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Pulmonology/Internal Medicine Departement, Faculty of Medicine,


Gadjah Mada University Dr. Sardjito Hospital, Yogyakarta
 SOB ( Short of Breathless ) or dyspnea, is a feeling
of difficult or labored breathing that is out of
proportion to the patient's level of physical activity.

 It is also described as faster breathing


accompanied by the sensations of running out of
air and of not being able to breathe fast or deeply
enough.

 It is a symptom of a variety of different diseases or


disorders and may be either acute or chronic.
 Orthopnea: breathlessness lying down flat

 Paroxysmal nocturnal dyspnea: inappropriate


breathlessness causing waking from sleep

 Tachypnea: increased rate of breathing

 Hyperpnea: increased level of ventilation

 Hyperventilation: over breathing


Rate

Depth

Rhythm and Pattern


 4 main causes are:
◦ Lung disease
 Parenchymal lung disease
 Vascular occlusive disease
 Diseases of chest wall/respiratory muscles
◦ Heart disease
◦ Obesity
◦ Functional hyperventilation
 Sensory inputs
◦ Lungs, ventilatory muscles, chemical receptors
transmit to brain

 Factors involved:
◦ effort to breath
◦ muscle fatigue
◦ blood pH
◦ PaCO2/PaO2
Findings Possible diagnosis
Wheezing, Pulsus paradoxus, accessory muscle use Acute asthma, COPD
exacerbation
Wheezing, clubbing, barrel chest, decreased breath COPD exacerbation
sounds
Fever, crackles, increased fremitus Pneumonia
Oedema, neck vein distension, S3 or S4 hepatojugular Congestive heart failure,
reflux, murmurs, rales, hypertension, wheezing pulmonary oedema
Wheezing, friction rub, lower extremity swelling Pulmonary embolism
Absent breath sounds, Hyperresonance Pneumothorax
Inspiratory stridor, rhonchi, retractions Croup
Stridor, drooling, fever Epiglottitis
Stridor, wheezing, persistent pneumonia Foreign body aspiration
Wheezing, intercostal retractions, apnoea Bronchiolitis
Sighing Hyperventilation
 Sudden Over days/weeks
◦ Lung collapse - CHF
◦ Inhaled foreign body - Pleural effusion
◦ Spontaneous Pneumothorax - Ca bronchus/trachea
◦ Pulmonary Embolism
 Rapid (hrs) Over months/years
◦ Asthma - TB
◦ Extrinsic Allergic alveolitis - Fibrosing alveolitis
◦ High altitude - Pneumoconiosis
◦ LVF (acute pulmonary Oedema)
◦ Pericardial tamponade Non respiratory causes
◦ Poisons - Anaemia
- Hyperthyroidism
- Obesity
 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?


 Has there been similar episodes?

 Are there associated symptoms?

 What is the past medical Hx?


◦ Smoking Hx?
◦ Medications?
80% 75%
70%
60%
50%
40%
30%
20% 10% 15%
10%
0%
Respiratory Cardiac Other
 Obstructive lung disease
◦ Asthma/COPD

 Pneumonia

 Pulmonary embolism

 Pneumothorax
 Obstructive lung disease
◦ Asthma/COPD

 Pneumonia

 Pulmonary embolism

 Pneumothorax
 Acute coronary syndromes

 CHF

 Dysrhythmias

 Valvular heart disease


 Acute coronary syndromes

 CHF

 Dysrhythmias

 Valvular heart disease


 Metabolic acidemias

 Severe anemia

 Pregnancy

 Hyperventilation syndrome
 Ability to speak

 Patient position

 Cyanosis
◦ Central vs. peripheral (acrocyanosis)

 Mental status
◦ Altered MS - hypoxemia/hypercapnia
 Pulmonary
◦ Use of accessory muscles
◦ Intercostal retractions Signs of severe
◦ Abdominal-thoracic discoordination respiratory
distress
◦ Presence of stridor

 Cardiac
◦ Check neck for presence of JVD
 Inspection
◦ Use of accessory muscles
◦ Splinting
◦ Intercostal retractions

 Percussion
◦ Hyper-resonance vs. dullness
◦ Unilateral vs. bilateral
 Auscultation
◦ Air entry
 Stridor = upper airway obstruction
◦ Breath sounds
 Normal
 Abnormal
 Wheezing, rales, rhonchi, etc.
◦ Unilateral vs. bilateral
 Neck
◦ ? JVD

 Auscultation
◦ Abnormal S2 splitting
◦ Present of S3 and/or S4
◦ Rubs
◦ Murmurs
What does
clubbing suggest?

Chronic Hypoxemia
 Common upper airway problems
◦ Infection
 Croup
 Retropharyngeal abscess
 Epiglottitis
◦ Foreign body aspiration
 Common lower airway problems
◦ Anaphylaxis
◦ Asthma
◦ Bronchiolitis
◦ Bronchopulmonary dysplasia
◦ Cystic fibrosis
◦ Foreign body aspiration
◦ Pneumonia
 Venous thrombosis/pulmonary embolism
◦ 3/1000 pregnancis
◦ Risk continues to the postpartum period
◦ Heparin outpatient treatment of choice
 Asthma
◦ Rule of 1/3
◦ Rx same as non-pregnant patient
 Pulmonary edema
◦ Preeclampsia
◦ Postpartum cardiomyopathy
 Dyspnea is common complaint
 Severity of dyspnea = severity of disease
 Dyspnea  high potential for significant
morbidity & mortality
 Respiratory rate is one of most sensitive
indicators of respiratory distress
 Mainstay of Rx = supplemental O2
 The #1 chief complaint in primary care
physicians’ offices is cough
 Most-- but not all-- cough seen by PCP’s
is acute cough related to viral upper and
lower respiratory tract infections
 Chronic cough is one of the most
common reasons for consultation with a
pulmonologist
 Health care costs for cough exceed
several billion dollars annually
 Attract attention
 Signal displeasure
 Protect the airway from pathogens,
particulates, food, other foreign bodies
 Clear the airways of accumulated secretions,
particles
 Vagus nerve is major
afferent pathway

 Stimuli arise from:


◦ Ear
◦ Pharynx
◦ Larynx
◦ Lungs
◦ Tracheobronchial tree
◦ Heart
◦ Pericardium
◦ Esophagus
 Aspiration of
oropharyngeal or stomach
contents (bacteria, food,
other)
 Acute airway obstruction
 Pneumonia

• Lung abscess
• Respiratory failure/ ARDS
• Bronchiectasis
• Pulmonary fibrosis
 Evidence-based
 Includes guidelines for
pediatric cough
 Should be used in
conjunction with
“clinical judgment”
 Divides cough in adults
by duration: acute,
subacute, chronic
Cough lasting less than 3 weeks

Key questions:
1. Is it life-threatening?
2. Are antibiotics needed?
Acute Cough

Life-threatening Dx History,
Examination, Non-life-threatening Dx
Investigations

Infectious Exacerbation of Environmental


pre-existing or Occupational
condition
Pneumonia,
severe
exacerbation of
asthma or COPD,
PE, Heart Failure, URTI LRTI Asthma Bronchiectasis UACS COPD
other serious
disease

Figure 1: The acute cough algorithm for the management of patients aged ≥ 15
years with cough lasting < 3 weeks. For diagnosis and treatment recommendations
refer to the section indicated in the algorithm. PE = pulmonary embolism; Dx =
diagnosis; Rx = treatment. For other abbreviations, see handout.
 Upper respiratory tract infection (URTI or URI)-
- “The Common Cold”
◦ Caused by viruses, e.g. rhinoviruses
◦ Nasal congestion, drainage
◦ Post-nasal drainage irritates larynx
◦ Inflammatory mediators increase sensitivity of
sensory afferents
◦ Antibiotics are NOT indicated
◦ Decongestants, cough suppressants of questionable
value
Cough lasting 3-8 weeks

Key questions:
1. Is it post-infectious?
2. If post-infectious, are antibiotics needed?
Subacute Cough
History and
Post-infectious Physical Exam Non-postinfectious

Workup same as
Pneumonia and chronic cough
other serious
diseases New onset or exacerbation of pre-
existing condition

Pertussis
UACS Asthma GERD Bronchitis

Bronchitis NAEB AECB

Figure 2: Subacute cough algorithm for the management of patients aged ≥ 15 years
with cough lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer
to section indicated in algorithm. AECB = acute exacerbation of chronic bronchitis.
For other abbreviations, please see syllabus.
 Cough lasting longer than 8 weeks
 Top 4 in immunocompetent patient with
normal CXR:
◦ Upper airway cough syndrome
◦ Asthma
◦ Gastroesophageal reflux disease
◦ Non-asthmatic eosinophilic bronchitis
 Cough may have more than one cause-- a
diagnostic challenge!
Terima Kasih