Prijo Sidipratomo Ketua PDSRI Disampaikan pada PIT IDI Jakarta Timur 14 Agustus 2009

The dyspnoeic patient

««uncomfortable sensation of breathing or awareness of respiratory distress« it causes more than 2.5 million clinician visits/year in the United States

Wang CS - Jama 2005; 294: 1944

The dyspnoeic patient
Causes of dyspnoea
Airways - Obstruction foreign body - Angioedema - Epiglottitis and other infections Lung Rapid onset of dyspnoea - Asthma - Pneumonia - Croup (laryngotracheobronchitis) - Bronchiolitis - Pulmonary contusion - Adult respiratory distress syndrome Slower onset of dyspnoea - Chronic obstructive pulmonary disease - Pneumoconiosis Chest Rapid onset of dyspnoea - Pneumothorax, tension/simple - Pleural effusion, haemo/pneumothorax - Rib fractures, flail chest Cardiac Rapid onset of dyspnoea - Congestive cardiac failure - Acute pulmonary edema - Acute myocardial infarction - Cardiac arrhythmias Vascular Rapid onset of dyspnoea - Pulmonary embolism Slower onset of dyspnoea - Pulmonary hypertension Others Rapid onset of dyspnoea - Psychogenic hyperventilation - Poisoning, eg. carbon monoxide, cyanide - Metabolic acidosis Slower onset of dyspnoea - Anaemia - Guillain-Barre syndrome

The dyspnoeic patient


Acute  Subacute  Chronic

Thomas P ± Australian Family Physician 2005; 34: 523

The dyspnoeic patient


Acute  Subacute  Chronic

Thomas P ± Australian Family Physician 2005; 34: 523

The dyspnoeic patient

Acute dyspnoea 
challenge for physicians  needs accurate and rapid diagnosis  early institution of appropriate symptomatic and evidence-based therapy

Wang CS ± JAMA 2005; 294: 1944

The dyspnoeic patient

How to manage the patient with acute dyspnoea? 
Assessment of Airway, Breathing, Circulation (ABC)  History (chronic disease, recent infections, trauma
environmental exposure, drugs, aspiration) 

Onset of dyspnoea (sudden vs days)  Associated symptoms and signs (chest pain, cough,
sputum, haemoptysis, stridor, wheeze, etc.)
Thomas P ± Australian Family Physician 2005; 34: 523

The dyspnoeic patient

Main causes of acute dyspnoea 
Congestive Heart Failure (CHF) Cardiac  Acute Myocardial Infarction (AMI)  Pulmonary Embolism (PE)  COPD/asthma Pulmonary  Pneumonia  Pneumothorax
Shiber JR ± Med Clin N Am 2006; 90: 453

The dyspnoeic patient

D//D Cardiac vs Pulmonary Dyspnoea 
difficult to assess  physical findings similar  different treatment and probability of worsening of the primary disease with the wrong therapy require early and correct diagnosis

How to propose a differential diagnosis?
Malas Ö ± Respiratory Medicine 2003; 97: 1277

The dyspnoeic patient 

CHF: dyspn.on exertion/paroxysmal nocturnal,orthopnea AMI: radiating chest pressure, dyspnoea, diaphoresis PE: sudden onset of dyspn, pleuritic chest pain, syncope COPD/asthma: cough, dyspnoea relieved with therapy Pneumonia: fever, productive cough, dyspnoea Pneumothorax: pleuritic chest pain, dyspnoea not
relieved with 02
Shiber JR ± Med Clin N Am 2006; 90: 453

The dyspnoeic patient 

Chest X-ray
routinely performed in acute dyspnoeic pts. > 40 years < 40 years only 14 % normal findings 68 % normal findings 13 % acute findings 18 % chronic findings

chest X-ray not indicated unless physical exam + or haemoptysis present
ACR Criteria of appropriateness for dyspnoea ± Radiology 2000; 215: 641

The dyspnoeic patient 

PULMONARY EMBOLISM (PE)  Congestive Heart Failure (CHF)  Acute Myocardial Infarction (AMI) potentially life-threatening diagnoses!!!

Pulmonary Embolism 
Most commonly missed diagnosis

The dyspnoeic patient 

PE can lead to early death or serious morbidity  Early diagnosis and appropriate management can decrease mortality and morbidity
* mortality rate: 2-8% if treated ~ 30% if not treated
Chen J-Y ± Int Heart J 2006; 47: 259
*Harrison A ± Am J Emerg Med 2005; 23: 371

Pulmonary Embolism 
Symptoms and signs 
Dyspnoea: 73% (most common)  Tachypnoea: 70%  Pleuritic chest pain: 66%

The dyspnoeic patient 

Cough, Haemoptysis, Syncope, Fever (less frequent)

similar frequency in patients without PE NOT SPECIFIC !
Shiber JR ± Med Clin N Am 2006; 90: 453

Pulmonary Embolism
history of VTE, malignancy, etc.)

The dyspnoeic patient 

Risk factor stratification (immobilization, surgery,  Physical examination (tachypnoea, tachycardia, hypotension,
hypoxia, II heart sound accentuated, right-sided S4, leg edema/ warmth/ erythema) 

ECG (sinus tachycardia, non specific ST-T wave changes,
right-sided heart strain, new right bundle branch block) 

Echocardiography (right-sided heart strain, thrombus in RV)  Chest X-ray (generally normal or non specific)
Shiber JR ± Med Clin N Am 2006; 90: 453

Diagnostic Testing
- CXR¶s
Chest X-Ray Myth: X³You have to do a chest x-ray so you can find xHampton¶s hump or a Westermark sign.´ Reality: Most chest x-rays in patients with PE are xnonspecific and insensitive

Diagnostic Testing
- CXR¶s
Chest radiograph findings in patient with pulmonary embolism
Result Cardiomegaly Normal study Atelectasis Elevated Hemidiaphragm Pulmonary Artery Enlargement Pleural Effusion Parenchymal Pulmonary Infiltrate Percent 27% 24% 23% 20% 19% 18% 17%

Chest X-ray Eponyms of PE XWestermark's sign
± A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels, sometimes with a sharp cutoff.

Hampton¶s Hump
± A triangular or rounded pleural-based infiltrate with pleuralthe apex toward the hilum, usually located adjacent to the hilum.

Radiographic Eponyms
- Hampton¶s Hump, Westermark¶s Sign

Westermark¶s Sign Hampton¶s Hump

The dyspnoeic patient 

Chest CT 
not recommended for the initial evaluation (unless suspected PE)  appropriate when clinic, X-ray, laboratory tests are non revealing/non diagnostic CT allows confident diagnosis or limited differential diagnosis

COPD, fibrosis bronchiectasis pneumoconiosis interstitial lung diseases
ACR Criteria of appropriateness for dyspnoea ± Radiology 2000; 215: 641

The dyspnoeic patient 

< 25% respiratory motion artifacts *

better image quality in dyspnoeic patients **
*Remy-Jardin M, Eur Radiol 2002; 12:1971 **Remy-Jardin M, Radiology 2007; 245: 315 

partial or complete filling defects  proximal extent of PE

Coronal MIP

Occlusion & Infarcts

The dyspnoeic patient

MDCT & Dyspnoea 
CT can identify alternative causes other than PE in dyspnoeic patients, also potentially life-threatening  recent advances in MDCT have improved patient care by minimizing diagnostic delay 
emerging use of whole-chest ECG-gated CT (also at low dose*) reinforces the role of CTA in acute clinical setting:
1- assessment of CAD as potential cause of dyspnoea 2- prognostic information in PE patients (RVF), useful to guide therapeutic decisions (surgery/ thrombolysis)
*d¶Agostino AG ± Eur Radiol 2006; 16: 2137

CT-venography: one-stop shopping?

Erasmus MC

Schoepf, Eur Radiol 2001

Erasmus MC


Be systematic

Check the quality of the film

Film Quality
First determine is the film a PA or AP view.
PA- the x-rays penetrate through the back of the patient xon to the film

AP-the x-rays penetrate through the front of the patient xon to the film. All x-rays in the PICU are portable and are AP view x-

Film Quality (cont)
Was film taken under full inspiration? -10 posterior ribs should be visible. Why do I say posterior here?
When X-ray beams pass through the anterior chest on to the film Under the patient, the ribs closer to the film (posterior) are most apparent.

A really good film will show anterior ribs too, there should Be 6 to qualify as a good inspiratory film.

Quality (cont.)
Is the film over or under penetrated if under penetrated you will not be able to see the thoracic vertebrae.

Quality (cont)
Check for rotation
± Does the thoracic spine align in the center of the sternum and between the clavicles? ± Are the clavicles level?

Verify Right and Left sides

Gastric bubble should be on the left

Now you are ready
Look at the diaphram: for tenting free air abnormal elevation Margins should be sharp (the right hemidiaphram is
usually slightly higher than the left)

Check the Heart
Size Shape SilhouetteSilhouette-margins should be sharp Diameter (>1/2 thoracic diameter is enlarged heart)
Remember: AP views make heart appear larger than it actually is.

Cardiac Silhouette

1. R Atrium 2. R Ventricle 3. Apex of L Ventricle

4. Superior Vena Cava 5. Inferior Vena Cava 6. Tricuspid Valve

7. Pulmonary Valve 8. Pulmonary Trunk 9. R PA 10. L PA

Check the costophrenic angles
Margins should be sharp

Loss of Sharp Costophrenic Angles

Check the hilar region
The hilar ± the large blood vessels going to and from the lung at the root of each lung where it meets the heart. Check for size and shape of aorta, nodes,enlarged vessels

Finally, Check the Lung Fields
Infiltrates Increased interstitial markings Masses Absence of normal margins Air bronchograms Increased vascularity


Lung findings
Darker areas
± ± ± ± radiolucent Pneumothorax Cysts/bulla Air bronchograms

Lighter areas
± Opacities ± ³infiltrates´
Blood Pus Water

± Nodules or mass

Lobar or not«. Pneumonia Pulmonary Edema
± ³fluffy,´ diffuse, ³bat wing´ distribution

± Cant tell by xray, need bronch

Pasien dengan asma bronkhiale kronik

Foto thorak dilakukan setelah penilaian klinik dilakukan dengan cermat Bila foto thorak negatip maka dilakukan CT Scan thorak Bila kecurigaan akan Emboli paru maka multislices CT Scan dapat langsung dikerjakan


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