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DYSPNEA

Dyspnea, also known as shortness of breath, is defined as a subjective experience of breathing discomfort and a feeling of insufficient air intake. It is caused by interactions between the brain and respiratory muscles and sensory input from receptors in the body. Common causes include cardiac and pulmonary diseases as well as mixed or non-cardiopulmonary etiologies. A thorough history, physical exam, and diagnostic tests are needed to determine the underlying condition and appropriate treatment. Treatment depends on the diagnosis but may include oxygen, positioning, relaxation techniques, medications, and treating the specific disease.

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148 views37 pages

DYSPNEA

Dyspnea, also known as shortness of breath, is defined as a subjective experience of breathing discomfort and a feeling of insufficient air intake. It is caused by interactions between the brain and respiratory muscles and sensory input from receptors in the body. Common causes include cardiac and pulmonary diseases as well as mixed or non-cardiopulmonary etiologies. A thorough history, physical exam, and diagnostic tests are needed to determine the underlying condition and appropriate treatment. Treatment depends on the diagnosis but may include oxygen, positioning, relaxation techniques, medications, and treating the specific disease.

Uploaded by

dr. snehal patil
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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DYSPNEA

-Dr. Snehal Patil


MD PART 1
Dyspnea; Breathlessness; Shortness of
Breath(SOB)

‘’Dyspnea’’
Dys: difficult, painful
Pneumea:breath
Breathlessness or dyspnoea 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 extrapulmonary 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
Mechanisms of Dyspnea
• Respiratory sensations are the
consequence of interactions b/w the
efferent , motor output from the brain
to the ventilatory muscles & afferent,
sensory input from receptors
throughout the body & integrative
processing of this information that we
infer must be occurring in the brain.
Pathophysiology
• Respiratory diseases can stimulate breathing and
dyspnoea 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.
• In cardiac failure, 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.
Terms in dyspneic patient
• Tachypnea: A respiratory rate greater
than normal. Normal rates range from
44 cycles/min in a newborn to 14 to 18
cycles/min in adults.
  
• Hyperpnea: Greater than normal
minute ventilation to meet metabolic
requirements.
  
• Dyspnea on exertion: Dyspnea provoked by physical
effort or exertion. It often is quantified in simple terms,
such as the number of stairs or number of blocks a
patient can manage before the onset of dyspnea.
  
• Orthopnea: Dyspnea in a recumbent position. It
usually is measured in number of pillows the patient
must use to lie in bed (e.g., two-pillow orthopnea).
  
• Paroxysmal nocturnal dyspnea: Sudden onset of
dyspnea occurring while reclining at night, usually
related to the presence of congestive heart failure.
• Hyperventilation: A minute ventilation
(determined by respiratory rate and tidal
volume) that exceeds metabolic demand.
ABG characteristically show a normal PO2
with an uncompensated respiratory
alkalosis (low PCO2 and elevated pH).
  
NYHA Classification
• Class 1 – No limitations.Ordinary
physical activity does not cause
dyspnea
• Class 2 – Slight limitation of physical
activity.
• Class 3 – Marked limitation of physical
activity.
• Class 4 – dyspnea at rest
Aetiology
• 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
Dyspnea
Etiologies: Pulmonary Causes
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
• 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
History Taking
nature of onset (acute, chronic) , duration ,
evolution over time
associated symptoms (cough, sputum ,wheeze,)
physiologic vs. pathologic

• Exposures
• Sick contacts
• Tobacco
• Occupational
• Hobbies
• Pets
• Drugs
• Radiation
Physical Examination
• Respiratory Rate
• Body habitus – cachexia / obesity
• Posture – leaning forward on elbows with COPD,
supine in bed
• Use of Accessory muscles
• Pursed lips
• Lower extremity edema – b/l – CHF & u/l –
thromboembolism
• Clubbing – malignancy
• Cyanosis – insensitive sign of severe hypoxemia
• Extent & Symmetry of chest expansion
Physical Examination
• Crackles, wheeze ( localised / diffuse )
• Decreased breath sounds – pneumothorax
, pleural effusion
• Elevated JVP , hepatojugular reflex, pedal
edema – RV Failure
• Diffuse,lateral displaced pt of max
impulse, S3 gallop ,crackles , elevated
JVP – LV Failure
Physical Examination: Vital Signs
• BP
•  if dyspnea significant
•  = life-threatening problem
• Pulse
• Usually 
• Bradycardia - severe hypoxemia
• Respiratory rate
• Sensitive indicator of respiratory distress
• DANGER = > 35-40 bpm or < 10-12 bpm
Physical Examination: Observation
• Ability to speak

• Patient position

• Cyanosis
• Central vs. peripheral (acrocyanosis)

• Mental status
• Altered MS - hypoxemia/hypercapnia
Physical Examination
• Pulmonary
• Use of accessory muscles
• Intercostal retractions Signs of severe
respiratory
• Abdominal-thoracic discoordination distress

• Presence of stridor

• Cardiac
• Check neck for presence of JVD
Physical Examination: Pulmonary

• Inspection
• Use of accessory muscles
• Splinting
• Intercostal retractions

• Percussion
• Hyper-resonance vs. dullness
• Unilateral vs. bilateral
Physical Examination: Pulmonary

• Auscultation
• Air entry
• Stridor = upper airway obstruction
• Breath sounds
• Normal
• Abnormal
• Wheezing, rales, rhonchi, etc.
• Unilateral vs. bilateral
Physical Examination: Cardiac
• Neck
• ? JVD

• Auscultation
• Abnormal S2 splitting
• Present of S3 and/or S4
• Rubs
• Murmurs
Easily Performed Diagnostic Tests

• Chest radiographs

• Electrocardiograph

• Screening spirometry
Investigations For Acute Severe Dyspnea
• ABC – establish airway and ensure
oxygenation
• CXR PA View
• Arterial Blood Gases measurements
• ECG
• Echocardiogram
• Spirometry
• HRCT
• CT pulmonary angiography
Investigations For Chronic Dyspnea
• Careful & Comprehensive history & phy.ex
to limit broad Diff.diagnosis.
• PFT, ABG,
• CXR PA View
• ECG
• Blood chemistries & CBC
• V/Q Scan
• Chest CT
• Thyroid Functioning Tests
Investigations For Chronic Dyspnea
• Bronchoscopy
• Lung Biopsy
• Laryngoscopy
ACUTE VS CHRONIC DYSPNEA

• Acute: Dyspnea (AP4) <30 days


that develops over hours or days :
• Asthma
• Pulmonary edema
• Pneumothorax
• Pulmonary embolism
• Pneumonia
•
• Chronic: Dyspnea >30 days
that develops over weeks, months or years.
• COPD
• Left ventricular failure
• Interstitial fibrosis
• Asthma
• Pleural effusion
Treatment
Non-Drug Treatments
• Positioning - sitting up
• Relaxation
• Humidified air
• Noninvasive positive pressure mask

Oxygen
Specific treatment according to diagnosis

Asthma------- Bronchodilators + anti inflammatory


Pneumonia--------Antibiotics
Pneumothorax ------Chest tube
Heart failure------- Diuretics + nitrate
Thank you!!!!!

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