• 1k likes • 1.8k Views
Dyspnea. Victor Politi, M.D., FACP Medical Director, St. Anthony’s School of Allied Health Professions, Physician Assistant Program. Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases. .
E N D
Dyspnea Victor Politi, M.D., FACP Medical Director, St. Anthony’s School of Allied Health Professions, Physician Assistant Program
Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.
Dyspnea - common complaint/symptom • “shortness of breath” or “breathlessness” • Defined as abnormal/uncomfortable breathing • Multiple etiologies - • 2/3 of cases - cardiac or pulmonary etiology
There is no one specific cause of dyspnea and no single specific treatment • Treatment varies according to patient’s condition • chief complaint • history • exam • laboratory & study results
Differential Diagnosis • Composed of four general categories • Cardiac • Pulmonary • Mixed cardiac or pulmonary • non-cardiac or non-pulmonary
Pulmonary Etiology • COPD • Asthma • Restrictive Lung Disorders • Hereditary Lung Disorders • Pneumonia • Pneumothorax
Cardiac Etiology • CHF • CAD • MI (recent or past history) • Cardiomyopathy • Valvular dysfunction • Left ventricular hypertrophy • Pericarditis • Arrhythmias
Mixed Cardiac/Pulmonary Etiology • COPD with pulmonary HTN and/or cor pulmonale • Deconditioning • Chronic pulmonary emboli • Pleural effusion
Noncardiac or Nonpulmonary Etiology • Metabolic conditions (e.g. acidosis) • Pain • Trauma • Neuromuscular disorders • Functional (anxiety,panic disorders, hyperventilation) • Chemical exposure
Easily Performed Diagnostic Tests • Chest radiographs • Electrocardiograph • Screening spirometry
In cases where test results inconclusive • complete PFTs • ABGs • EKG • Standard exercise treadmill testing/ or complete cardiopulmonary exercise testing • Consultation with pulmonologist/cardiologist may be useful
ABGs • Commonly used to evaluate acute dyspnea • can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia • normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea • Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing
PULSE OX • Rapid, widely available, noninvasive means of assessment in most clinical situations- • insensitive (may be normal in acute dyspnea) • The % of Oxygen saturation does not always correspond to PaO2 • The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels
What is Asthma • A Chronic disease of the airways that may cause: • Wheezing • Breathlessness • Chest tightness • Nighttime or early morning coughing
The bronchospasm characteristic of the acute asthmatic attack is typically reversible. It improves spontaneously or within minutes to hours of treatment
Asthma can exist by itself or coexist with chronic bronchitis, emphysema, or bronchiectasis
Symptoms/Chief Complaint • Progressive dyspnea • Cough • Chest tightness • Wheezing/coughing
The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction
Focus of Therapy • Pharmacologic manipulation of airway smooth muscle • Do not overlook physiologic impairment caused by mucous production and mucosal edema • Bronchospasm can be reversed in minutes • Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - • may lead to atelectasis, infectious bronchitis, pneumonitis
Asthma Triggers • Immunologic reaction • Viral respiratory/sinus infections • change in temperature/humidity • Drugs/Chemicals - • aspirin, NSAIDS • Exercise • GE reflux • Laughing/coughing • Environmental factors - • strong odors, pollutants, dust, fumes
Patient Exam • Wheezing • may be audible w/o stethoscope • Use of accessory muscles of inspiration • diaphragmatic fatigue • Paradoxical respirations • - reflect impending ventilatory failure • Altered mental status - • lethargy, exhaustion, agitation, confusion
Patient Exam • Hypersonance to percussion • decreased intensity of breath sounds • prolongation of expiratory phase w or w/o wheezing
Patient Exam • The intensity of the wheeze may not correlate with the severity of airflow obstruction • “quiet chest” - very severe airflow obstruction
Asthma Treatment • Nebulized B-adrenergic drugs • Corticosteroids • Nebulized anticholinergics • Magnesium sulfate • Oxygen • Long acting beta-agonists • Inhaled steroids
Managing Asthma: • Indications of a severe attack: • Breathless at rest • hunched forward • talking in words rather than sentences • Agitated • Peak flow rate less than 60% of normal
Treatment Goals of Severe Asthma • Improve airway function rapidly • Avoid hypoxemia • Prevent respiratory failure and death
COPD • Hallmark symptom - Dyspnea • Chronic productive cough • Minor hemoptysis • pink puffer • blue bloater
COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat.
COPD - Physical Findings • Tachypnea • Accessory respiratory muscle use • Pursed lip exhalation • Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing
Dominant Clinical Forms of COPD • Pulmonary emphysema • Chronic bronchitis • Most patients exhibit a mixture of symptoms and signs
COPD - Advanced Dx • secondary polycythemia • cyanosis • tremor • somnolence and confusion due to hypercarbia • Secondary pulmonary HTN w or w/o cor pulmonale
COPD Treatment Strategy • Elimination of extrinsic irritants • bronchodilator & glucocorticoid therapy • Antibiotics • Mobilization of secretions • “respiratory vaccines” • Oxygen therapy - if oxygen saturation <90% at rest on room air
6th leading cause of death in the US • Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases
Common types of respiratory infections • Tracheobronchitis • Pneumonia • Effusions • Empyema • Abscess • Cavitary lesions • post-obstructive
Common Respiratory Viruses • Influenza A & B • Parainfluenza 1& 3 • Respiratory Syncytial Virus • Adenovirus • Cytomegalovirus • Herpes Simplex & Zoster/varicella • Hanta Virus Infection
Respiratory Syncytial Virus • Rapid diagnosis of Respiratory Syncytial Virus Infection by immunofluorescence of respiratory secretions
Classic Pneumonia Symptoms • Dyspnea, chills • high fever, cough/sputum • pleuritic chest pain
Viral Pneumonia - symptoms • Chest Pain • Fever • Dyspnea • Prodrome - malaise, upper respiratory symptoms, and other GI symptoms
Viral pneumonia - Clinical Findings • Minimal/variable • Chest exam - may reveal wheezing • Fine rales if heard can signify interstitial involvement • Chest x-ray - patchy densities or interstitial involvement
Viral pneumoniaManagement /Prophylaxis • Supportive treatment - decrease severity of symptoms • bed rest • analgesics • expectorants • Patients w/ • airway obstruction - treat w/bronchodilators • secondary bacterial infection - antibiotics
Atypical Pneumonia • Accounts for 25% of community acquired pneumonias • Mycoplasma/chlamyda/legionella • can case extrapulmonary manifestations - • meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia • typically bilateral infiltrates on chest x-ray • primarily effects younger persons