Clinical approach Dyspnoea A simple and practical approach.pptx

how to approach a person with breathlessness

1. Clinical approach to a patient with dyspnoea P.S.Shajahan MD ,MPhil

2. Disclosures NIL 17 th South Zone PG Meet, August 30 & 31 TVPM

3. W hat is dyspnoea ? Term used to characterize 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 . M ay induce secondary physiological and behavioral responses. Dyspnoea results from mismatch between central respiratory motor activity and incoming afferent information from the receptors in airway, lungs and chest wall structures 17 th South Zone PG Meet, August 30 & 31 TVPM

4. Definitions of dyspnoea Difficult, labored, uncomfortable breathing” “awareness of respiratory distress” “the sensation of feeling breathless or experiencing air hunger” “an uncomfortable sensation of breathing” Acute – Hours to days Chronic - More than 4 to 8 weeks 17 th South Zone PG Meet, August 30 & 31 TVPM

5. Dyspnoea – a symptom Subjective – a symptom only felt by the person who experience it Discomfort associated with the act of breathing in circumstances that is unexpected. Further characterize by: nature of onset (acute, chronic), duration evolution over time associated symptoms (cough, chest pain, wheeze, orthopnea) physiologic vs. pathologic 17 th South Zone PG Meet, August 30 & 31 TVPM

6. Dyspnoea – common clinical problem Common in patients with cardiac or respiratory disease as well as in healthy individuals who are obese and/or deconditioned Prevalence of dyspnea in healthy adults (< 65 yrs) ranges from 10 -18%. >30% of elderly individuals (≥ 65 years of age) report breathlessness with activities of daily living, including walking on a level surface or up an incline Independent predictor of mortality even after adjusting for age, sex, smoking history, and prior occupation. Eur J Epidemiol 2001; 17:223-229 17 th South Zone PG Meet, August 30 & 31 TVPM

7. Dyspnoea evaluation – caveats Discrepancy between patient’s perception (under-reported) and physician’s clinical evaluation (under-recognized). Important to recognize fatigue vs. activity intolerance vs. dyspnea. Co-existence of multiple causes of dyspnea is common; so, need to be able to define relative contribution of each component – lung/ cardiac disease as opposed to obesity, anemia or thyroid disorders. Pulmonary function tests and exercise studies do not assess severity of feeling of breathlessness (a sensation); but rather address functional capacity or physiological consequences. Don’t mislead by the so called ‘normal O2 saturation’ 17 th South Zone PG Meet, August 30 & 31 TVPM

8. Language of dyspn o ea Cultural or language differences may result in patients using different words to describe the same sensory experience Sensation may differ depending o n pathophysiology of dys p n o ea 17 th South Zone PG Meet, August 30 & 31 TVPM

9. Descriptors u tilized in Dyspnea Questionnaires My breath does not go in all the way. My breathing requires effort. I feel that I am smothering. I feel a hunger for more air. My breathing is heavy. I can not take a deep breath. I feel out of breath. My chest feels tight. My breathing requires more work I feel that I am suffocating I feel that my breath stops. I am gasping for breath. My chest is constricted. I feel that my breathing is rapid. My breathing is shallow. I feel that I am breathing more. I can not get enough air. My breath does not go out all the way. My breathing requires more concentration. Am Rev Respir Dis . 1990;142:1009- 1014 Am Rev Respir Dis . 1991;144:826- 832 17 th South Zone PG Meet, August 30 & 31 TVPM

10. Cluster analysis of symptoms Descriptor Condition Chest Tightness Asthma (Simon et al., 1990) Inability to get a deep breath Unsatisfying Breath COPD Hyperinflation (O'Donnell et al., 1997) Air Hunger Urge to Breathe Congestive heart failure COPD Asthma Neuromuscular weakness (Simon et al., 1990) Heavy Breathing Breathing More Peripheral muscle atrophy Cardiovascular deconditioning (Mahler et al., 1996) 17 th South Zone PG Meet, August 30 & 31 TVPM

11. Differential Diagnosis Asthma Primary lung cancer Metastatic cancer Chronic bronchitis Bronchiolitis Laryngeal disease Tracheal stenosis Tracheaomalacia Alveolitis Drug toxicity Anaphylaxis Emphysema Chronic Bronchitis Pneumonitis Pulmonary edema Pulmonary fibrosis Abdominal distention Chest wall trauma Pulmonary effusion Pericardial effusion Pulmonary hypertension Pulmonary embolism Vasculitis Myocardial Infarction Arrhythmia Myocardial ischemia Congestive heart failure Intracardiac shunt Left ventricular hypertrophy Atrial myxoma Pericarditis Myocarditis Valvular disease Myopathy Neuropathy Phrenic nerve dysfunction Spinal cord injury Anemia Deconditioning Gastroesophageal reflux disease Hyperthyroidism Metabolic Acidosis ARDS Sepsis Psychogenic dyspnea Acute bronchitis High altitude pulmonary edema PLUS HUNDREDS MORE>>>>>>>>>> 17 th South Zone PG Meet, August 30 & 31 TVPM

12. Brief differential diagnosis 17 th South Zone PG Meet, August 30 & 31 TVPM

13. So where do we start ? 17 th South Zone PG Meet, August 30 & 31 TVPM

14. History: 56% accurate for all causes 67% accurate for cardiac causes 47% accurate for pulmonary causes History, Physical Exam ination , Chest X- Ray 66% accurate for all diagnoses 81% accurate for most common diagnoses 27% of CXR will demonstrate ‘s ome ’ findings Michelson, Emergency Medicine Clinics of North America , 1999 History, Physical examination and Chest Radiograph 17 th South Zone PG Meet, August 30 & 31 TVPM

15. Organize our thoughts Is the dyspn o ea … –A new problem? –An exacerbation of a chronic problem? –A combination? Is the dyspn o ea … –Pulmonary? –Cardiac? –Neither? Is the dyspn o ea - one of the deadly but subtle diagnoses we should think of every time? 17 th South Zone PG Meet, August 30 & 31 TVPM

16. A new problem? Pneumonia Myocardial ischemia Pulmonary embolism Anaphylaxis Arrhythmia Trauma Keys to Diagnosis: No history of prior cardiopulmonary disease Atypical of other disease presentations New risk factors – e.g. recent surgery Is the Dyspnoea… 17 th South Zone PG Meet, August 30 & 31 TVPM

17. Asthma COPD Congestive Heart Failure Interstitial Lung Disease Cardiac Arrhythmia Neuromuscular Disorder Anemia Keys to diagnosis: Past medical history Typical or atypical of prior presentations Is there a reason this presentation could be different than usual? Precipitating or exacerbating factors e.g. missed medications, dietary indiscretion, infection Corroborating findings on physical examination and testing Is the Dyspnoea… An exacerbation of a preexisting problem? 17 th South Zone PG Meet, August 30 & 31 TVPM

18. A combination of a new and chronic problem? - Recurrent disease Myocardial ischemia Pulmonary embolism Arrhythmia Multiple diseases conspiring together: Infection exacerbating Heart Failure Arrhythmia exacerbating Heart Failure Anemia exacerbating Cardiac Ischemia COPD complicated by pneumonia Keys to Diagnosis: Stable disease becoming unstable Findings consistent with multiple processes – e.g. fever and diffuse wheezing Is the Dyspnoea… 17 th South Zone PG Meet, August 30 & 31 TVPM

19. Pulmonary? – Airway: Asthma COPD Anaphylaxis Tracheal pathology Parenchymal (V/Q Mismatch): Pneumonia Pulmonary embolism Decreased Tidal Volume or Functional Residual Capacity: Pneumothorax Keys to Diagnosis: Abnormal breath sounds, I:E Ratio, Stridor Chest X- Ray Is the Dyspnoea… 17 th South Zone PG Meet, August 30 & 31 TVPM

20. Is the Dyspnea… Cardiac? Myocardial Ischemia Left Sided Dysfunction CHF Atrial Fibrillation Aortic stenosis or insufficiency Right Sided Dysfunction Pulmonary hypertension Sleep apnea Insufficient filling / preload Pericardial effusion / tamponade Keys to Diagnosis EKG Murmurs Bedside ECHO 17 th South Zone PG Meet, August 30 & 31 TVPM

21. Something else entirely? Neuromuscular disease Anemia Metabolic acidosis Toxic exposure Endocrine disorder Obesity/deconditioning Traumatic injury Abdominal distention Psychogenic Is the Dyspnoea… 17 th South Zone PG Meet, August 30 & 31 TVPM

22. Diagnoses to Consider e very t ime Myocardial Ischemia Pulmonary Embolism Infection/Sepsis Pericardial Tamponade Arrhythmia 17 th South Zone PG Meet, August 30 & 31 TVPM

23. Assessment of dyspnoea Listen/Observe What does it mean to the patient / carer? Onset Triggers / What eases it? Levels of significance – during activity/rest , in different positions. Pattern of breathing, colour, respiratory rate Are they anxious? Oxygen saturations 17 th South Zone PG Meet, August 30 & 31 TVPM

24. mMRC NYHA 17 th South Zone PG Meet, August 30 & 31 TVPM

25. Nearly All Patients: Pulse Oximetry Electrocardiogram Chest X- Ray Diagnostic tests 17 th South Zone PG Meet, August 30 & 31 TVPM

26. Select Patients Complete Blood Count Basic bioc hemistry Panel Arterial Blood Gas Peak Flow / Spirometry Cardiac Troponin Bedside Ultrasound D-dimer BNP Diagnostic Tests 17 th South Zone PG Meet, August 30 & 31 TVPM

27. Stepwise Diagnostic Algorithm Initial Step – History and Physical examination Guides entry into the algorithm. If H&P suggests a diagnosis → proceed directly to confirmatory testing. Always consider that multiple causes may coexist. 17 th South Zone PG Meet, August 30 & 31 TVPM

28. Tier I – Noninvasive Screening Tests Chest X-ray (CXR), Pulmonary Function Tests (PFTs), Blood tests (CBC,TFT,BNP etc.), ECG Helps to diagnose directly or indicate which subsequent tests are most useful. PFTs typically follow or accompany CXR unless cardiovascular or other non respiratory cause is suspected. 17 th South Zone PG Meet, August 30 & 31 TVPM

29. Tier II – Advanced Noninvasive Testing CPET (Cardiopulmonary Exercise Testing) : used if Tier I is nondiagnostic; helps distinguish circulatory vs respiratory limitations. Tier IIa – Noninvasive Cardiac Testing : echocardiogram, radionuclide ventriculography, stress testing, or Holter monitoring as indicated. 17 th South Zone PG Meet, August 30 & 31 TVPM

30. Tier III & IV – Directed High-Level Testing / Therapeutic Trial Tier III : targeted or invasive tests based on prior results to confirm etiology or assess severity. Tier IV : empiric therapeutic trial guided by objective findings (e.g., asthma trial after positive Broncho provocation challenge, CHF treatment after cardiac testing). Response to therapy can refine diagnosis or determine need for further testing 17 th South Zone PG Meet, August 30 & 31 TVPM

31. History Quality of sensation, timing, positional disposition Persistent vs. intermittent Physical examination General appearance : speak in full sentences? Accessory muscles? Color? Vitals : tachypnea? Pulsus paradox? Oximetry evidence of desaturation? Chest : wheezes, rales, rhonchi, diminished breath sounds? Hyperinflated? Cardiac exam : JVP elevated? Precordial impulse? Gallop? Murmur? Extremities : E dema? Cyanosis? At this point, diagnosis may be evident, if not Proceed for further evaluation Preliminary investigations CXR, ECG, PFT 17 th South Zone PG Meet, August 30 & 31 TVPM

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33. J Thorac Dis. 2019 Oct;11(Suppl 17):S2117–S2128 17 th South Zone PG Meet, August 30 & 31 TVPM

34. Key points Dyspnoea is a subjective experience influenced by complex interactions between the respiratory, cardiovascular and nervous systems. The initial consultation should focus on detailed history, physical examination and assessment tools to identify potential causes and the severity of dyspnoea . Pulmonary function tests and thoracic imaging are critical early investigations for diagnosing and characterizing lung diseases that cause dyspnoea . 17 th South Zone PG Meet, August 30 & 31 TVPM

35. Key points Dynamic tests, such as the 6MWT, dynamic expiratory phase CT or CPET can provide valuable data on the functional impact and underlying causes of unexplained dyspnoea When dyspnea persists despite optimal treatment of the underlying disease, treatment should focus on the symptom rather than the disease and particularly on the specific mechanisms contributing to an individual's dyspnoea 17 th South Zone PG Meet, August 30 & 31 TVPM

36. If you can't breath nothing else matters Thank you all