Approach to Dysnea and Wheezing

The presentation covers clinical aspects in a patient of breathlessness and wheezing. It includes thorough history taking and clinical examination. A part of respiratory physiology and sounds heard on auscultation are also covered. Gradings of dysnea are explained.

1. Approach to Breathlessness Bhoopendra Kumar 3432 (8 th Semester MBBS)

2. What is Dyspnea /Breathlessness? Dyspnea is the unusual and uncomfortable awareness of difficult or labored breathing Normal resting patients are unaware of the act of breathing It is subjective and its quality is unique ~ 95% of cases are due to one of five major causes: cardiac (e.g., CHF), pulmonary (e.g., COPD, asthma, ILD), psychogenic factors, GERD, and deconditioning Dyspnea is termed acute if it develops over hours to days and chronic when it occurs for more than four to eight weeks.

3. Some Distinct Terms Orthopnea: Dyspnea upon lying in the supine position. Characteristic of CHF and, in rare cases, of bilateral diaphragmatic paralysis Trepopnea : Dyspnea upon lying in the lateral decubitus position. Most often occurs in patients with CHF Platypnea : Dyspnea upon assuming the upright position Bendopnea : Dyspnea when leaning forward

4. Bendopnea . Do you want to check JVP?

5. Dysnea happens when a mismatch occurs between afferent and efferent signaling. As the brain receives afferent ventilation information, it is able to compare it to the current level of respiration by the efferent signals. If the level of respiration is inappropriate dysnea might occur

6. History In A Case Of Dyspnea Duration, onset, course and progression Grade Associated symptoms: Substernal chest pain with myocardial ischemia; fever, cough, and sputum with respiratory infections Positional variation of dyspnea ( othopnea , platypnea , trepopnea ) or PND Seasonal and diurnal variation: Intermittent dyspnea in asthma and COPD Smoking and environmental exposure history Tuberculosis: Past history/contact history/family history Socio-economic status

7. mMRC Grading

8. NYHA Grading

9. Approach To Dyspnea

10. General Physical Examination Built and appearance (BMI for objective assessment) Neck circumference Laryngeal length Vitals with oxygen saturation (SpO2) Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema JVP Single breath count

11. RESPIRATORY TRACT EXAMINATION Upper respiratory tract examination: Nasal cavity, oral cavity and pharynx

12. Respiratory System Examination INSPECTION- Shape of the chest and movement of the chest (symmetry?) Position of trachea Position of apical impulse Chest deformities, use of accessory muscles, dilated veins, scars or sinuses, indrawing of intercostal spaces, visible fullness Paradoxical breathing Lower chest indrawing (Hoover’s sign)

13. Barrel shaped chest

14. Trail’s sign

15. PALPATION- Any local rise of temperature or tenderness Confirming the findings of inspection Vocal fremitus Measurements: AP diameter, transverse diameter, chest circumference, hemithorax measurements, expansion Respiratory System Examination

16. Assessment of position of trachea

17. Vocal fremitus

18. Golden rule of Respiratory Examination Always examine the NORMAL side first

19. Percussion

20. Respiratory System Examination AUSCULTATION- Air entry and character of breath sounds Intensity of breath sounds Any added sounds Vocal resonance

21. Auscultation of chest

22. Approach To Dyspnea

23. Chest Xray- PA View Full blood count with ESR Blood chemistry- LFT/ LFT HIV, Anti-HCV, HBsAg ANA, RF Mantoux testing Sputum AFB, GeneXpert Diagnostic thoracocentesis TO SEND:

24. FIRST INVESTIGATION?

25. NORMAL CXR-PA VIEW

26. Approach to wheezing Bhoopendra Kumar 3432 8 th Semester MBBS

27. Wheezing Wheezing is a high pitched, continuous and musical sound that originates from oscillations in narrowed airways. Heard more commonly during expiration Sign of lower airway obstruction

28. Types of Wheeze Monophonic Wheeze: Single Pitch, produced in larger airways during expiration Polyphonic Wheeze: Multi- Pitch Sound, widespread narrowing or various levels of narrowing.

29. Causes Bronchial Asthma LRTI: Increased sensitivity of respiratory tract after infection Bronchiolitis : in the first 2 years Topical Eosinophilia : frequent in adults Hypersensitivity Pneumonitis Inhaled Foreign bodies Enlarged mediastinal LN, CF, Pulmonary Hemosiderosis .

30. Episodic vs multi trigger wheeze Episodic Wheeze: wheeze in response to viral cold normal between episodes Multitrigger Wheeze: Triggered by infection, exercise, allergen Symptoms may be present between episodes Likely to be asthmatic

31. History Age: more common in children Onset Progression Duration Aggravating Factors Relieving factors Severity: altered sleep, awakening, night cough

32. Associated Symptoms: Breathing difficulty, cough. Possible Triggers: Active/Passive Smoking, Pets, Pollen, Dust, Mites, Humidity, Smoke from kitchen Any history of allergy/itching/sneezing Food Allergy Family history of asthma, allergy

33. E xamination Normal/Drowsy/Irritable Vitals: Pulse- Bounding pulse in asthma due to CO2 trapping Tachypnoea Temperature- Fever

34. Head to Toe Examination: Clubbing – Bronchiectasis , CF Cyanosis -- Severe Asthma Lymphadenopathy - Infections Face– Allergic Shiners, Transverse crease on nose, Dennie Morgan fold Cushingoid facies - long term steroid therapy

35. Respiratory System Barrel Shaped Chest Harrison sulcus Chest wall expansile movement diminshed bilaterally Accessory muscles of respiration working Lower chest indrawing Hyper resonant percussion note Cardiac dullness obliterated Upper border of liver dullness at a lower position

36. Diagnosis and investigation Clinical Recurrent attacks of wheezing or spasmodic cough suggest asthma Bronchodilator response CBC Absolute Eosinophil count Chest Xray PFT and Spirometry

37. Chest X- ray Asthma- bilateral and symmetrical air trapping Bronchiolitis - Hyperinflation of chest with scattered areas of infiltration

38. Thank You