Breathlessness

Approach to a patient with breathlessness

1. Shortness of Breath Photo by James Heilman, MD / CC BY-SA 3.0

2. Contents Definition Grades of breathlessness Common causes History taking Abnormalities on physical examination Differential diagnosis Initial investigations Basic management

3. Definition Undue awareness of breathing and is normal with strenuous physical exercise Sense of awareness of increased respiratory effort that is unpleasant and that is recognized by the patient as being inappropriate Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable need to breathe. It is unusual among sensations, as it has no defined receptors, no localized representation in the brain, and multiple causes both in health (e.g. exercise) and in diseases of the lungs, heart or muscles. Patients use terms such as ‘shortness of breath’, difficulty getting enough air in’, ‘tiredness’, ‘difficult, laboured , uncomfortable breathing; it is an unpleasant type of breathing, though it is not painful in the usual sense of the word’

4. MRC Dyspnoea Scale Grade Degree of breathlessness related to activity 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying on a level or when walking up a slight hill 3 Walks slower than most people on the level, stops after a mile (1.6 km) or so, or stops after 15 minutes walking at own pace 4 Stops for breath after walking 100 yards (90 m), or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing/undressing

5. New York Heart Association (NYHA) Functional Classification Grade Symptoms Grade 1 ( Mild ) No limitation on physical activity. Ordinary physical activity doesn't cause undue fatigue, palpitation,  dyspnoea Grade 2 ( Mild ) Slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in fatigue, palpitation,  dyspnoea. Grade 3 ( Moderate ) Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. Grade 4 ( Severe ) Unable to carry out any physical activity without discomfort. Dyspnoea present at rest, if any physical activity is undertaken the discomfort increases.

6. Common Causes System Acute dyspnoea Cardiovascular Acute pulmonary oedema Respiratory Acute severe asthma Acute exacerbation of COPD Pneumothorax Pneumonia Pulmonary embolus ARDS Inhaled foreign body Lobar collapse Laryngeal oedema Others Metabolic acidosis Psychogenic hyperventilation

7. System Chronic exertional dyspnoea Cardiovascular Chronic heart failure Myocardial ischaemia Respiratory COPD Chronic asthma Bronchial carcinoma Interstitial lung disease Chronic pulmonary thromboembolism Lymphatic carcinomatosis Large pleural effusions Others Severe anaemia Obesity Deconditioning Common Causes

8. History taking Patient's details : Name Age Sex Occupation : paint sprayers, rubber industry workers are prone to lung disease Address Date of Admission

9. History taking Chief Complaints Shortness of breath for how many days / weeks History of Presenting Illness Onset : gradual/sudden Progression : worsen/better Severity : NYCA/MRCA grading Diurnal variability : worsen at night / morning- asthma Postural variability : orthopnoea , PND-CVS Aggravating factors : pollen, dust, cold climate - asthma, sinusitis Relieving factors : rest, medication

10. History taking Associated symptoms : Cough : yes/no If yes , onset/duration/progression - chronic cough - bronchiectasis Frequency, severity Diurnal variability - might indicate asthma Postural variability - might indicate bronchiectasis Productive/ dry cough Sputum : How much? Frequency? - Copious sputum suggestive of bronchiectasis Colour? – White (viral) , yellowish (bacteria), rusty (pneumonia) Consistency Foul smell? - Suggestive of bronchiectasis, suppurative lung disease

11. History taking Associated symptoms : Haemoptysis : Duration, onset, progression Amount of blood? Associated with melena or epistaxis? Might be due to malignancy Chest pain : Onset , duration, progression Site? Bilateral/ unilateral Type of pain Radiating - CVS pathology Pain on deep inspiration, pain relief when lie on same side- pleuritic chest pain

12. History taking Associated symptoms: Fever : Onset, progression, duration Associated with chills or rigor, night sweats High / low grade Evening rise of temp - TB Wheezing – asthma Weight lost - TB, malignancy Palpitation - CVS pathology Sinusitis Rhinitis

13. History taking Past History : History of TB, Measle/whopping cough, Asthma/ allergy, IHD, chest trauma/ surgery , similar complains, DM/HTN Personal History : Diet, Addiction, Bowel/Bladder movement, Sleep, Appetite Smoking- highly ass with Emphysema Alcoholism - Aspiration Pneumonia Lost of appetite & weight - TB, Malignancy Family History : Asthma, TB, Cystic Fibrosis, Malignancy Anyone with similar complaints

14. History taking Social history : Economic status, income, type of house, water source, no. of people staying in one house Congested homes/ low economic status - risk of lung pathology Menstrual history : To rule out pregnancy

15. Abnormalities on Physical Examination

16. General Physical Examination BMI – Normal : 18.5 – 22.9 ( Asian ) 18.5 – 24.9 ( Non-Asian ) Obesity might be the cause of the breathlessness Extra weight in the chest and abdomen Increased work load on muscles that control breathing

17. Vital Signs : Pulse Rate – Normal (60-90 beats/min) Tachycardia : Pneumonia , Atrial Fibrillation Bradycardia : Myocardial Infarction Blood Pressure – Normal (120/80 mmHg) Hypotension : Pneumothorax , Myocardial Infarction Hypertension : Cardiac Failure Temperature High : Tuberculosis, Pneumonia Respiratory Rate – Normal (14-16 breaths/min) Tachypnoea : Pulmonary Embolism , Anxiety Bradypnoea : Myocardial Infarction

18. Head to Toe Examination Nails and Hands Pallor ( Left Heart Failure ,COPD) Cyanosis ( Cardiac Failure , COPD , Pulmonary oedema ) Clubbing ( Carcinoma of Bronchus , Pulmonary Fibrosis ,Bronchiectasis , Lung Abscess , Pleural Empyema ) Koilonychia ( Anaemia ) Neck : JVP increased ( Right Heart Failure caused by Chronic Pulmonary Hypertension in severe lung disease such as COPD )

19. Head to Toe Examination Face : Eyes – Pallor ( Anaemia ) Lips and Tongue – Cyanosis ( Cardiac Failure , COPD ) Indicate poor oxygenation of blood Lower limb : Pitting Pedal Oedema Unilateral – DVT Bilateral – Congestive Heart Failure

20. Respiratory System Examination Auscultation Stridor ( Laryngeal Oedema , Foreign bodies ) Diminished Vesicular Breath Sounds ( Obesity , Pleural Effusion , Pneumothorax , COPD , Lung collapse ) Bronchial Breath Sounds ( Lung consolidation in pneumonia ) Vocal Resonance ( over consolidated lung , the spoken numbers are clearly audible but over an effusion or collapse they are muffled ) Rhonchi / Wheeze ( COPD , Bronchial Asthma ) Pleural Rub ( Pneumonia , TB ) Crackles

21. Examination Sequence Note the patient’s general appearance and  demeanour . Look for central cyanosis of the lips and tongue. Examine the skin for rashes and nodules. Listen  for  hoarseness and stridor. Examine the hands for finger clubbing, peripheral cyanosis and tremor. Measure the blood pressure. Examine the neck for raised JVP and cervical lymphadenopathy. Record the respiratory rate. Observe the breathing pattern, and look for use of accessory muscles. Inspect the chest front and back for abnormalities of shape and scars. Feel the trachea and cardiac apex beat for evidence of mediastinal shift. Percuss the chest front and back for areas of dullness or hyperresonance . Listen to the chest front and back for altered breath sounds and added sounds. Certain groups of physical signs are typically associated with particular pathological changes in the lungs.

22. Differential diagnosis Develop differential diagnosis in a patient with breathlessness based on history and examination

23. Differential Diagnosis

24. Differential Diagnosis

25. Evaluation Plan initial investigations and basic management based on the differential diagnosis

26. Bedside investigations Pulse Oximetry A spectrophotometric device that measures arterial oxygen saturation by determining the differential absorption of light by oxyhaemoglobin and deoxyhaemoglobin . This allows detection and ongoing monitoring of hypoxaemia with initiation of oxygen supplementation as necessary, while undertaking diagnostic work-up for its cause Peak Flow Rate Person's maximum speed of expiration. Normal test results depends on age year gender and sometimes occupation. Helps to differentiate between pulmonary and cardiac causes of dyspnoea. Low peak flow rates are associated with obstructive lung disease such as asthma, COPD, and cystic fibrosis. Normal: 80-100 per cent of usual flow rate.

27. Bedside investigations Pulse Oximetry Peak Flow Rate

28. Radiology Chest X-Ray To determine the lobe / area in which the lung is affected. Make out any cardiomegaly in the PA view of the x-ray Check for any fluid / consolidation of the lungs. Check for any structural damage such as a broken rib Chest fluoroscopy / Sniff test Determines how well lungs, diaphragm, or other parts of your chest are working. Uses more radiation than a standard chest X-ray. It detects the movement of the diaphragm when the patient breathes. Hence able to detect any abnormal diaphragmatic conditions.

29. Radiology Chest X-Ray Chest fluoroscopy / Sniff test

30. Electrocardiogram To detect underlying causes of cardiac origin that causes breathlessness. Coronary artery diseases can be a major causes of breathlessness. If needed an angiogram can be done to make out any blockage to the coronary arteries.

31. Lung Biopsy Invasive procedure. Involves removal of a small piece of lung tissue which can be sent for investigations. Types: bronchioscopic , needle, open, video associated thoracoscopic surgery. Diagnose certain condition such as sarcoidosis or pulmonary fibrosis and even lung cancers.

32. Treatment Management of breathlessness

33. Pharmacological The treatment of breathlessness is complex. It depends on the underlying causes. Opioids-either oral or parenteral-are now considered to be the gold standard in reducing ventilator demand.  A slow release preparation of morphine has been found to be beneficial Anxiolytics such as benzodiazepines may assist in the anxiety component of breathlessness. However, these may be poorly tolerated in some patients, especially in those with liver failure. Long acting beta agonists may be beneficial in breathlessness due to COPD in reducing the work of breathing. Bronchodilators help in relaxing muscles and improving muscle tone in the airways. 

34. Oxygen Treatment Evidence have shown oxygen treatment is of no use in a patient with breathlessness WITHOUT hypoxia. Otherwise, high flow oxygen of >60 percent is used except in COPD patients.

35. Non-pharmacological There does seem to be a relationship between anxiety and breathlessness, however, which one comes first is difficult to tell. Strategies such as relaxation training and distraction do seem to help as do cognitive behavioural therapies. Controlled breathing exercises and techniques such as an upright leaning forward position and pursed lip breathing are also beneficial therapies. Chest wall vibration, neuro-electrical muscle stimulation, walking aides, and breathing training.

36. Thank you!