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Approach toDyspnea
Dr.Bilal Natiq Nuaman,MD
C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.
Lecturer in Iraqia Medical College
2017
Dyspnea; Breathlessness; Shortness of
Breath(SOB)
• ‘’Dyspnea’’
Dys: difficult, painful
Pneumea:breath
• Breathlessness or dyspnea can be defined as the feeling of an uncomfortable need to breathe.
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 extra pulmonary afferent receptors and the transmission of afferent information to the cerebral cortex, where the sensation is perceived as uncomfortable or unpleasant
Patients perceptions:
✓ Unsatisfied inspiration
✓ Chest tightness
✓ Sensation of feeling breathless
✓ Cannot get enough air
✓ Hunger for air
✓ Incomplete exhalation
Pathophysiology :
Respiratory diseases can stimulate breathing and dyspnea by:
➢ stimulating intrapulmonary sensory nerves (e.g. Pneumothorax, interstitial inflammation and pulmonary embolus)
➢ increasing the mechanical load on the respiratory muscles (e.g. airflow obstruction or pulmonary fibrosis)
➢ Causing hypoxia, hypercapnia or acidosis, stimulating
chemoreceptors.
Common Pulmonary Causes
• Obstructive lung disease
• Asthma/COPD (Chronic Bronchitis ,Emphysema)
• Pneumonia
• Pulmonary embolism
• Pneumothorax
cardiac failure can stimulate breathing and dyspnea by:
➢ pulmonary congestion reduces lung compliance and can
also obstruct the small airways.
➢ In addition, during exercise, reduced cardiac output
limits oxygen supply to the skeletal muscles, causing
early lactic acidaemia and further stimulating breathing
via the central chemoreceptors.
Common Cardiac Causes
• Acute coronary syndromes
• CHF
• Dysrhythmias
• Valvular heart disease
Stages of dyspnea
1-EXERTIONAL DYSPNEA- DYSPNEA DUE TO EXERCISE
2-PND - PAROXYSMAL NOCTURNAL DYSPNEA
3-ORTHOPNEA – SOB LYING FLAT AND BETTER SITTING UP (CHF, pregnancy, resp.muscle weakness)
4-RESTING DYSPNEA- DYSPNEA AT REST
Common Miscellaneous Causes
• Metabolic acidosis
• Severe anemia
• Pregnancy
• Hyperthyroidsm
• Hyperventilation syndrome
Differential diagnosis of dyspnea
Patients with breathlessness present either with
Chronic exertional dyspneaOr
Acute dyspnea,when symptoms are prominent even at rest.
• Chronic: Dyspnea >30 daysthat develops over weeks, months or years.
• COPD
• Left ventricular failure
• Lung fibrosis
• Asthma (uncontrolled)
• Pleural effusion
conscious level declines or if severe respiratory acidosis is
Pulmonary oedema is suggested by pink, frothy sputum and
bi-basal crackles;
asthma or COPD by wheeze and prolonged expiration;
pneumothorax by a silent resonant hemithorax; and
pulmonary embolus by severe breathlessness with normal
breath sounds.
eg swelling may suggest cardiac failure or, if asymmetrical,
venous thrombosis causing pulmonary embolism.Arterial blood gases, a chest X-ray and an ECG should beobtained to confirm the clinical diagnosis, and high concentrations of oxygen given pending results.
rgent endotracheal intubation may become necessary if the
present.
Physical signs in dyspnic patient
Investigations
Chest radiograph (CXR): weather cardiac or pulmonary
Cardiac Causes! Pulmonary causes!
ECG Pulmonary function test(PFT)
(abnormally significant) (abnormally significant)
Echo CT scan of chest
(abnormally significant) (abnormally significant)
Corona angiography Lung Biopsy
CXR