Dyspnea

Definition

 Dyspnea is defined as an awareness of

difficulty in breathing.
 Most patients suffer from actual difficulty,
some patients just taste an awareness of
hyperventilation.
How to describe these sensations

 Cannot get enough air

 Air does not go all the way down
 Smothering feeling in the chest
 Tightness in the chest
 Fatigue in the chest
Objective signs

 Dilatation of nares, cyanosis , use of

accessory muscles of respiration
 Abnormalities of respiratory rate, depth or
rhythm
 Desaturation/hypoxemia
 Abnormalities of organs
Multiple etiologies

 2/3 of cases - cardiac or pulmonary etiology

High altitude

 Normal person may experience the

physiologic dyspnea during heavy exercise
 Environment short of oxygen(high altitude)
Etiology

 Respiratory disease
 Heart disease
 Increase of abdominal pressure (massive
ascites, pregnancy etc)
 Hematological disease
 Toxic
 Nero-Psychogenic
 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
– Increase of abdominal
– Hematological disease
– Toxic
– Nero-Psychogenic
Pulmonary Etiology

 COPD
 Asthma
 Restrictive Lung Disorders
 Pneumonia
 Pneumothorax
 Airway obstruction
 Cancers
Respiratory dyspnea

 Respiratory dyspnea is caused by abnormal

ventilation and gas exchange.
 Reduction in ventilation capacity,
hypercapnia and hypoxemia resulting from
respiratory disease.
 Three clinical types: inspiratory dyspnea,
expiratory dyspnea, mixed dyspnea.
Inspiratory dyspnea

 Clinical characteristics: visible indrawing over

the sternal notch, the supraclavicular spaces,
the intercostal spaces and the epigastrium in
the inspiration .
 Accompanied by a coarse, low pitched
inspiratory wheezing(stridor) and dry cough.
 Stenosis and obstruction of larynx, trachea,
and bronchi(upper airway)
Expiratory dyspnea

 Clinical characteristics: expiration is

prolonged and laboured with wheezing.
 Cause: the decrease of lung elasticity and
spasm narrowing of the bronchioles and
smaller bronchi.
 Familiar diseases: emphysema , bronchial
asthma and chronic asthmatic bronchitis .
Mixed dyspnea

 Clinical characteristics: breathing is difficult

during both inspiration and expiration.
Respiratory frequency increase and
respiration superficial.
 Cause: decrease of ventilators and gas
exchange capacity
 Familiar diseases: severe pneumonia,
pulmonary fibrosis, massive atelectasis etc
Cardiac dyspnea

 Cardiac dyspnea is usually attributable to

pulmonary vascular congestion resulting
from the left and/or right heart failure.
 Dyspnea is the primary symptom of left heart
failure.
Cardiac Etiology

 CHF
 CAD
 MI (recent or past history)
 Cardiomyopathy
 Valvular dysfunction
 Left ventricular hypertrophy
 Pericarditis
 Arrhythmias
Left heart failure

Diseases:
 Coronary heart disease

 Hypertensive heart disease

 Rheumatic heart disease

 Congenital heart disease

 Cardiomyopathy

 (Young/elder pts)
Left heart failure

Mechanism:
 Lung congestion decrease gas dispersion

 Alveoli are stiff and more work is needed to

overcome elastic recoil

 The high alveolar pressure stimulate stretch

receptor
 High pulmonary circulation pressure

stimulate respiratory nerve center

Left heart failure

Clinical representation:
 Dyspnea on exertion

 Orthopnea

 Paroxysmal nocturnal dyspnea(PND)

Dyspnea on exertion

 Difficulty in breathing when the patient is in

activity , relieved when he relaxes.
 Doing exercise impel more blood into
pulmonary circulation.
 More oxygen is needed for body demand,
especially the heart.
Functional classification

 Class Ⅰ– no limitation: Ordinary physical

activity does
 Class Ⅱ– slight limitation of physical activity
 Class Ⅲ– Marked limitation of physical activity
 Class Ⅳ– inability to carry or any physical
activity without discomfort
Orthopnea

Difficulty in breathing in the supine position

relived by sitting up
 Reduce the degree of pulmonary congestion

by pooling blood in the lower extremities

 Improve the diaphragmatic movement

 Increase vital capacity

Paroxysmal nocturnal dyspnea

 The patient awakes short of breath at night,

but often obtain relief by sitting up for a
period of time.
 Physical examination: moist rales at the both
lung bases, tachycardia, wheezing and
bronchospasm (cardiac asthma ).
Paroxysmal nocturnal dyspnea

Causes:
 Supine posture for sleep impel more blood

into pulmonary circulation, and decrease vital

capacity.
 Vague excitement cause coronary artery

constriction and bronchioles spasm.

 Respiratory center less sensitive
Right heart failure

Underlying diseases:
 Acute pulmonary hypertension which caused

by pulmonary embolism
 Chronic cor pulmonale which caused by

chronic obstructive pulmonary disease

Right heart failure

Mechanism:
 The pressure of right atria and superior vena cava is

the natural stimulus of respiratory center.

 Hypoxemia and the accumulation of the acid

metabolites stimulate respiratory center.

 The restriction of the respiratory movement caused

by enlargement of liver, ascites and pleural effusion.

Biventricular failure

Left heart failure plus right heart failure may

cause severe dyspnea

Diseases
later stage of all kinds of heart diseases
e.g. cardiomyopathy.
Restricted pericarditis
Mixed Cardiac/Pulmonary Etiology

 COPD with pulmonary HTN and/or cor

pulmonale
 Pulmonary emboli
 Chest trauma
Noncardiac or Nonpulmonary
Etiology

 Metabolic conditions (e.g. acidosis)

 Severe Pain
 Mutiple Trauma
 Neuromuscular disorders (Myasthenia Gravis)
 Functional (anxiety,panic disorders, hyperventilation)
 Medications
Toxic dyspnea

In the metabolic acidosis (uremia and

diabetic acidosis ), the acid metabolites
stimulate the respiratory center, causing
deep and regular respiration (Kussmanul)
with snoring.
Toxic dyspnea

The overdose of morphine and pentobarbital

can depress respiratory center causing slow
respiration or Cheyne-Stokess respiration.
Neuro-Psychogenic dyspnea

Neurogenic: The respiratory center was

damaged while patient suffering from cerebro-
vascular disease. The respiration becomes
deep, slow and irregular.

Psychogenic : anxiety/ hysterical /panic attack

Patient suffer from hysteria will be seen
repetitive deep, signing respiration with
numbness of extremities or lips
Haematologicl dyspnea

 The decrease of oxygen-carrying capacity

and oxygen content develop abnormal
respiration and increase heart rate, such as
severe anemia, carbon monoxide.
 Hypotension can stimulate respiration when
patient suffer from shock.
Accompanying symptoms

Paroxysmal dyspnea with wheezing:

bronchial asthma
cardiac asthma.
Paroxysmal severe dyspnea :
acute larynx edema,
spontaneous pneumothorax,
massive pulmonary embolism.
Accompanying symptoms

Dyspnea with chest pain:

lobar pneumonia,
pulmonary infarction,
spontaneous pneumothorax,
acute exudative pleurisy,
acute myocardial infarction,
bronchial carcinoma.
Accompanying symptoms

Dyspnea with fever:

pneumonia,
lung abscess,
pulmonary tuberculosis,
pleurisy,
acute pericarditis,
nervous system diseases.
Accompanying symptoms

Dyspnea with cough and purulent sputum:

chronic bronchitis,
obstructive pulmonary emphysema with infection,
purulent pneumonia,
lung abscess;
Dyspnea with large amount of foamy sputum :
acute left ventricular heart failure
organophosphorus poisoning.
Accompanying symptoms

Dyspnea with coma:

cerebral hemorrhage,
pneumonia with shock,
uremia,

diabetic ketoacidosis,

acute poisoning.
 Easily Performed Diagnostic Tests

 Chest radiographs

 Electrocardiograph

 Screening spirometry
 In cases where test results inconclusive
– complete PFTs
– ABGs
– EKG
– Standard exercise treadmill testing/ or complete
cardiopulmonary exercise testing
– Consultation with pulmonologist/cardiologist may
be useful