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Approach to

Dyspnea
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
LUMHS, Jamshoro

Definition

Awareness of his own breath

Hyperventilation
Signing breath
In ability to take deep breath

Orthopnea dyspnea on recumbence

Dyspnea
Definitions

Dyspnea of exertion (DOE)

Orthopnea

Exertion-induced SOB

Recumbent-induced SOB

Paroxysmal nocturnal dyspnea (PND)

Sudden SOB after recumbent

PND (Cardiac Asthma)

Sever breathness at night relieved when


patient sits up

Case 1

73 y/o F presents to the ED with complaints


of SOB for the last 2 days

Case 2
28 year male presented with high grade fever,
cough on examination bronchial breathing
a) Diagnosis
b) Investigation & Mangement

Dyspnea
Rapid Assessment

ABCs

Mental status

Presence of cyanosis

Dyspnea
Initial Interventions

IV assess

Pulse oximetry; supplemental O2

Cardiac monitor

What Are the Indications for


Airway Management?

Secure & maintain patency


Protection

AMS or altered gag


C-spine

Oxygenation
Ventilation
Treatment Suction, medications

Dyspnea
History

Prolonged questioning can be counterproductive

Yes/No questions if significantly dyspneic


Unlike pain, severity of dyspnea = severity of disease

What does patient mean by SOB?

How long has SOB been present?

Is it sudden or gradual

Does anything make it better or worse?

Dyspnea
History

Has there been similar episodes?

Are there associated symptoms?

What is the past medical Hx?

Smoking Hx?
Medications?

Cause

Acute
Bronchial asthma
Pneumonia
Pneumothorax
thromboembolic disease
Cardiac
Pulmonary oedema
Non cardiac pulmonary oedema
psychogenic

Chronic
Pulmonary Cause
1. COPD
Chronic Bronchial Asthma
Emphysema Chronic Bronchitis
2. Restrictive Lung Disease
Sarcoidosis
Rheumatoid lung
fibrosing alveolitis
Pneumoconosis

Dyspnea
Etiologies

Dyspnea
Etiologies: Pulmonary Causes

Dyspnea
Common Pulmonary Causes

Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax

Dyspnea

Common Pulmonary Causes

Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax

Dyspnea
Etiologies: Nonpulmonary
Causes

Dyspnea
Common Cardiac Causes

Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease

Dyspnea
Common Cardiac Causes

Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease

Dyspnea
Common Miscellaneous
Metabolic acidemias
Causes

Severe anemia

Pregnancy

Hyperventilation syndrome

Dyspnea
Physical Examination: Vital
Signs
BP

Pulse

if dyspnea significant
= life-threatening problem
Usually
Bradycardia - severe hypoxemia

Respiratory rate

Sensitive indicator of respiratory distress


DANGER = > 35-40 bpm or < 10-12 bpm

Dyspnea
Physical Examination: Observation

Ability to speak

Patient position

Cyanosis

Central vs. peripheral (acrocyanosis)

Mental status

Altered MS - hypoxemia/hypercapnia

Dyspnea
Physical Examination

Pulmonary

Use of accessory muscles


Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor

Cardiac

Check neck for presence of JVD

Signs of severe
respiratory
distress

Dyspnea
Physical Examination: Pulmonary

Inspection

Use of accessory muscles


Splinting
Intercostal retractions

Percussion

Hyper-resonance vs. dullness


Unilateral vs. bilateral

Dyspnea
Physical Examination: Pulmonary

Auscultation

Air entry

Stridor = upper airway obstruction

Breath sounds

Normal
Abnormal

Wheezing, rales, rhonchi, etc.

Unilateral vs. bilateral

Dyspnea
Physical Examination: Cardiac

Neck

? JVD

Auscultation

Abnormal S2 splitting
Present of S3 and/or S4
Rubs
Murmurs

What does
clubbing suggest?
Chronic Hypoxemia

Pneumonia
1.Fever with chills
2.Pleuratic chest pain
3. purulent sputum
4. History of upper respiratory symptoms
5.signs of consolidation
6.x-ray chest
7. CBC
8. Blood culture
9. ABG acute bronchial asthma age startedat
childhood

2. Acute Bronchial Asthma


1.Age start in young age
2. Family History
3. H/O Allergic Rhinitis
4.Physical exam
5.barrel shape chest
6.X-ray chest
7. ABG

Pneumothorax
1.Suden chest pain
2. dyspnea,caugh
3. H/O asthma
4.COPD
5.Examination, trachea, shifted to opposite side
absent breath sound
6 x-ray chest

3. Acute Pulmonary edema


Previous H/O Heart Disease
b) Hyperthyroidism
c) Rheumatic Heart disease (ms)
Sign of LVF
a) Tachycardia
b) Pulses alternan
c) Basal criptation
d) ECG change
e) X-ray Chest ( cardiomegaly)
f)
Echo
a)

Pulmonary Embolism
a)
b)
c)
d)
e)
f)
g)
h)
i)

History of prolonged remobilization


pelvic surgery
contraceptive pills
cyanosis
ECG
x-ray chest
ABG
ECHO
PIQ study

Case 1
History

Symptoms started 2 days ago


Onset gradual and progressive
Exertion makes it worse
New onset
(+) chest pain, cough, DOE, PND
No past medical Hx
No medications or smoking Hx

Case 1
Physical Examination

Moderate respiratory distress, talks in partial


sentences, prefers to sit in ED cart
BP = 190/110 mmHg; HR = 118 /min; RR =
36 bpm; afebrile; SpO2 = 85%
HEENT: no angioedema
Lungs: rales & wheezing bilaterally
Cardiac: (+) JVD; (+) S3
Skin: no rashes
Extremities: no edema

Case 1

What are likely etiologies for this patients


dyspnea?

Heart failure
? ACS

Dyspnea
Diagnostic Adjuncts

What study will most patients with dyspnea


get?

CXR

Indicated in most cases of dyspnea, especially newonset

Case 1

Dyspnea
Diagnostic Adjuncts

What other non-laboratory study would you


like?

ECG

Indicated if cardiac etiology suspected or cardiac history

Case 1

Dyspnea
Diagnostic Adjuncts

What lab tests might be useful in dyspnea


workup?

ABG

Troponin

If any question about ventilatory or acid-base status


Beware of interpretation of (Aa)O2
How would it be helpful in our patient?

B-type natriuretic protein (BNP)


Laboratory studies based on suspected etiology of
dyspnea

Dyspnea
Treatment

Cornerstone of Rx

Assuring oxygenation/ventilation
Supplemental O2

PaO2 > 60 mm Hg; SpO2 > 90%

Specific Rx depends on working diagnosis

Dyspnea
Special Considerations: Pediatrics

Common upper airway problems

Infection

Croup
Retropharyngeal abscess
Epiglottitis

Foreign body aspiration

Dyspnea
Special Considerations: Pediatrics

Common lower airway problems

Anaphylaxis
Asthma
Bronchiolitis
Bronchopulmonary dysplasia
Cystic fibrosis
Foreign body aspiration
Pneumonia

Dyspnea
Special Considerations: Pregnant
Patient
Venous thrombosis/pulmonary embolism

Asthma

3/1000 pregnancis
Risk continues to the postpartum period
Heparin outpatient treatment of choice
Rule of 1/3
Rx same as non-pregnant patient

Pulmonary edema

Preeclampsia
Postpartum cardiomyopathy

Case
Conclusion

Diagnosis = CHF & subacute MI

Treatment

IV nitroglycerin
IV furosemide

Reassessment much improved