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EVALUATION OF DYSPNOEA DR. PRAPULLA CHANDRA
DEFINITION OF DYSPNOEA
Dyspnoea is a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interaction among multiple physiological, psychological, social, and environmental factors, and it may induce secondary physiological and behavioral responses.
MECHANISM OF DYSPNOEA
Receptors involved in mechanism of dyspnea1) J receptors – alveolo-capillary junction
• Stimulated by pulmonary congestion ,oedema, micro emboli.
• Responsible for rapid shallow breathing
2) Stretch receptors – thoracic cage & lung
3) Chemoreceptors - carotid arteries, aorta & reticular substance of medulla
Stimulated by hypoxia, excess of CO2, decrease in PH
4) Receptors in the respiratory muscle – immediate cause of appreciation of dyspnea
COPD
Thorax is in hyperinflated position/Diaphragm
Work of breathing is high, O2 cost of breathing high
Derangement of dead space ventilation & alveolar capillary gas exchange
Afferent stimuli to sensorymotor cortex
Dyspnoea
INTERSTITIAL LUNG DISEASE
Work of breathing & O2 cost of ventilation increased
Effort of respiratory muscles in ventilation stimulate afferent impulses
DYSPNOEA
Pleural effusion & Pneumothorax
collapse of the normal lung hypoxia
muscles at mechanical disadvantage
Dyspnoea
Anemia Inadequate O2 delivery to respiratory muscles
increased respiratory drive
Dyspnoea
PULMONARY EDEMA alveolar & interstitial edema stimulate J-receptors
Dyspnoea
MUSCULOSKELETAL DISORDERS Hightened motor drive required to activate
weakened respiratory muscles
Dyspnoea
STEPWISE APPROACH
history
physical examination
investigations
treatment
HISTORY TAKING
Onset Position Timing Severity Ppt/Relieving factors Associated symptoms
•
Minutes• Pneumothorax
• Pulmonary oedema
• Major pulmonary embolism
• Foreign body
• Laryngeal oedema
Hours
• Asthma
• Left heart failure
• Pneumonia
Days• Pneumonia
• ARDS
• Left heart failure
• Repeated pulmonary embolism
Weeks• Pleural effusion
• Anemia
• Muscle weakness
• Tumours
ONSET OF DYSPNOEA
Months• Pulmonary fibrosis
• Thyrotoxicosis
• Muscle weakness
Years Muscle weakness
COPD
Chest wall disorders
ACUTE DYSPNOEA
RESPIRATORY CAUSES -PNEUMOTHORAX
-ACUTE ASTHMA
-ACUTE PULM.EMBOLISM
-UPPER AIRWAY OBSTRUCTION
-PULMONARY EDEMA
-TRAUMA
-FOREIGN BODY
CARDIAC CAUSES
Acute MI Acute valvular insufficiency Aortic dissection Complete heart block Pericardial tamponade Congestive heart failure
CHRONIC DYSPNOEA
AIRWAYS 1. Obstructive airway disease 2. Asthma 3. Chronic bronchitis 4. Empyema 5. Cystic fibrosis
PARENCHYMAL
1. ILD 2. Malignancy -primary -secondaries
PLEURAL
1. Effusion 2. Malignancy 3. Fibrosis
PULM-VASCULAR DISEASE
1. A-V Malformations 2. Vasculitis 3. Veno-occlusive disease
OTHER CAUSES
CONGESTIVE HEART FAILURE CONSTRICTIVE PERICARDITIS NEUROMUSCULAR DISORDERS ANEMIA
POSITION
ORTHOPNOEA
• CCF• LVF• COPD• Br.asthma• Massive pleural effusion• Bil diaphragm palsy.• Ascites• GERD
PLATYPNOEA • Left atrial myxoma• Massive pulm. Embolism• Pulm. AV fistula• Paralysis of intercostal .m• Hepato
pulmonary syn.
TREPOPNOEA
• DISEASE OF ONE LUNG/ BRONCHUS• CCF
TIMING
NOCTURNAL ONSET DYSPNOEA
- CHF - COPD - BRONCHIAL ASTHMA - SLEEP APNOEA - POST NASAL DRIP - NOCTURNAL ASP. IN GERD
PAROXYSMAL NOCTURNAL DYSPNOEA
Severe difficulty in breathing that awakens the patient from sleep and forces him to a sitting or standing position.
Almost always implies underlying heart failure
POSTPRANDIAL DYSPNOEA
GERD ASPIRATION FOOD ALLERGY
GRADING
DYSPNOEA GRADING SCALES
Visual analogue scale Borg scale Bode index Sherwood jones grading American thoracic society scaling NYHA Scale MRC Classification MMRC dyspnoea scale
EXAMPLE OF A VISUAL ANALOG SCORE. THESE CAN BE ADAPTED TO ANY SYMPTOM AND CAN BE SUPPLEMENTED WITH ANCHORING VERBALOR VISUAL DESCRIPTORS AS SHOWN HERE.
SHERWOOD JONES GRADING
Grade 1a : housework/job with moderate difficulty
1b : with great difficulty
Grade 2a : confined to chair/bed but able to get up with moderate difficulty.
2b : with great difficulty
Grade 3 : totally confined to chair/bed
Grade 4 : moribund
GRADE 1 –Dyspnoea only with unusual exertion.
GRADE 2 –Dyspnoea on doing ordinary activity
GRADE 3 –Dyspnoea on doing less than ordinary activity.
GRADE 4 –Dyspnoea at rest.
NYHA SCALE
I. Not troubled by breathlessness with
strenuous exercise.
II. Shortness of breath when hurrying or walking up a slight hill.
III. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace.
IV. Stops for breath after walking about 100m or after a few min. or level ground.
V. Too breathless to leave the house or breathless when dressing or undressing.
MRC CLASSIFICATION
0. Not troubled by breathlessness with strenuous exercise.
1. Shortness of breath when hurrying or walking up a slight hill.
2. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace.
3. Stops for breath after walking about 100m or after a few min. or level ground.
4. Too breathless to leave the house or breathless when dressing or undressing.
MMRC SCALE
PPT/RELIEVING FACTORS
Precipitating factors :
+ exercise
+ exposure – cigarette ,allergens
+ occupational exposure
+ obesity
+ severe weight loss
+ medication Relieving factors :
- rest
- medication
ASSOCIATED SYMPTOMS
-FEVER
-CHEST PAIN
-Central chest pain
-Pleuritic chest pain
-Pericardial pain
-WHEEZE
Chronic sputum production
Change in the pitch of voice
Palpitations and syncope
Haemoptysis
Dysphagia or odynophagia
Vomiting and diarrhoea
Heart burn
Muscle weakness or myalgias
Visual disturbances & headache
Bone pain
PAST MEDICAL HISTORY SURGICAL HISTORY DRUG HISTORY OCCUPATIONAL HISTORY SMOKING HISTORY
PHYSICAL EXAMINATION
EXAMINE NOSE LOOK FOR CYANOSIS PALLOR ICTERUS CLUBBING EDEMA CERVICAL LYMPHADENOPATHY
RAISED JVP PERIPHERAL PULSES AND BRUITS GOITRE
Hypotension, tachycardia, and tachypnea : acute pulmonary edema , ARDS
Hypertension in a dyspnoeic patients:
hypertension-related diastolic heart failure with pulmonary oedema, hyperthyroidism, or phaeochromocytoma
Pulsus paradoxus - asthma, COPD, cardiac tamponade.
BLOOD PRESSURE
Cardiovascular examination Elevated neck veins, extra heart sound (S3 gallop
rhythm), and fluid retention - congestive heart failure. Elevated neck veins, pulsus paradoxus, a pericardial
knock, pericardial rub, and the Kussmaul's sign - Constrictive pericarditis and effussion
An irregular or fast heart beat - a tachyarrhythmia or atrial fibrillation.
A loud S2 -PAH A systolic heart murmur- acute valvular insufficiency,
mechanical valve malfunction.
Respiratory examination
Pursed lip breathing - COPD.
A barrel chest - emphysema and cystic fibrosis.
Stridor -upper airway obstruction
Hoarseness - in laryngitis, laryngeal tumours, vocal cord paralysis.
The trachea may deviate away from the lesion-tension pneumothorax or a large pleural effusion.
Unilateral dullness to percussion - pleural effusion, atelectasis, foreign body aspiration, pleural tumours, or pneumonia.
Hyper-resonance - pneumothorax or severe emphysema.
Subcutaneous emphysema - pneumomediastinum
Neurological examination
Cranial nerve palsies associated with dyspnoea -botulism.
Ptosis -myasthenia gravis, myotonic dystrophy, or botulism.
Pneumothorax
Sudden-onset dyspnoea associated with unilateral chest pain may indicate acute pneumothorax.
On examination, breath sounds are unilaterally absent, and percussion of the ipsilateral chest may reveal tympany.
The trachea may also be deviated away from the lesion.
Acute asthma
Acute-onset dyspnoea associated with wheezing and cough, especially in a person with prior history of asthma
Asthma is diagnosed based on the history and demonstration of airflow obstruction reversibility.
RESPIRATORY CAUSES
Anaphylaxis Exposed to a medication, food product, or insect bite.
Sudden-onset dyspnoea is accompanied by cutaneous manifestations , voice changes, a choking sensation, tongue and facial oedema, wheezing, tachycardia, and hypotension.
Nausea, vomiting, and diarrhoea
Pulmonary contusion History of trauma
may present with dyspnoea, circulatory collapse, and shock.
Acute pulmonary embolism
Sudden dyspnoea and chest pain, associated with tachycardia, tachypnoea, hypotension, hypoxaemia, hemoptysis and calf tenderness.
Foreign body aspiration
History of epilepsy, syncope, altered mental status (e.g., intoxication, hypoglycaemia), or choking and coughing after ingesting food (particularly nuts) may suggest foreign body aspiration.
Cyanosis and stridor followed by hypotension and circulatory collapse .
Upper airway obstruction
Significant dyspnoea, inspiratory stridor, and occasionally expiratory wheezing, exacerbated by exercise.
Acute myocardial infarction Presents with central chest pain radiating to the
shoulders and neck frequently accompanied by dyspnoea.
► O/E patient may be clammy and hypotensive.
S3 or S4 gallop rhythm
pulmonary rales.
characteristic ECG changes,
elevated cardiac enzymes
CARDIAC CAUSES
Acute valvular insufficiency Acute dyspnoea,
systolic murmur and signs of acute cardiovascular collapse with hypotension, tachycardia, and pulmonary rales.
An echocardiogram is typically required to establish the diagnosis.
Aortic dissection Dyspnoea
severe chest pain that may radiate to the back.
hypotension and absent peripheral pulses.
Emergency echocardiogram or a CT chest is used for diagnosis.
Congestive heart failure Presents with dyspnoea worsened by exertion,
orthopnoea and paroxysmal nocturnal dyspnoea, elevated neck veins, peripheral fluid retention, an S3 gallop rhythm, and pulmonary congestion (fine bibasal rales) .
The CXR shows characteristic signs of pulmonary venous congestion with cardiomegaly.
Echocardiography.
B-type natriuretic peptide >100 pg/ml
Complete heart block Dyspnoea with weakness, light-headedness, or syncope.
ECG
Pericardial tamponade Dyspnoea accompanied by neck vein and facial
engorgement, shock, peripheral cyanosis, and tachycardia.
An enlarged cardiac silhouette on CXR and a low-voltage ECG, echocardiography.
INVESTIGATIONS
CBP – Anemia , polycythemia ( ch.Hypoxemia),
BIOCHEMICAL – - Occult renal disease - acid – base derangement - collagen vascular disease - thyroid diseaseBNP – Secreted by ventricles in response to
inc. ventr . pressure . - LVF ,COR PULMONALE CXR – SPIROMETRY – (airway & parenchymal
diseases)
ECG - CAD, pulm HTN, arrhythymiasPFT – - lung volume & flow rate - DLco - Arterial blood gases - Cardiopulmonary exercise testing - bronchial challenge - maximal insp. Pressure Imaging techniques - VP scan - CT (HRCT/contrast) CT angiogram - Gallium scan - Diaphragmatic fluoroscopy BRONCHOSCOPY
CARDIAC EVALUATION –
-ECHO
-Thallium scan
-Holter monitoring(occult ischemia /arrythmia)
-Cardiac monitoring
-Cardiac catherisation (with exercise)
CARDIOPULMONARY EXERCISE TESTING
ESOPHAGEAL EXAMINATION / pHmonitoring
ENT examination
Sleep studies
Psychological assessment
Treat the underlying cause
Pneumothorax - closed tube thoracostomy
Foreign body removal
Asthma – bronchodilators,steroids
Anaphylaxis – adrenaline & avoidance of
precipitating agent
TREATMENT
TREATMENT STRATEGIES
REDUCE VENTILATORY DEMAND DECREASE SENSE OF EFFORT IMPROVE RESP.MUSLE FUNCTION PULMONARY REHABILITATION
REDUCE VENTILATORY DEMAND
-Treat airway disease
-Supplemental oxygen
-Opiates & sedatives.
-Exercise training.
-Cognitive behavioural therapy
DECREASE SENSE OF EFFORT & IMPROVE RESP. MUSCLE FUNCTION
-Energy conservation (walk slowly)
-Breathing strategies ( pursed lip breath)
-Position ( leaning forwards)
-Correct obesity / malnutrition
-Inspiratory Muscle exercise
-Resp . Muscle rest(nasal /transtracheal O2)
-Medication (theophylline)
PULMONARY REHABILITATION
PATIENT EDUCATION EXERCISE TRAINING OPTIMIZE BODY COMPOSITION PSYCHOSOCIAL SUPPORT PHYSIOLOGIC ASSESSMENT