CLIND 1552 – Week #9 – Shortness of Breath

Shortness of Breath #2

Objectives
1. Recognize the signs of dyspnea (difficult or labored breathing) in various age groups
2. List highly suggestive risk factors or symptoms associated with dyspnea
3. Define jugular venous distention (JVD) and its etiology (cause of a disease or condition)
4. Identify five differential diagnoses for dyspnea
5. List common diagnostic tests to assist in determining the etiology of dyspnea

Objective #1: Recognize the signs of dyspnea in various age groups

For Pediatric Patients
- Nasal flaring (nostrils widening when breathing)
- Intercostal or suprasternal retractions (intercostal space is the area under the ribs and suprasternal is just
above the sternum in the midline)

For Adult Patients

- Tripod position (patient sits leaning forward, supporting their weight by placing elbows on knees)
- Accessory muscle use (sternocleidomastoid and scalene muscles used to elevate the chest)

Objective #2: List highly suggestive risk factors or symptoms associated with dyspnea
Highly Suggestive – INCREASED risk for coronary artery disease (CAD)
Patient is a 66-year-old woman (older female)
Poorly controlled diabetes (DM)
Poorly controlled hypertension (HTN)

Note: Non-Adherence to medications can TRIGGER an acute decompensation of a chronic disease.

Orthopnea (SOB when lying flat) can indicate heart failure – Why? Because the heart cannot pump fluid
throughout the body when lying down, and blood can backflow into the lungs and block the alveoli, resulting in a
condition similar to pulmonary edema.

Paroxysmal Nocturnal Dyspnea (PND) (sudden-onset nighttime SOB) can indicate heart failure – Why?
Because excess fluid builds in the lungs due to decreased strength of cardiac pumping, often being relieved by standing
upright.

Swelling in legs/ankles and weight gain can indicate heart failure.

Highly Suggestive – Signs of Dyspnea

- Dullness to percussion (indication of denser tissue) of the lungs
Consolidation of alveoli (pneumonia) and pleural effusion (fluid in the lower lung space)

- Crackles (Rales) in the Lungs

Abnormalities of the Lung Parenchyma
+ Pneumonia (infection that inflames air sacs, bilaterally or involving individual lobes within lungs
that may then fill with fluid)
 + Interstitial lung disease (group of disorders that cause scarring of lung tissue, like hazardous
materials – asbestos, coal mining – or autoimmune diseases)

+ Pulmonary fibrosis (damage and subsequent scarring of lung tissue, which makes it harder to
expand lungs and intake air)

+ Pulmonary edema (condition caused by excess fluid in the lungs, usually caused by heart failure)

+ Atelectasis (a complete or partial collapse of a lobe or whole lung caused by inhaled objects,
asthma, anesthesias, and other lung diseases)

Abnormalities of the Airways

+ Bronchitis (inflammation of the bronchioles, limiting the amount of air carried to the alveoli and
therefore blood)
+ Bronchiectasis (condition in which the airways become damaged and cannot clear mucus
effectively, caused by pneumonia or cystic fibrosis)

NOTE: Atelectasis and bronchitis can be cleared with COUGH (productive cough) in many cases.

Fine Crackles – described as a sudden inspiratory opening of the small airways that were held closed
during the previous expiration phase
Coarse Crackles – described as boluses (a relatively large quantity) of gas passing through the airways
as they open and close intermittently

- S3 Gallop (ventricular gallop, larger amount of blood strikes the left ventricle)
Extra Heart Sound early in Diastole, where an excess volume of blood is left over in the heart (fluid
overload), because of heart failure

- Edema (Swelling) of Lower Extremities (Legs and Ankles)

Pitting Edema is when you can push on the swelling and the indentation remains. It is a sign of fluid
overload in the tissues (caused by prolonged standing, immobilization, venous insufficiency, types of
drugs, or heart failure)
Nonpitting Edema is when you push on the swelling and NO indentation remains, a sign of fluid
overload in the tissues (caused by impaired lymphatic drainage because of lymph vessel/node
disruption or leaky capillaries from burns, bites or allergic reactions)

- Elevated Jugular Venous Distention (JVD)

Objective #3: Define Jugular Venous Distention and its Etiology

Visualize: JVD is when a vein (the jugular vein) on the side of the neck appears to bulge out
Placement: Carotid arteries are more medial – jugular veins more lateral (on the neck)

Measuring Jugular Venous Pressure (JVP)

Why the RIGHT Internal Jugular?
Because it’s got a straight shot down the superior vena cava (SVC) and the right atrium (RA)

What’s the difference between JVP and JVD?

JVP = the WHOLE measurement > 8cm (mid right atrium 5cm + sternal angle 3cm = 8cm)
JVD = only number above the sternal angle > 3cm above the sternal angle

What Angle is used to Measure JVP?

First, DON’T get set on a number, start at 90° (standing UPRIGHT) and then go to 60° (lying down
slightly), 30° (more-so)
Next, REMEMBER that you’re looking for the angle needed to see the highest point of pulsation of
the right internal jugular vein
NOTE: Pressure (P) or JVP DOES NOT CHANGE.

NOTE: The ability to SEE the JVP DOES CHANGE: the column of blood will rise or fall depending on the position of
the heart.

Etiology of JVD (Elevated JVP)

An increase in JVP tells us that there is an increase in RA P
Elevated RA P will indicate heart failure
May reflect an underlying left heart abnormality

Objective #4: Identify Five Differential Diagnoses for Dyspnea

Neuromuscular – Myasthenia gravis (weakness and rapid fatigue of muscles under voluntary control caused
by breakdown in communication between nerves and muscles)

Lung – Pulmonary Embolus (one or more arteries in the lungs become blocked by a blood clot, most often
from a clot originating in the legs – Deep Vein Thrombosis (DVT)), Pneumonia (ABOVE), Chronic Obstructive
Pulmonary Disease (COPD, group of lung diseases – bronchitis, emphysema - that make it difficult to breathe)

Blood – Anemia (condition in which the blood has a decreased amount of healthy red blood cells)

Heart – Heart Failure (condition in which the heart does not pump as well as it should), Myocardial
Ischemia (coronary artery disease, condition in which there is damage or disease in the heart’s own major vessels;
usually from the buildup or plaque, inhibiting blood flow), Aortic Stenosis (narrowing of the aortic valve that keeps it
from opening fully and decreases the amount of blood while increasing the amount of pressure, making the heart work
harder)

Objective #5: List common diagnostic test to assist in determining etiology of dyspnea
What tests do we have?
- Blood Test (Biochemical Markers): BMP (Basic Metabolic Panel – Ca2+, Na+, K+, Cl-, HCO3-, CO2,
Glucose, Blood Urea Nitrogen (BUN), Creatinine), CMP (Complete Metabolic Panel – Everything in
BMP + ALP, ALT, AST, Bilirubin), CBC (Complete Blood Count – RBC, HCT, HGB) TSH (Thyroid
Panel – Thyroid Stimulating Hormone, Free T4 (Thyroxine)), Troponin (Heart protein, indicates damage
to Heart), Lipid Panel (Cholesterol, Triglycerides, High-Density Lipoprotein (HDL), Low-Density
Lipoprotein (LDL)), Urinalysis (appearance and concentration of urine), Glycohemoglobin (HA1c –
testing for glucose in the blood)
- Imaging (anatomy and structure): CXR, echocardiography, angiography
- Imaging (physiology and function): ECG/EKG, echocardiography

Diagnostic Testing for Heart Failure

- Imaging for structural damage – CXR
- Imaging for functional damage – Echocardiogram (diastolic dysfunction) and ECG (hypertensive heart
disease)
- Blood Testing – CMP, CBC, troponin

Assessment and Planning for Treatment of Heart Failure

- Initial Treatment: (Acute treatment of heart failure) Diuretic (increase the amount of water and salt
expelled from body as urine), Beta-Blockers (lower blood pressure by blocking epinephrine), ACE
Inhibitor (dilate blood vessels and raise blood flow), Aspirin (NSAIDs, blood thinners to reduce risk of
heart attack), Statin (lower blood cholesterol)
- Further Testing: (Evaluation for the etiology of heart failure) stress test of the heart
- Plan for Prevention: (Avoid triggers and facilitate compliance) counseling, social services, heart failure
education (referral to heart failure clinic and/or rehabilitation)
 SOS

Mrs. Hernandez is a 66-year-old female patient

that presents to the office complaining of
fatigue and shortness of breath. She mentions
that during the past week, she has had trouble
“catching my breath” and “difficulty lying flat.” She has been having to use
extra pillows on her bed to lift her head to rest, which she says helps to relieve
her shortness of breath. During the history she mentions increased stressors in
her family that she feels have contributed to her trouble sleeping and fatigue. Her stress also makes her upset and leads
to her forgetting to take her normal medications. She is worried because her symptoms seem to be increasing in
severity.

Symptom –

Organ System –

Science –

Practice

1. A patient mentions to their physician that they have smoked and after some determination, the physician
notes that the patient smokes ½ pack a day for 20 years. What is the pack/year history?
a. 5
b. 10
c. 15
d. 20
e. 25

2. Which muscles are mostly responsible in chest wall movement in addition to diaphragm contraction?
a. Scalenes, rectus abdominus
b. External intercostals, scalenes
c. Quadratus lumborum, trapezius
d. Latissimus dorsi, external intercostals
e. Internal intercostals, sternocleidomastoids

1b. 10 pack year

2b.External intercostals, scalenes