chest pain Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea ACUTE DYSPNEA-ASSOCIATED SYMPTOMS Dyspnea

  32. Motor neuron disease • Myasthenia gravis + + + • ++++Bronchiectasis • ++ Chronic bronchitis • Asthma(yellow-green) • pulmonary embolism • tumor • COPD(acute exacerbation • Pulmonary edema • vasculitis Sputum hemoptysis bulbar symptoms ACUTE DYSPNEA-ASSOCIATED SYMPTOMS Dyspnea

  33. No wheeze Wheeze ±sputum smoking Occupational history ±crackles ±clubbing ±pleurisy ±hemoptysis Atopic? sputum +++ Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea CHRONICDYSPNEA-ASSOCIATED SYMPTOMS Dyspnea (months-years) with chronic pulmonary disease Pulmonary embolism Bronchiectasis Pneuömo-cniosis Asthma COPD ILD

  34. Anamnesis Work/effort Acute dyspnea Chronic dyspnea Associated symptoms Positionaldyspnea POSITIONAL DYSPNEA Paroxysmal nocturnal: severes shortness of breath and coughing that generally occur at night Orthopnea: shortness of breath which occurs when lying flat Trepopnea: sensed while lying on one side but not on the other Platypnea: shortness ofbreath worsens when sitting or standing up Dyspnea due to exercise

  35. APPROACH TO THE DIAGNOSIS OF DYSPNEA

  36. TREATMENT OF DYSPNEA TREATMENT DIAGNOSIS SAT PaO2 (<%90-92) Heart failure,pulmonary edema Pneumothorax Pulmonary embolism Asthma attacs COPD exacerbations Foreign body aspiration Pneumonia ARDS Hemothorax Oxygen Diuretics Chest tube Anticoagulan or thrombolytic theraphy Short acting bronchodilators Bronchodilators,antibiotics,sist. steroids Bronchoscopy antibiotics IMV Pleural drenage

  37. TREATMENT OF DYSPNEA Am Respir Crit Care Med. Vol 185,2012

  38. OXYGEN TREATMENT

  39. HELIOX TREATMENT

  40. PHARMACOLOGICAL TREATMENT Opioids have been the most widely used. Short-term administration reduces breatlessness. Long-term efficacy is limited and conflicting. Associated with frequent side effects (constipation) Respiratory depression is uncommon with the doses used to treat dyspnea, even in elderly patients

  41. PHARMACOLOGICAL TREATMENT Nebulized furosemide has been investigated as a novel pharmacologic approach. The mechanism of the effect is uncertain. Decreased breatlessness induced in normal volanteers. Currently insufficient data to support its use in the treatment of dyspnea.

  42. PHARMACOLOGICAL TREATMENT Anxiolytics Antidepressants Fhenothiazines Indomethacin Inhaled topical anesthetics Nitrous oxide Sodium bicarbonate INEFFECTIVE Can Respir J 2011;18:69-78 Cochrane Databasa Syst Rev 2010; Thorax 2008;63:872-875

  43. PULMONARY REHABILITATION Integral component of the management of patients with chronic lung disease. Decreases dyspnea during exercise Improved exercise tolerance Inspiratory muscle training (IMT) reduces of dyspnea intensity and dynamic hyperinflation

  44. NONPHARMACOLOGICAL APPROACHES Coldair Chestwallvibration Noninvasiveventilation ALTERNATIVE MEDICINE Acupuncture Yoga

  45. Hycinth Mimosa bloossom Daisy Spring flower Narcissus flower THANK-YOU FOR YOUR ATTENTION

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