an approach to Difficulty in breathing/ Shortness of breath dyspnoea.pptx

dyspnoea

1. Approach to patient with DYSPNEA

2. Definitions: Dr. Narendra P. Giri/An approachto the patient of Dyspnoea ▶ Dyspnoea: “A 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.”-American thoracic society Difficulty in breathing/ Shortness of breath Undue awareness of unpleasant breathing Experienced as ‘cannot get enough air’, ‘air does not go all the way down’, smothering feeling or tightness or tiredness of chest’, ‘choking sensation’ etc.

3. Definitions.. 3 ▶ Orthopnoea :- Dyspnoea in supine position, usually seen in CCF but may also be seen in Asthma and chronic Bronchitis and is a regular finding in the rare occurrence of bilateral diaphragmatic paralysis. ▶ Trepopnoea :-Dyspnoea in lateral decubitus position most oftenly seen in patients with heart disease. ▶ Platypnoea : Dyspnoea in upright position . Possible causes are intracardiac shunt, pulmonary parenchymal ventilation/perfusion mismatch, and pulmonary arteriovenous shunts.

4. Pathophysiology: 4

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6. Approach to the patient 6

7. Triage: Rapid assessment of patient according to the severity for prioritizing the treatment 7 ▶ RED FLAGS in Dyspnoea : suspected upper airway obstruction (e.g. stridor); tachypnoea (> 24 breaths/minute) or apnoea; gasping or breathing effort without movement of air; chest retractions or use of accessory muscles of respiration; presence of hypotension; presence of hypoxaemia/ Cyanosis; unilateral or absent breath sounds; and altered consciousness.

8. Acute Dyspnoea ▶ New onset or abruptly worsening dyspnea within the preceeding 2 weeks. ▶ Causes: U p p e r A i rwa y O b st r uction Lower Airwa y D isease Parenchymal Lung disease Inhaled foreign body Acute Bronchitis Pneumonia Anaphylaxis Asthma Lobar collapse Epiglotitis Acute exacerbation of COPD Acute respiratory distress Syndrome (ARDS) Extrinsic compression eg. Rapidly expanding haematoma Acute exacerbation of Bronchiectasis

9. Acute Dyspnoea causes contd… 9 Other Respiratory Causes Cardiovascular Causes Other causes Pneumothorax Acute cardiogenic Pulmonary Oedema Metabolic Acidosis Pleural Effusion Acute coronary syndrome Psychogenic Brea t hlessness Pulmonary Embolism (PE) Cardiac tamponade Acute Chest wall Injury Arrhythmia Acute Valvular Heart disease

10. Chronic Dyspnoea 10 ▶ Breathlessness of more than 2 weeks duration ▶ Common Causes Respiratory Causes Asthma Bronchiectasis COPD Cystic fibrosis Pleural Effusion Pulmonary Hypertension Ca Lungs eg. Bronchial ca Pulmonary Vasculitis Interistitial Lung Disease e.g sarcoidosis TB Chronic pulmonary Thromboembolism Laryngeal/tracheal stenosis eg. extrinsic compression, malignancy

11. Chronic Dyspnoea Causes contd.. 11 Cardiovascular causes Other causes Chronic Heart Failure Severe Anaemia Coronary artery disease Obesity Valvular Heart disease Chest wall disease eg Khyphoscoliosis Paroxymal Arrythmia Physical deconditioning Constrictive pericarditis Diaphragmatic Paralysis Pericardial effusion Psychogenic hyperventilation Cyanotic Heart disease Neuromuscular disease eg. Myasthenia gravis, muscular dystrophy Cirrhosis (Hepato-pulmonary syndrome) Tense ascites

12. Stepwise approach 12 1. History : The terminology used by the patient can sometimes give a clue to the cause of dyspnoea: ▶ chest tightness or constricted breathing -bronchial asthma; ▶ smothering or suffocating sensation-heart failure, acute coronary syndromes; ▶ need to sigh- heart failure ( ‘ sigh’ dictionary meaning :-emit a long, deep audible breath expressing sadness, relief, tiredness, or similar) The followings should be recorded during History taking:- onset, duration, pattern, progression, severity, diurnal variation, relation to exercise, exertion, aggravating and relieving factors etc.

13. Onset Within Minutes Pneumothorax Pulmonary oedema Major pulmonary embolism Foreign body Laryngeal oedema Within Hours Asthma Left heart failure Pneumonia Within Days Pneumonia ARDS Left heart failure Repeated pulmonary embolism Within Weeks Pleural effusion Anaemia Muscle weakness Tumours Within Months Pulmonary fibrosis Thyrotoxicosis Muscle weakness Within Years Muscle weakness COPD Ches t wal l disorder 13

14. Position Orthopnoea (dyspnea in supine position) Platypnoea (Dyspnoea in assuming upright position ) T repo p noe a ( dyspn o ea in lateral decubitus position ) CCF LVF COPD Bronchial asthma Massive pleural effusion Bilateral diaphragm palsy. Ascites GERD Left atrial myxoma Massive pulmonary Embolism Pulmonary Atri o ve nous fistula Paralysis of intercostal muscles Hepato pulmonary syndrome Large foramena ovale Disease of one lung or bronchus like unilateral pleural effusion CCF ,

15. T im i ng Nocturnal onset Dyspnoea Paroxymal Nocturnal Dyspnoea Post Prandial Dyspnoea CHF COPD BRONCH I AL A S THMA S L EEP A P NOEA NOCTURNAL ASPIRATION IN GERD Left heart failure Nocturnal episodes of asthma Nocturnal episodes of recurrent minute pulmonary emboli Sleep apnea with arousal Nocturnal angina with dyspnoea (angina equivalent) Nocturnal aspiration in gastro- oesop h agea l r e flux di s ea se GERD ASPIRATION FOOD ALLERGY 15

16. Severity 16 33 of 103

17. Precipitating and Relieving Factors Precipitating Factors Relieving Factors exercise exposure – cigarette, allergens occupational exposure obesity Medication like Aspirin, Beta Blockers etc rest Medication Expectoration of sputum 17

18. Associated Symptoms Symptoms Differential Diagnosis Wheeze COPD/emphysema, asthma, allergic reaction, CHF (cardiac wheeze) Pleuritic chest pain Pneumonia, pulmonary embolism, pneumothorax, COPD, asthma Fever Pneumonia, bronchitis, TB, malignancy Cough Pneumonia, asthma, COPD/ emphysema Haemoptysis Pneumonia, TB, pulmonary embolism, malignancy Peripherial Oedema Acute heart failure, pulmonary embolism (unilateral) Pulmonary oedema (pink frothy sputum) Acute and chronic heart failure, end-stage renal and liver diseases, ARDS Tachypnoea Pulmonary embolism, acidosis (including aspirin tox icity), a nxiety

19. Past History T hur s d ay, Sept emb er 12, 2019 Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 19 CCF HTN, DM, Dyslipidaemia, Obstructed sleep apnoea Acute exacerbation of COPD COPD Acute exacerbation of Bronchial Asthma Asthma PE DVT, Prolonged immobilization, Long travel, recent surgery, long bone fracture Respiratory muscle weakness Myasthenia gravis, Muscular Dystrophies Acute Angina/ MI Coronary Heart disease

20. ▶ Family History ▶ Occupational History ▶ Drug History ▶ Travel History 20

21. 2. Physical Examination 21 ▶ General condition of the patient ▶ The breathing pattern- ▶ Shallow rapid breathing as in ILD ▶ Deep Rapid breathing eg Kussmaul’s breathing ▶ Irregular breathing eg Chyne strokes breathing ▶ Use of Accessory muscles of respiration ▶ General body Built- ▶ Lin and thin-COPD ▶ Obse/ oedamatous- CCF ▶ Decubitus- Orthopnoea, Trepopnoea, Platypnoea, Tripod position in COPD

22. ▶ Pallor ▶ Lymphadenopathy ▶ Clubbing ▶ Cyanosis ▶ Oedema ▶ Thyroid gland ▶ Speech- Can the patient complete a sentence in one breath? ▶ Vitals ▶ BP-Hypotention- poor prognosis, ▶ Hyper t ensio n -hypert e nsio n - rela t e d diastoli c hear t failure with pulmonary oedema, hyperthyroidism, or phaeochromocytoma ▶ Pulsus Paradoxus- asthma, COPD, cardiac tamponade 22

23. ▶ Pulse- Rate, Rhythm, Volume, Force ▶ Respiratory rate- Tachypnoea ▶ Temperature- Fever ▶ Pupilary Reaction 23

24. Systemic Examination 24 Respiratory System ▶ Insepection - Inspect the nose, nasal cavity, pharynx and chest ▶ Purpsed lips and Prolonged expiration-COPD ▶ Foreign body in the respiratory tract, ▶ swelling of mouth, tongue, pharynx - Anaphylaxis/ Angioedema ▶ Barrel shaped chest-Emphysema and Cystic Fibrosis

25. ▶ Tracheal Deviation-In contralateral side-Pleural effusion, lung mass, Pneumothorax ▶ Ipsilatera l deviati o n i n lo b ar/lun g colla p se, lung fibrosis ▶ Voice-Hoarseness-in laryngitis, laryngeal tumours, vocal cord paralysis. ▶ JVP- raised in Right heart failure and in conditions which increases blood pressure in superior Vena cava ▶ Kyphosis/Scoliosis ▶ Chest movement-Symmetry, Intercostal recession ( in upper airway obstruction), Inward movement of lower ribs during inspiration (COPD) ▶ 25

26. Palpation ▶ Lymph nodes-cervical, supraclavicular, axillary ▶ P os i ti o n of t h e t r ac h ea ▶ Mea s uremen t of c hes t expans i on ▶ R educe d i n o bstructiv e disord e r ▶ Unilateral reduction in pneumothorax, pleural effusion, lung collapse, fibrosis 26

27. Percussion 27 ▶ Unilateral dullness to percussion - pleural effusion (stony dullness), atelectasis, foreign body aspiration, pleural tumours, or pneumonia. ▶ Hyper-resonance - pneumothorax or severe emphysema.

28. Ascultat i on 28 ▶ Reduced Breath sounds-COPD ▶ Bronchial breathing sounds in peripheral region- Consolidation ▶ Wheese-Asthma, COPD ▶ Crackles- ▶ C r ackle s i n th e begi n nin g of inspiratio n - CO P D ▶ L o calize d lo u d an d c o ars e crackle s - are a of br o nc h iect a sis ▶ Fine an d late ins p irator y crackle s - Diffus e interisti t ial fibrosis ▶ Absent Breath sounds unilaterally- lung collapse, pneumothorax

29. Cardiovascular System 29 ▶ Inspection ▶ Anaemia ▶ C y an o sis ▶ Clubbi n g ▶ Oed e ma ▶ JVP ▶ Palpation ▶ Pulse ▶ BP

30. Auscultation ▶ Heart sounds ▶ S3 g a llop i n ad u lts i n L V F , less comm o nl y seen i n Mitral regurgitation, Constrictive pericarditis. Can also be found in Thyrotoxicosis, pregnancy, fever, anaemia. ▶ Murmurs- Stenosis and Regurgitations T hur s d ay, Sept emb er 12, 2019 Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 30

31. Investigations: 31 1. Blood tests : ▶ CBC-for assessing infections eg. Pneumonia, URTI, Acute infective exacerbation of COPD ▶ Hb level to assess anaemia ▶ ESR and CRP to assess inflammation ▶ Renal Function test for occult renal disease ▶ Thyroid Function test ▶ Arterial Blood Gas (ABG)-to assess the cause of acidosis, state of ventilation and perfusion and type of respiratory failure.

32. Blood tests contd.. 32 ▶ Biomarkers : Natriuretic peptides- Brain Natriuretic peptides (BNP) and N terminal Pro-hormone Brain Natriuretic peptide (NT proBNP)-Released from ventricle myocytes in response to increased pressure to the ventricles. Increased in clinically relevant congestive heart failure. Troponins - If the clinical evidence points to an acute coronary syndrome as the cause of dyspnea, serial determination of cardiac troponin (troponin I or troponin T) is helpful. This can be used to rule out acute myocardial ischemia with a high degree of certainty.

33. Biomarkers contd… 33 c . D-dimers D-dimers are fibrin degradation products generated by fibrinolysis; they are found in higher concentrations after thrombotic events. They have a high negative predictive value in the diagnostic evaluation of pulmonary embolism .

34. Investigations contd.. 34 Chest X-ray : ▶ Can assess Pulmonary consolidation (Pneumonia), Hyperinflation (COPD) Fluid collection (Pleural effusion), Pulmonary oedema (Bat’s wing pattern), lung collapse, fibrosis, etc. ▶ Size of heart etc. ECG and Echocardiogram : ▶ Can assess Cardiac pathology

35. Investigations contd.. 35 ▶ Pulmonary Function test : ▶ FEV1/FVC should be more than 70% if low suggests Obstructive pathology eg. COPD ▶ I f FVC i s less tha n 80 % of th e previo u s baseli n e of the same patient suggests Restrictive pathology eg. Reduced compliance ( Fibrosis etc) ▶ CT scan of Pulmonary Artery if Pulmonary embolism is suspected ▶ Sputum examination: In suspected TB, Pneumonia and infected COPD cases

36. Some specific conditions of Dyspnoea: 36 1. Acute exacerbation of Asthma : ▶ P as t Hist o ry of Bronchial Asthma ▶ T achy p nea , wheez e s, an d a pr o lo n g e d ex p irat o ry p h ase are typical clinical findings ▶ Spirometry shows a decrease in both the forced expiratory volume at one second (FEV1) and the peak expiratory flow (PEF) . ▶ The o b structi o n , an d th e symptoms, impr o ve markedly after the inhalation of a bronchodilator drug (β2- agonist or anticholinergic drug).

37. 2 . Acute Exacerbation of COPD ▶ P as t Hist o ry of C OPD ▶ barre l sha p e d chest ▶ Purpsed lips an d pr o lo n ged expirati o n ▶ Us e of accessor y muscl e of r espirati o n ▶ Cur r en t or pas t smoking hist o ry ▶ Reduced breath sounds with prolonged expiration, expiratory wheeze, Hyper-resonant percussion note ▶ CXR - H y perinflate d lun g s wit h flat dia p hragms ▶ S p ut u m P ro d uc t ion 37

38. 3. Pneumonia : 38 ▶ D yspno e a, Pl e ur i ti c pai n , feve r , an d coug h ar e ty p ical accompanying symptoms. ▶ Examination reveals tachypnea, inspiratory crackles, and sometimes bronchial breathing. ▶ Laboratory testing (inflammatory parameters), chest x-ray, and in some cases chest CT are diagnostically helpful. 4. Interistitial Lung Diseases (ILD): ▶ Patients report chronic shortness of breath and nonproductive cough, and they are often smokers. ▶ Examination reveals crackling rales at the bases, and sometimes also digital clubbing and hourglass nails. ▶ Pulmonary function testing reveals low vital capacity (VC) and total lung capacity (TLC).

39. 39 Right Middle lobe Pneumonia

40. Pulmonary Embolism : ▶ Often characterized by dyspnea of acute onset with pleuritic pain and sometimes have hemoptysis. ▶ Examination reveals shallow breathing and tachycardia, Tachypnoea, hypotension. ▶ History of DVT, recent Surgery, Long bone fracture or prolonged immobilization or recent long travel. ▶ D-dimer test or CT of pulmonary artery are used for diagnosis Pneumothorax : ▶ Sudden-onset dyspnoea associated with unilateral chest pain may indicate acute pneumothorax. ▶ On examination, breath sounds are unilaterally absent, and percussion of the ipsilateral chest may reveal tympany. ▶ The trac h e a m a y als o b e deviat e d awa y from the lesion 40

41. 7. Anaph y laxis: ▶ Exposed to a medication, food product, or insect bite. ▶ Sudden-onset dyspnoea is accompanied by cutaneous manifestations , voice changes, a choking sensation, tongue and facial oedema, wheezing, tachycardia, and hypotension. 8. Acute myocardial infarction : ▶ Presents with central chest pain radiating to the shoulders and neck frequently accompanied by dyspnoea. ▶ O/E patient may be clammy and hypotensive. ▶ S3 or S4 gallop rhythm ▶ pulmonary rales. ▶ characteristic ECG changes, elevated cardiac enzymes Thursday,

42. 9. Acute valvular insufficiency 42 ▶ Acute dyspnoea, ▶ systolic murmur and signs of acute cardiovascular collapse with hypotension, tachycardia, and pulmonary rales. ▶ An echocardiogram is typically required to establish the diagnosis. 10. Aortic dissection ▶ Dyspnoea ▶ severe chest pain that may radiate to the back. ▶ hypotension and absent peripheral pulses. ▶ Emergency echocardiogram or a CT chest is used for diagnosis.

43. 11. Congestive heart failure ▶ Presents with dyspnoea worsened by exertion, ▶ orthopnoea and paroxysmal nocturnal dyspnoea, elevated neck veins, peripheral fluid retention, an S3 gallop rhythm, and pulmonary congestion (fine bibasal rales) . ▶ The CXR shows characteristic signs of pulmonary venous congestion with cardiomegaly. ▶ Echocardiography. ▶ Brain natriuretic peptide >100 pg/ml 43

44. CXR of CCF 44

45. 12. Pericardial tamponade ▶ Dyspnoea accompanied by neck vein and facial engorgement, shock, peripheral cyanosis, and tachycardia. ▶ An enlarged cardiac silhouette on CXR and a low-voltage ECG, echocardiography. 45

46. Pericardial Tamponade 47

47. 13. Psychogenic Breathlessness and Hyperventilation Syndrome ▶ Reach to this Diagnosis after excluding all the serious causes of dyspnea ▶ Patient complain of ‘inability to take a deep enough breath’ leading to extra deep sighs being taken. ▶ Other symptoms-digital and perioral paresthesia, light headedness, central chest discomfort or even carpo-pedal spasm due to acute respiratory alkalosis ▶ Rarely disturbs sleep and frequently occurs at rest ▶ Provoked by stressful situation ▶ Can even be relieved by exercise ▶ ABG shows normal PaO2, low PaCO2 and alkalosis. 47

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