Approach to patients with Dyspnea

1. Approach to patients with Dyspnea Dr.Hadil Al Otair MRCP,FCCP

2. Dyspnea Definition: An unpleasant or uncomfortable awareness of breathing.

3. Outline: - Control of breathing - Causes of acute dyspnea & their clinical features - Causes of chronic dyspnea - Investigations for chronic dyspnea

4. Dyspnoea An unpleasant or uncomfortable awareness of breathing Ability tobreathing ↑Demand

5. Control of breathing • Afferent (sensory ) information Chemoreceptors: Central (medulla) Peripheral (Carotid &Aortic bodies) Mechanoreceptors (Airways ,lungs, chest wall) • Respiratory control system • Efferent respiratory dischargesto ventilatory muscles

7. Caruana-Montaldo B. et.al. Chest 2000;117:205-225

10. Causes of " Acute " Shortness of Breath

11. Factors Causing sensation of dyspnea Chemicals: - Hypoxemia - Hypercapnea - Acidosis Vascular: - Pulmonary Artery (PHT) - Ventricle Pressure (CHF) Chest Wall & Neuro-muscular: - Guillen-Barre - Kyphoscoliosis Inflation & Deflation receptors in Airways. - Asthma - COPD - IPF

12. CARDIAC PULMONARY • Pulmonary edema • Cardiac tamponade • Pulmonary embolism • Pneumothorax • Acute asthma • Aspiration syndrome • Fat embolism • Amniotic fluid embolism • Inhalation injury (co-poisoning) • Upper airway obstruction • Anaphylaxis • Traumatic

14. DIAGNOSIS HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS Pulmonary Edema • Risk factors: • Smoking • HTN-DM, lipid • or prior H/O • heart cocaine • use • H/O rheumatic • heart disease • Gallop rhythm • Murmur • JVP • LL • Edema • Bibasilar • crackles • ECG, CE • Chest x-ray • Symptoms: • Orthopnea, PND’s • Assoc. chest pain • Palpitations • Sweating

15. DIAGNOSIS HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS • Known asthmatic • H/O atopy • Preceeding URTI • Symptoms: wheezes • Tachypnea • Tachycardia • Wheezes • Pulsus paradoxus • CXR • PFT Acute Asthma

16. Management of Acute Asthma Assessment of attack severity . Clinical Findings . Peak Flow Measurement . Arterial Blood Gases EAR Early Asthmatic Response 30min – 4H LAR Late Asthmatic Response 3H – 12 H

20. One Hour

21. Patients at risk of developing severe or fatalasthma:. Previous life-threatening attacks Severe disease Hospital admission during the previous year One or more emergency room visits in the last year Patients’ noncompliance Psychosocial problems Three or more categories of antiasthmatic drugs prescribed Discontinuity of medical care

22. Life threatening Asthma Patterns of Fatal Asthma: 1) Acute on Chronic Asthma 2) Hyper Acute Asthma Clinical Findings: Silent Chest Cyanosis Exhaustion Bradycardia Hypotension PFR < 30%

23. PULMONARY EMBOLISM Risk factors Presenting Symptoms Physical Findings Investigations Therapy

24. DIAGNOSIS HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS • Risk factors: • H/O hypercoagulable disorder, recent DVT • Surgery, immobility • cancer • Symptoms: pleuritic • Chestpain,SOB • hymoptysis • ABG • CXR • ECG • VQ • Spiral CT • Doppler LL Pulmonary Embolism • tachycardia • Tachypnea • Loud P2 • Pleural effusion • Acute Cor Pulmonale • hypotension

28. DIAGNOSIS HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS • tall, thin, young • patient. H/O pleural • aspiration or biopsy • Symptoms: wheezes • one hemithorax • Hyperinflated • Hyperresonance • ↓ breath sounds • Trachea + • mediastinal shift Pneumothorax • CXR esp • exp. film

30. Pneumothorax Major Types: Spontaneous:Primary peak 20-30 yrs,4:1 male :female Tall thin ,cigarette smokers,positive family history Secondary:Parenchymal lung disease e.g sarcoidosis,IPF,Emphysema,Necrotising pneumonia incl.Tb,PCP, Iatrogenic: Pleural tap,transbronchial lung biopsy,positive pressure ventilation. Traumatic:Rib fracture,bronchial rupture,esophageal rupture

31. Pneumothorax Mechanism rupture of subpleural bleb or parenchymal process eroding visceral pleura this may also cause partial bronchial obstruction(check -valve mechanism) & hyperinflation

32. Complications Tension Pneumothorax When significant positive pressure in the pleural space results in severe compression of ipsilateral lung,contralateral shift of the mediastinum Results from one way valve mechanism how to diagnose ? What to do?

33. Pneumothoraxmanagement Observation: in small pneumothorax(<15%) primary , spontaneuos or iatrogenic not ventilated Oxygen; Increase the pressure gradient between pleural space&capillaries by decreasing partial pressure of nitrogen chest tube thoracotomy

34. Recurrence:10-50% 60% after the second recurrence Sclerotherapy,Thoracotomy

35. DIAGNOSIS HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS Fat Embolism • Trauma • Long bone fracture • ↓ level of consciousness • petechial rash Non-specific • CXR • urine fat Amniotic Fluid Embolism • Prolonged labour • PROMAmniotic Fluid • Assisted labour Non-specific • CXR

36. Chronic dyspnea • Major causes: Asthma COPD Bronchiectasis Interstitial lung disease Heart failure or cardiomyopathy

37. Evaluation • History& physical exam • CXR • PFTS • Oximetry • Echocardiogram • CT-lungs - I.L.D _ Bronchiectasis - Occult emphysema - Chronic thromboembolic dis. • Cardiopulmonary exercise

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