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Dyspnea: The

Pulmonary
Perspective
Section of Pulmonary and
Critical Care
DYSPNEA:
Breathing
Life into a
Complex
Symptom
Maria Piedad Rosales – Natividad, MD and Patrick Gerard L, Moral, MD
Section of Pulmonary and Critical Care Medicine
Department of Medicine, UST Faculty of Medicine and Surgery
Definition
• “a person’s uncomfortable sensation
associated with breathing”
• a perception by the individual and is entirely
subjective
• not a clinical observation, nor does it relate
directly to any physiological or laboratory test
• the patient’s interpretation of a reduction in
pleasant breathing.

Frontline Cardiopulmonary Topics / Dyspnea,


2001*
OBJECTIVES
• review the different pathophysiologic events
• integrate subjective and objective data in
order to come up with a logical diagnosis of
the cause of dyspnea
• select and prioritize ancillary procedures in
the diagnosis and management of the
disease
• apply basic pharmacologic and non-
pharmacologic therapy based on
etiopathogenesis of the disease
Evaluation of
the Dyspneic
Patient
• acquisition of a detailed history describing
the conditions under which the patient has
been or is currently experiencing dyspnea
• a physical examination
• a chest radiograph
• measurements of pulmonary mechanics
Frontline Cardiopulmonary Topics / Dyspnea,
2001*
Patient presents
with dyspnea Initial hypotheses

ID, CC, HPI PE


More questions
Ask questions Examine
HPI, PMH, FH. patient
Px is better; no Px DIES Social, ROS
further care
Refine hypotheses Lab tests
Observe
results
Chronic
Disease ECG, etc. Radiologic
studies
Treat patient
Select most likely
accordingly
diagnosis
Once an emergent situation
has been excluded, the patient's
airway, mental status, ability to
speak, and breathing effort
should be reevaluated. A focused
history should be obtained, and a
physical examination completed.
Patient presents
with dyspnea Initial hypotheses

ID, CC, HPI PE


More questions
Ask questions Examine
HPI, PMH, FH. patient
Px is better; no Px DIES Social, ROS
further care
Refine hypotheses Lab tests
Observe
results
Chronic
Disease ECG, etc. Radiologic
studies
Treat patient
Select most likely
accordingly
diagnosis
Listening to the Patient
•Getting to know the
patient
•Characterizing the
symptom
•Understanding its
effects on the patient
•Achieving a common
perception of the
problem
Getting to know
the patient
• Name
• Age
• Sex
• Race / Nationality / Ethnicity
• Civil Status
• Occupation
• Residence
• Religion
Communication

Hingal
sumisikip ang
dibidib
Kapos ng
hininga
Nasasakal
Hinahapo
Are all episodes of dyspnea
pathologic?

yes no
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Normal Dyspnea
• Dyspnea may occur normally in states of
intense exercise, such as running,
mountain climbing, lifting, rowing, and
swimming, where the stress of breathing
is a direct result of intense physical effort
and not a consequence of
cardiopulmonary or metabolic disorder.
Key Questions
• Quality (description, progression)
• Location / Radiation
• Severity (bearable, intolerable)
• Timing /Duration (acute, chronic)
• Setting
• Precipitating (body positions, exposures)
Palliating (body positions, medications)
• Associated symptoms (chest pain, cough)
Quality
• I feel that I am •My breathing requires
suffocating effort
• My chest feels tight •I cannot get enough air
• My breathing is heavy
•I feel a hunger for air
•My breathing is shallow
• I feel that I am
smothering •I feel out of breath
• My breath does not go in •My chest is constricted
all the way •My breathing requires
• My breath does not go
work
out all the way
• I feel that I am breathing
more
CHEST 2000; 118:679–690
Severity
• The usual technique is to determine the amount
of effort required to bring on dyspnea.
– How far can the patient walk, at a normal pace (in meters)
before stopping due to shortness of breath?
– Can the patient walk uphill?
– How many flights of stairs can the patient climb?
– In conversation, can the patient finish a sentence (or word)
without taking a breath?
– During telephone conversations, does the patient notice
shortness of breath?
• These questions should be asked at each visit
to assess symptom progression or
improvement.
Visual Analogue Scale
No shortness of breath

100 mm line

Shortness of breath as bad as can be


Borg Scale
0 - Nothing at all
0.5 - Very, very slight
1 - Very slight
2 - Slight
3 - Moderate 4
- Somewhat severe
5 - Severe 6
- 7
- Very Severe 8
- 9
- Very, very severe
10 - Maximal
Timing
• Onset of dyspnea: recent or remote,
• Has there been a recent change in
severity?
• Acute, subacute, or chronic
• Recurrent or continuous
Time Course
Setting - Precipitating
Palliating
Associated Symptoms
Associated Symptoms
Key Questions
• Cardiac questions
– presence or absence of chest pain, orthopnea,
paroxysmal nocturnal dyspnea (PND), edema, weight
gain, and any cardiac medications or cardiac
diagnoses of the patient.
• Pulmonary questions
– presence or absence of wheezing, chest tightness,
cough, sputum production, pleuritic pain, sleep
patterns (apneas), and a history of tobacco smoking
• Other
– history of cirrhosis, renal insufficiency, anemia, or
endocrine abnormalities, all of which can be quickly
reviewed.
Patient presents
with dyspnea Initial hypotheses
PULMONARY
ID, CC, HPI PE
More questions
Ask questions Examine
HPI, PMH, FH. patient
Px is better; no Px DIES Social, ROS
further care
Refine hypotheses Lab tests
Observe
results
Chronic
Disease ECG, etc. Radiologic
studies
Treat
Select most likely
patient
diagnosis
accordingly
Afferent and Efferent Signals

Manning HL, Schwartzstein, RM. Mechanisms of disease: Pathophysiology of dyspnea. New Engl J Med. 1995;
Ventilatory Control
Neurogenic Voluntary Control Chemical
anxiety / hysteria
Factors Stimuli
cortex
Pulmonary receptors Respiratory Center
sensitive to stretch and stimulated by increase
Chest wall PaCO2 and H+
bronchial irritation (stimulated receptors
in asthma, pulmonary embolism and
pneumonia)
Carotid and
Juxta capillary (J) receptors Aortic Bodies
stimulated by pulmonary congestion (heart stimulated by
failure)
increase PaO2 <
Muscle and joint 8kPa
receptors stimulated
by exercise
Dyspnea
respiratory cardiopulmonary
respiratory
drives system response
drives
cardiopulmonary
system response
• The work of breathing must be appropriate to
the task and in the context of the resultant
cardiovascular and respiratory responses.
Pulmonary Sources
Respiratory work
major components:
obstructive
1. resistive load
– the resistance of moving

restrictive
air through the airways
2. elastic load
– the load imposed by
elasticity and recoil of the
lungs, thorax, and
respiratory musculature

vascular
Restrictive
Obstructive
Vascular
• Ventilation
• No perfusion Migration

Embolus

Thrombus
Gas Diffusion
• Thickness of membrane
• Surface area of
membrane O2
• Diffusion coefficient of
gas
O2
• CO driving pressure O2
• RBC volume
• Rate of reaction of Hgb
and CO
Patient presents
with dyspnea Initial hypotheses

ID, CC, HPI PE


More questions
Ask questions Examine
HPI, PMH, FH. patient
Px is better; no Px DIES Social, ROS
further care
Refine hypotheses Lab tests
Observe
results
Chronic
Disease ECG, etc. Radiologic
studies
Treat
Select most likely
patient
diagnosis
accordingly
Additional Data
• Past Medical History
– Immunizations, past ailments, allergies
• Family History
– Pedigree chart, household contacts
• Social History
– Smoking (pack years); substance abuse
• Occupational History
– Present and previous employment
• Review of Systems
– All other symptoms not referable to the
pulmonary system
Tobacco Use
• Pack-Year History
– Pack/s of cigarettes per day x number of
years
– One pack: 20 cigarettes
– Ex-smoker; Still smoking?
– Practices: (Ilocos – placing the lit end in
the mouth)
• Environmental tobacco smoke
(Passive smoking)
• Other tobacco products
Historical Data
C.O. complains of shortness of breath

General Data

Chief Complaint

History
Social/ Family/ Past
Medical/Occupational
Review of Systems
Dyspnea
General Data:
•42, male – cardiac, pulmonary
•asian – if pulmonary, not cystic fibrosis or
alpha-1 antitrypsin deficiency
•politician – cardiac
•Pampanga – volcanic dust exposure?
History:
•progressive – cardiac, pulmonary (COPD)?
•worsened with dust and heat – asthma / COPD
•relieved by salbutamol– asthma, / COPD
•episodic/ at rest– asthma/ COPD/ cardiac/ embolism
Dyspnea
Additional history:
•smoker – cardiac, pulmonary (STOP!)
•obesity – cardiac, restrictive lung,
embolism
•hypertension– cardiac; medication
exacerbates asthma
•Pain reliever– drug allergy (ask about dyspnea
occurring with drug intake)
•Family hx – (+) asthma; PTB less likely
•Politician – no other occupational risks
Dyspnea
Review of Systems:
•Weight gain – hypothyroid; familial;
anxiety
•Morning headaches– sleep apnea
•Daytime somnolence– sleep apnea;
work related
•Cold intolerance – hypothyroidism
•Morning nasal stuffiness – rhinitis
•Epigastric pain – peptic ulcer; reflux; NSAID
•Knee pains – osteorathritis
•Edema – cardiac, obesity; DVT; cor pulmonale
Differential Diagnosis
•Cardiac – Coronary Artery Disease
–Dyspnea – congestive heart failure
•Bronchial asthma or COPD
–Dyspnea – obstructive lung disease
•Obesity ( familial or due to hypothyroidism)
–Dyspnea - restricitive
•Deep venous thromboses > embolism
–Dyspnea - vascular
•Anxiety
–Dyspnea - psychogenic
Anxiety symptoms may
imply psychogenic causes
of dyspnea, but organic
etiologies always should
be considered first.
Patient presents
with dyspnea Initial hypotheses

ID, CC, HPI PE


More questions
Ask questions Examine QuickTimeª and a
YUV420 codec decompressor
are needed to see this picture.

HPI, PMH, FH. patient


Px is better; no Px DIES Social, ROS
further care
Refine hypotheses Lab tests
Observe
results
Chronic
Disease ECG, etc.
QuickTimeª and a
Animation decompressor
Radiologic
are needed to see this picture.
studies
Treat
Select most likely
patient
diagnosis
accordingly
Initial Assessment of Patients
with Dyspnea
• Assess airway patency and listen to the
lungs.
• Observe breathing pattern, including use
of accessory muscles.
• Monitor cardiac rhythm.
• Measure vital signs and pulse oximetry.
• Obtain any history of cardiac or pulmonary
disease, or trauma.
• Evaluate mental status.
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Inspection
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Palpation
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Percussion
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Percussion
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Physical Examination
Pneumonia Effusion Pneumothorax Atelectasis

INSPECTION Normal Lagging Lagging Lagging


(trachea)
(midline) (contralateral) (contralateral) (ipsilateral)

PALPATION Inc. fremiti Dec. fremiti Dec. fremiti Dec. fremiti

PERCUSSION Dullness Dullness Hyperresonance Dullness

AUSCULTATION Inc. BS Dec. BS Dec. BS Dec. BS


Communicating with the patient
•Give reassurance
•Address the needs of
the patient while taking
your history
•Assure the patient of
your availability
•Emphasize the
partnership in treatment
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General Data
•C.O.
•42 year old
•Male
•Married (one wife)
•Asian - Filipino
•Government worker
•Pampanga
•Roman Catholic
History
•1 year before admission,
he developed shortness of
breath upon walking 100
meters. It would be
worsened by dust
exposure and heat.This
would partly be relieved by
intake of salbutamol by
inhaler.
History
•1 month before
admission, he would
experience dyspnea after
walking 10 meters. He had
occasional cough, with
occasional increases in
severity of the shortness of
breath even at rest that
would resolve
spontaneously. Wheezing
would occasionally be
heard.
Additional Data
•Past Medical History
–No vaccination
–Obesity - sibutramine
–Hypertension on metoprolol
–Osteoarthritis – on celecoxib
•Family History
–(+) asthma – father; (-) PTB;
Obesity – parents and siblings
•Social History
–20 pack years smoker until now
•Occupational History
–Politician; no previous job
Review of Systems
•100 lbs weight gain in 2
years
•Morning headaches
•Daytime somnolence
•Cold intolerance
•Morning nasal stuffiness
•Epigastric pain
•Knee pains
•Edema of both lower
extremities with discoloration
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