approach to dyspnea dr. ghulam hussain baloch associate professor of medicine lumhs, jamshoro
TRANSCRIPT
Approach to Dyspnea
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
LUMHS, Jamshoro
Definition
Awareness of his own breath
Hyperventilation Signing breath In ability to take deep breath
Orthopnea dyspnea on recumbence
DyspneaDefinitions Dyspnea of exertion (DOE)
Exertion-induced SOB
Orthopnea Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND) Sudden SOB after recumbent
PND (Cardiac Asthma)
Sever breathness at night relieved when patient sits up
Case 1
73 y/o F presents to the ED with complaints of SOB for the last 2 days
Case 2
28 year male presented with high grade fever, cough on examination bronchial breathing
a) Diagnosis
b) Investigation & Mangement
DyspneaRapid Assessment ABC’s
Mental status
Presence of cyanosis
DyspneaInitial Interventions IV assess
Pulse oximetry; supplemental O2
Cardiac monitor
What Are the Indications for Airway Management? Secure & maintain patency Protection
AMS or altered gag C-spine
Oxygenation Ventilation Treatment – Suction, medications
DyspneaHistory 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?
DyspneaHistory Has there been similar episodes?
Are there associated symptoms?
What is the past medical Hx? Smoking Hx? Medications?
Cause
Acute Bronchial asthma Pneumonia Pneumothorax thromboembolic disease Cardiac Pulmonary oedema Non cardiac pulmonary oedema psychogenic
Chronic
Pulmonary Cause1. COPD Chronic Bronchial Asthma Emphysema Chronic Bronchitis 2. Restrictive Lung Disease Sarcoidosis Rheumatoid lung fibrosing alveolitis Pneumoconosis
DyspneaEtiologies
75%
10% 15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Respiratory Cardiac Other
DyspneaEtiologies: Pulmonary Causes
DyspneaCommon Pulmonary Causes Obstructive lung disease
Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax
DyspneaDyspneaCommon Pulmonary Causes Obstructive lung disease
Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax
DyspneaEtiologies: Nonpulmonary Causes
DyspneaCommon Cardiac Causes Acute coronary syndromes
CHF
Dysrhythmias
Valvular heart disease
DyspneaCommon Cardiac Causes Acute coronary syndromes
CHF
Dysrhythmias
Valvular heart disease
DyspneaCommon Miscellaneous Causes Metabolic acidemias
Severe anemia
Pregnancy
Hyperventilation syndrome
DyspneaPhysical Examination: Vital Signs BP
if dyspnea significant = life-threatening problem
Pulse Usually Bradycardia - severe hypoxemia
Respiratory rate Sensitive indicator of respiratory distress DANGER = > 35-40 bpm or < 10-12 bpm
DyspneaPhysical Examination: Observation
Ability to speak
Patient position
Cyanosis Central vs. peripheral (acrocyanosis)
Mental status Altered MS - hypoxemia/hypercapnia
DyspneaPhysical Examination
Pulmonary Use of accessory muscles Intercostal retractions Abdominal-thoracic discoordination Presence of stridor
Cardiac Check neck for presence of JVD
Signs of severe respiratory distress
DyspneaPhysical Examination: Pulmonary Inspection
Use of accessory muscles Splinting Intercostal retractions
Percussion Hyper-resonance vs. dullness Unilateral vs. bilateral
DyspneaPhysical Examination: Pulmonary Auscultation
Air entry Stridor = upper airway obstruction
Breath sounds Normal Abnormal
Wheezing, rales, rhonchi, etc.
Unilateral vs. bilateral
DyspneaPhysical Examination: Cardiac Neck
? JVD
Auscultation Abnormal S2 splitting Present of S3 and/or S4 Rubs Murmurs
What does clubbing suggest?
Chronic Hypoxemia
Pneumonia
1.Fever with chills2.Pleuratic chest pain3. purulent sputum4. History of upper respiratory symptoms 5.signs of consolidation 6.x-ray chest 7. CBC 8. Blood culture 9. ABG acute bronchial asthma age startedat
childhood
2. Acute Bronchial Asthma
1.Age start in young age
2. Family History
3. H/O Allergic Rhinitis
4.Physical exam
5.barrel shape chest
6.X-ray chest
7. ABG
Pneumothorax
1.Suden chest pain
2. dyspnea,caugh
3. H/O asthma
4.COPD
5.Examination, trachea, shifted to opposite side
absent breath sound
6 x-ray chest
3. Acute Pulmonary edema
a) Previous H/O Heart Disease b) Hyperthyroidism c) Rheumatic Heart disease (ms)Sign of LVFa) Tachycardia b) Pulses alternanc) Basal criptationd) ECG changee) X-ray Chest ( cardiomegaly)f) Echo
Pulmonary Embolism
a) History of prolonged remobilization b) pelvic surgery c) contraceptive pills d) cyanosis e) ECG f) x-ray chestg) ABGh) ECHOi) PIQ study
Case 1History
Symptoms started 2 days ago Onset gradual and progressive Exertion makes it worse New onset (+) chest pain, cough, DOE, PND No past medical Hx No medications or smoking Hx
Case 1Physical Examination Moderate respiratory distress, talks in partial
sentences, prefers to sit in ED cart BP = 190/110 mmHg; HR = 118 /min; RR =
36 bpm; afebrile; SpO2 = 85% HEENT: no angioedema Lungs: rales & wheezing bilaterally Cardiac: (+) JVD; (+) S3 Skin: no rashes Extremities: no edema
Case 1
What are likely etiologies for this patient’s dyspnea?
Heart failure ? ACS
DyspneaDiagnostic Adjuncts What study will most patient’s with dyspnea
get?
CXR Indicated in most cases of dyspnea, especially new-
onset
Case 1
DyspneaDiagnostic Adjuncts What other non-laboratory study would you
like?
ECG Indicated if cardiac etiology suspected or cardiac history
Case 1
DyspneaDiagnostic Adjuncts
What lab tests might be useful in dyspnea workup? ABG
If any question about ventilatory or acid-base status Beware of interpretation of (A–a)O2
Troponin How would it be helpful in our patient?
B-type natriuretic protein (BNP) Laboratory studies based on suspected etiology
of dyspnea
DyspneaTreatment Cornerstone of Rx
Assuring oxygenation/ventilation Supplemental O2
PaO2 > 60 mm Hg; SpO2 > 90%
Specific Rx depends on working diagnosis
DyspneaSpecial Considerations: Pediatrics Common upper airway problems
Infection Croup Retropharyngeal abscess Epiglottitis
Foreign body aspiration
DyspneaSpecial Considerations: Pediatrics Common lower airway problems
Anaphylaxis Asthma Bronchiolitis Bronchopulmonary dysplasia Cystic fibrosis Foreign body aspiration Pneumonia
DyspneaSpecial Considerations: Pregnant Patient 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
CaseConclusion Diagnosis = CHF & subacute MI
Treatment IV nitroglycerin IV furosemide
Reassessment – much improved