SOB

1. SOB Khalid Al-Mobaireek

2. Introduction and Definition • Pathophysiology • Causes • Approach • cases

3. Dyspnea • common symptom • may be the primary manifestation of lung disease, cardiac, anemia, obesity, or deconditioning.

4. What is Dyspnea? • Dyspnea: breathing discomfort • “Subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity” – ATS Consensus Statement 2012 “Uncomfortable awareness of breathing” • Major problem: Lack of a valid, reliable measure of the degree of Dyspnea • Physical symptoms define ‘dyspnea intensity’ • Emotional response determines ‘degree of distress’ • Dyspnea is complex multidimensional symptom

5. Dyspnea can be: • acute develops over hours to • chronic > 4-8 weeks. • acute worsening of chronic breathlessness (eg, CF, heart failure).

6. Introduction and Definition • Pathophysiology • Causes • Approach • cases

8. Regulation of the respiratory system

9. receptors • Chemoreceptors (peripherally and centrally located) • mechanoreceptors (located in the airways, lungs and chest wall)

10. Chemoreceptors • stimulated by changes in PCO 2 and PO 2 levels. • Central chemorecepters are in the medulla. • Peripheral chemoreceptors are in the aortic arch and carotid bodies

12. Mechanoreceptors • located in the airways, lungs and the chest wall. • Lungs: three main types: • pulmonary stretch receptors: increased airway tension and lung volume (asthma related dyspnea) • Irritant receptors: bronchial walls • C-fibers: near alveoli in the pulmonary parenchyma, • Chest wall receptors: respond to restricted chest wall movements.

14. PATHOPHYSIOLOGICAL FEATURES • In normal:respiratory muscles work only during inspiration • the diaphragm does most of the work. • The work of inspiration is the sum of the work necessary to overcome: • the elastic forces of the lung • the tissue viscosity of the lung and chest wall • airway resistance.

15. classic sign of dyspnea • The accessory muscles of inspiration: • the sternocleidomastoid • Serratus anterior • external intercostal muscles • Contraction of these muscles increases the –veintrathoracic pressure. • The negative pressure draws in the soft tissues of the chest wall (retractions:suprasternal, infrasternal, intercostal, subcostal, and supraclavicular). • Other way to maintain an adequate MV is to increase the RR(tachypnea). • Nasal flaring MV= TV X RR

16. Expiration • Little energy is expended during normal expiration. • Relaxation of the diaphragm, elastic recoil of the lungs and chest wall, and compression of the lungs by the intraabdominal organs. • In obstructive airway disease: more force is needed. • In tachypnea: no time for elastic recoil to allow adequate exhalation between breaths. • In either instance the accessory muscles of expiration are used: • The abdominal recti muscles: force the abdominal contents against the diaphragm to compress the lungs • the internal intercostal muscles contract to pull the ribs downward.

17. Introduction and Definition • Pathophysiology • Causes • Approach • cases

18. * Foreign body (airway or esophagus), Croup, Epiglottitis, Retropharyngeal abscess, Enlarged tonsils or adenoids, tumors (vc, larynx, trachea, Mediastinum), Diphtheria, Bacterial tracheitis, Ingestion of caustic substance, Vascular ring, Tracheal laryngeal web, Bronchomalacia, choanal atresia

19. Introduction and Definition • Pathophysiology • Causes • Approach • cases

20. Approach • Step 1: ABC (i.e is the patient stable?) • a patient presenting with dyspnea must be evaluated for life threatening causes. • acute in onset. • FB, pneumothorax, tamponade. • After these causes are ruled out, further evaluation can proceed.

23. History • complete description of the dyspnea: • Onset: • sudden (eg, inhaled FB, pneumothorax) • evolved over several hours (eg, asthma, diabetic ketoacidosis). • duration • the frequency of attacks of dyspnea • Triggers • severity (daily activities restriction. However, dyspnea sensation can be affected by the patient's anxiety level, previous experiences. • Aggrivating factors: patient's position • associated symptoms such as cough, wheezing, sputum, and pleuritic pain.

24. history of other known illnesses, allergies, illnesses in the family. • social history: Deconditioning can be present in sedentary life style, smoking and environmental exposure. • Medication effect can directly cause a sensation of dyspnea (e.g opioids) not compliant or recently stopped taking medications (such as lasix for fluid overload, or brochodilators).

25. Physical exam • While taking the history you can also begin the inspection.  • vital signs including O2 sat. Does the patient have fever? • Growth parameters • Finger clubbing • inspection of the upper airways • What position is the patient in? (sitting forward, etc) • Does the patient have stridor?  Tracheal tug?

26. extrathoracic obstruction: • Hoarsness (larynx)? • Cough sound? • Does the patient have signs of increased WOB (inter/subcostal retractions)? • Consider intrathoracic respiratory causes. • Does the patient have a wheeze? • Does the wheeze respond to bronchodilators? • Full cardiac and pulmonary exams.

27. Cardiac • Does the child develop SOB during feeds or activity? Have poor weight gain? • Does the anterior left hemithorax look more prominent? • Does the patient have periorbitalema?  Hepatomegaly? • Does the patient have tachychardea more than tachypnea.

28. Important clinical clues • Hypoxia: • most worrisome endpoint of SOB. • Central Cyanosis: • Deoxygenated hemoglobin is at least 5g/100mL of blood, or that O2 sats have dropped below 85%.  • either severe respiratory disease or cyanotic CHD. • Peripheral cyanosis: if without central cyanosis, is a sign of decreased peripheral (not necessarily hypoxia).

29. After basic evaluation, formulating a hypothesis: there is primary cardiac, pulmonary, or neurologic pathology • multiple systems may be impacted simultaneously.

30. Lab • ABG: can indicate the elevated CO 2 levels, acidosis • Electrolyte abnormalities. • complete blood count: anemia. • EKG: heart rhythmsCXR: pneumonia, pulmonary edema, FB. • CT scan of the chest: pulmonary embolism and a multitude of pulmonary and vascular diseases.

31. Echocardiography: strucure, pulmonary pressures, assessing systolic function • Troponin testing to evaluate for myocardial ischemia • BNP and nt-pro-BNP separate dyspnea due to CHF versus pulmonary causes. • Cardiopulmonary exercise testing: in cases of exertional dyspnea, when cardiac or pulmonary disease is at early stages.

32. Introduction and Definition • Pathophysiology • Causes • Approach • cases

33. Case Presentation #1 • 2 years old with sudden onset of SOB • Previously healthy • Normal growth • Mild tachypnea with normal saturation. • Lungs: decrease breath sounds over the right hemithorax. Monotonus wheeze heard more on the right.

35. Case Presentation #2 • A 5 year old male presents to your office with a cough and SOB • Cough is productive, SOB increased at night, recurrent • Worse with exercise and with upper respiratory infections • Growth has been normal • Chest xray findings are normal except for mild hyperinflation

36. Physical Exam • Wheezing • Crackles in the lung • Muscle retractions

37. Pulmonary Function Testing

38. Normal Flow Volume Loops

39. Case # 3 • A 4-month-old infant boy is brought to the Emergency Room because of SOB. • Physical Examination Afebrile HR 160 bpm RR 70 breaths/min HbSaO2: 88% on RA Weight: 3.2 kg GENERAL: Very thin, appearing to be malnourished; HEENT: normal CHEST : equal breath sounds; diffuse ronchi ABDOMEN: distended; no organomegaly NEUROLOGIC : normal

40. Case # 3 • PMHx: Born at term; No problems at birth. Hospitalized at 1 month of age for pneumonia; Chronic cough; Frequent vomiting and diarrhea • Immunizations: None • Social Hx: The family lives in riyadh with average income • FHx: An older sibling died at 1 year of age from unknown illness • Nutrition & Growth: breast fed; have good appetite poor weight gain

41. SWEAT TEST • Sweat Chloride: 80 mmol/L Normal <40 mmol/L Borderline 40-60 mmol/L Abnormal >60 mmol/L *However, in infants anything >30 should be repeated and worked up

42. Case #4 BG “A” is an ex-24 week preemie with BPD, a history of a PDA, who is now preparing to be discharged home from the NICU She is now 4 months of age (41 weeks gestational age) She still has SOB mostly occurring with feeds, with desats to the 80s and Baseline oxygen saturations are normal

45. Case Presentation #5 • six year old female presents to the ER after a one week history of nasal congestion and mild cough. Two days ago, she developed high fevers, chills, and increased cough. • Upon arrival in the ER, she is ill-appearing, tachypneic, and febrile. • PE: Rales are appreciated on exam over right posterior lung fields.

46. Case Presentation #5 PMHx: No prior pneumonia or wheezing FHx: +Asthma (brother) IMM: Missing part of primary series. SHx: No recent travel out of the country. Laboratory: WBC 35,000

47. Radiographic Findings

48. Case #6 A 2-month-old infant boy is brought to the Emergency Room because of persistent cough and difficulty in breathing. On examination the infant has audible stridor, a harsh, “honking” cough, and suprasternal and subcostal chest wall retractions

49. Sites & Sounds of Airway Obstruction Snoring Inspiratory Stridor Voice quality Cough quality Expiratory Stridor

50. Which are the most common cause(s) of stridor in a 2-month-old infant? • Infectious • Trauma • Congenital, idiopathic • Neurologic disorders