04 Approach To Dyspnea diagnosis and managment.pptx

Approach To Dyspnea

1. Approach To Dyspnea Presented by: Dr farhad nasiri , PG y2, internal medicine dep, Aliabad teaching hospital KMUS, MOHE Islamic Emarat Afghanistan

2. Introduction Definition Measurement of Dyspnea Types of Dyspnea Causes of Dyspnea Diagnosis Investigation DDX Treatment

3. Introduction Dyspnea is one of the most common presenting symptoms encountered by clinicians Dyspnea has been reported in 50 % of patient admitted to acute, tertiary care hospitals & 25% of patients ambulatory settings Data from population-based studies have shown that the prevalence of mild to moderate dyspnea ranged from 9% -13% in adults. This figure ranged from 15%-18% in adults aged 40 years or older; and 25%-27% in persons aged 70 years or more.

4. Definition subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors and may induce secondary physiological and behavioral responses

5. To Be Kept in Mind!

6. Measurement of Dyspnea

7. Types of Dyspnea Orthopnea PND Platypnea Trepopnea

8. Orthopnea Orthopnea-dyspnea on lying flat and is a sign of advanced heart failure. Lying flat increases venous return and in patients with left ventricular impairment may precipitate pulmonary edema. The severity can be graded by the number of pillows used at night, e.g. 'three-pillow orthopnea'

9. PND PND-sudden breathlessness waking the patient from sleep. It is caused by accumulation of alveolar fluid. Patients may choke or gasp for air, sit on the edge of the bed and open windows in an attempt to relieve their distress

10. Platypnea Platypnea ( platypnoea -orthodeoxia syndrome) breathlessness on sitting upright with relief on lying down is rare and due to right-to-left shunting through a patent foramen ovale , atrial septal defect ora large intrapulmonary shunt. It is much rarer than orthopnea and is usually associated with deoxygenation

11. Trepopnea Breathlessness when lying on one side is due to unilateral lung disease ( Patient prefers the healthy lung down), dilated cardiomyopathy ( Patient prefers right side down) or tumors compressing central airways in major blood vessels.

12. Causes

13. Cardiac Cough not prominent after dyspnea Orthopnea common PND common  Edema Raised JVP Evidence of valvular heart defect Reduced urine output Benefit with diuretics Pulmonary Dyspnea Cough prominent precedes dyspnea No orthopnea Sputum production and wheezing No PND Normal urine output No change with diuretics VS

14. Diagnostic Approach History Onset-sudden onset (acute pulmonary thromboembolism, acute coronary syndrome or spontaneous pneumothorax, acute respiratory distress syndrome (ARDS), foreign body aspiration, psychogenic causes should be high in the list of differential diagnosis.   Duration -slowly progressing over hours or days include bronchial asthma, chronic obstructive pulmonary disease (COPD), pleural effusion, pneumonia, congestive heart failure, small pulmonary emboli, interstitial lung disease or malignancy; psychogenic  causes; and cardiac diseases like coronary artery disease,  congestive heart failure

15. Common Associated Symptoms

16. Physical examination Whether the patient is able to complete full sentences while talking. Use of accessory muscles of respirations. • paradoxical breathing or sitting in tripod position Signs of pallor, cyanosis, clubbing and pedal edema are looked Hemodynamic stability. Whether the patient is able to maintain saturation on room air is assessed using pulse oximetry. Measuring blood pressure pulsus paradoxus should be watched for as its presence points to pericardial disease, restrictive heart disease. the symmetry of chest wall movements with respiration is observed

17. Physical examination Percussion (e.g., dull note in pleural effusion, hyper resonant in tension pneumothorax). Auscultation (wheeze, crepitations, decreased or hyperreasonant sounds, bronchial breath sounds). signs of heart failure should Elevated jugular venous pressure (JVP), peripheral edema, S3 gallop rhythm, presence of murmurs Paradoxical inward movement of abdominal muscles indicate weakness of diaphragm.

18. Investigation ECG Chest X-Ray Lung U/S Complete Hemogram Serum Electrolytes ABG D-Dimer Exercise test PFT ( Spirometry Including)

19. Treatment Depending the initial aetiological clues, further diagnostic work-up is planned and the patient is administered appropriate specific treatment accordingly

20. References Harrison’s: 20 th Edition: Alterations in Circulatory and Respiratory Functions. Dyspnea, Rebecca M.Baron 226: 33, 2020 Banzett RB et al: Multidimensional dyspnea profile: An instrument for clinical and laboratory research. Eur Respir J 45:1681, 2015. Laviolette L, Laveneziana P on behalf of the ERS Research Seminar Faculty: Dyspnoea : A multidimensional and multidisciplinary approach. Eur Respir J 43:1750, 2014. Parshall MB et al: An Official American Thoracic Society Statement: Update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 185:435, 2012. Wahls SA: Causes and evaluation of chronic dyspnea. Am Fam Physician 86:173, 2012.

21. Thanks