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Breathlessness, shortness of breath, or dyspnea is a difficult symptom for some patients to explain and quantify. Tend to be subjective to some individual to further explain. It can be a natural consequence of strenuous physical exercise.
Physiological or pathological cause in origin
Defined as the sensation of uncomfortable breathing. This breathing discomfort may reflect an increased awareness of breathing or the sense that breathing is different, difficult or inadequate. Several factors may operate in an individual patient to produce breathlessness.
The clinical analysis of the breathless patient comprises both an assessment of the severity of breathlessness and identification of its cause.
Begin by assessing the patient’s stability. If the patient unable to talk or complete a full sentence without pausing for a deep breath, move quickly to stabilize the patient. Return to the interview after the patient is more comfortable.
Common cause of breathlessness MINUTES HOURS Pneumothorax Asthma Pulmonary embolism Pulmonary oedema Pneumonia Pulmonary oedema DAYSWEEKS Pleural effusion AECOAD Pneumonia Pulmonary TB Acute asthma Metabolic acidosis .
chest pain & lightheadedness Aspiration Cardiac tamponade .Anaphylaxis 50% of patient will have dyspnea associated with anaphylaxis Dyspnea due to aspiration generally begins abruptly within hours of the event Tamponade is associated with dyspnea.
. higher in population with comorbid illness 40% patient with Guillain Barre synd will requires assisted ventilation d/t muscle weakness The lifetime risk in men is 12% for heavy smoker & <0.001% for non smokers Severe metabolic acidosis compensate by hyperventilating. This may cause dyspnea 0r tachypnea without dyspnea. aspirin overdose) Prevalence of pneumonia in healthy patient with acute cough approx. lactic acidosis.Acute pneumonia Respiratory muscle weakness Spontaneous pneumothorax Metabolic acidosis(DKA.67%.
MI. neuromuscular disorder Psychiatric: Panic attack. Pulmonary: Asthma. primary pulmonary hypertension. COPD. interstitial lung disease. Miscellaneous: Anemia. anxiety disorder . pleural effusions.Chronic dyspnea Cardiac: cardiomyopathies. pericardial disease. chronic pneumonia. chronic pulmonary embolism. pulmonary neoplasm (primary/mets).
Need intubation?.... ..
AIRWAY ASSESSMENT Outlines of Presentation Anatomy Terminology History Physical Examination Management of Difficult Intubation .
ANATOMY I.upper respiratory system .
ANATOMY II.Lower respiratory system .
larynx .ANATOMY III.
ANATOMY IV .
difficulty with tracheal intubation or both” “When it is not possible for the unassisted anaesthesiologist to maintain the SpO2 >90% using 100% oxygen and positive pressure mask ventilation in a patient “ Difficult mask ventilation .TERMINOLOGY I Difficult airway is said to occur “When one experiences difficulty with mask ventilation.
TERMINOLOGY II Difficult laryngoscopy “When it is not possible to visualize any portion of the vocal cords with conventional laryngoscope” Difficult endotracheal intubation “When proper insertion of the tracheal tube with conventional laryngoscopy requires more than 3 attempts or more than 10 minutes” .
HISTORY I Taking an adequate history is necessary to anticipate possible complications. .
HISTORY II Condition that may associated with difficult airway included Obesity Pregnancy and labour Increased risk of laryngeal eodema in preeclamsia Microanathia Macroglossia Congenital syndromes (eg: Pierre-Robin. TreacherCollin) Burn contracture involving the head and neck Anatomical abnormalities .
. The tongue tends to fall back and downward (glossoptosis) and there is cleft soft palate.Pierre Robin syndrome Pierre Robin syndrome is a condition present at birth marked by a very small lower jaw (micrognathia).
malformed and/or prominent ears . affects the head and face. also called mandibulofacial dysostosis. Characteristics include: down-slanting eyes notched lower eyelids underdevelopment or absence of cheekbones and the side wall and floor of the eye socket lower jaw is often small and slanting forward fair in the sideburn area underdeveloped.Treacher Collins Syndrome Treacher Collins Syndrome.
rheumatoid arthritis or subluxation or .HISTORY III Evidence of airway obstruction Tumour or oedema involving upper airway Large goitre Acute epiglottitis Maxillofacial injury Airways burns Cervical spine problem Fracture-dislocation cervical spine Ankylosing spondylitis.
HISTORY IV History of upper airway compromise during sleep History of radiotherapy head and neck region History of difficult intubation during previous anaesthetics .
HISTORY V Past Medical History Bronchiol COPD Electrolytes Asthma imbalance Myasthenia gravis HPT DM Allergy History Drugs/food .
PHYSICAL EXAMINATION I Body weight and general status Expect difficulty in obese patients (body weight > 90kg or > 20% above ideal weight) Pregnant ladies particularly those in third trimester of pregnancy .
PHYSICAL EXAMINATION II Inspection in anterior and lateral views Inspect the facial features for bony or soft tissue abnormalities: Small receding chin. tumour and oedema . Mandibular or maxillary fractures.
scarring.Examine the neck for swelling. tracheal deviation and position of thyroid cartilage . goitre.
. respiratory distress and paradoxical respiration.Inspection in anterior and lateral views Noted the pattern of respiration for presence of stridor. tachypnoea.
Protruding incisors.PHYSICAL EXAMINATION III Mouth Opening Modified Mallampati Classification Inter-incisor gap (expect difficulty if< 3cm) Any intra oral cavity swelling: Eg . adenotonsillar hypertrophy. crown or dentures Dentition Position of lower teeth in relation to upper teeth . loose or missing teeth Orthodontic work with cap.
rotation Excluded cervical spondylosis.extension.any pain in the neck.5cm. or neurological symptoms in the arm Thyromental distance. If less expect difficulty Sternomental distance >12. If less.Should be > 6.5cm.PHYSICAL EXAMINATION IV Neck Movement Neck movement-flexion.expect difficulty .
PHYSICAL EXAMINATION V Indirect laryngscope Relevant in laryngael tumour or thyroid enlargement scheduled for surgery Radiological examination Chest x-ray Cervical x-ray To look for fracture dislocation of cervical spines .
.Modified Mallampati Classification Mallampati reported a correlation between the visibility of oropharyngeal structures and the degree of difficulty of glottic exposure on direct laryngoscope Laryngoscopy was difficult in Class III and IV The test is performed at the patient’s bedside with the patient sitting up and the observer at eye level. The patient is asked to open the mouth fully and protrude the tongue. Visualization and identification of pharyngeal structures is made without phonation.
uvula. uvula visible.Modified Mallampati Classification Class I: Soft palate.tonsillar pillars visible Class II: Soft palate. tonsillar pillars not visible Class III: Only soft palate visible Class IV: No pharyngeal structures except hard palate visible .
Cormack and Lehane Classification Grade I Visualization of the entire laryngeal aperture Grade II Visualization of the posterior portion of laryngeal aperture Grade III Visualization of the tip of epiglottis Grade IV Visualization of the soft palate only In Grade III and IV. intubation is considered to be difficult .
MANAGEMENT MANAGEMENT OF KNOWN DIFFICULT AIRWAY Inform senior colleague. specialist in charge and discuss options available for patient Regional anaesthesia Local anaesthesia GA with spontaneous respiration via facial mask or laryngeal mask airway .
MANAGEMENT Ensure Empty Stomach and decreased gastric acidity Implementation of fasting guidelines Use antacids or H2 receptor antagonist Inform surgeon about Potential airway problem Option of tracheostomy .
MANAGEMENT Difficult Intubation Equipment should be checked and there are in good working order .
Laryngoscopes of different types and sizes .
ET tubes with various types and sizes .
Stylet and gum elastic bougie .
.Laryngeal mask airway (LMA) of various sizes. Trachlight. intubating LMA. LMA Proseal.
Ambu bag .
Airway adjunct such as oesohageal-tracheal laryngeal Fibreoptic Combitube. tube laryngoscope and its accesories Invasive means of airway: cricothyrotomy or minitracheostomy .
pulse oximetry. BP. capnography. .MANAGEMENT Preoxygenation with 100% oxygen for 3-5 minutes prior to induction of anaesthesia Establish monitors consisting ECG.
MANAGEMENT Ensure that the intubating condition are optimal “Sniffing the morning air position” .
MANAGEMENT Consider using alternative laryngoscope blade and handle Macoy blade to retract the epiglottis Straight blade in patient with receding chin. prominent incisors or if epiglottis is long and floppy Short handle in a patient with short neck and pendulous breast .