Transcript
Dyspnea: The Dyspnea: The Pulmonary Pulmonary PerspectivePerspective
Section of Pulmonary and Section of Pulmonary and Critical CareCritical Care
DYSPNEA: Breathing Life into a Complex Symptom
Maria Piedad Rosales – Natividad, MD and Patrick Gerard L, Moral, MD Section of Pulmonary and Critical Care Medicine
Department of Medicine, UST Faculty of Medicine and Surgery
Definition• “a person’s uncomfortable sensation
associated with breathing”• a perception by the individual and is entirely
subjective• not a clinical observation, nor does it relate
directly to any physiological or laboratory test• the patient’s interpretation of a reduction in
pleasant breathing.
Frontline Cardiopulmonary Topics / Dyspnea,2001*
OBJECTIVES• review the different pathophysiologic events• integrate subjective and objective data in
order to come up with a logical diagnosis of the cause of dyspnea
• select and prioritize ancillary procedures in the diagnosis and management of the disease
• apply basic pharmacologic and non-pharmacologic therapy based on etiopathogenesis of the disease
Evaluation of the Dyspneic Patient
• acquisition of a detailed history describing the conditions under which the patient has been or is currently experiencing dyspnea
• a physical examination• a chest radiograph• measurements of pulmonary mechanics
Frontline Cardiopulmonary Topics / Dyspnea,2001*
Patient presents with dyspnea
More questions
ECG, etc. Radiologic studies
Lab tests
Ask questionsID, CC, HPI
Initial hypotheses
Select most likely diagnosis
Treat patient accordingly
Observe results
Px is better; no further care
Px DIES
Chronic Disease
Examine patient
PE
Refine hypotheses
HPI, PMH, FH. Social, ROS
Once an emergent situation has been excluded, the patient's airway, mental status, ability to speak, and breathing effort should be reevaluated. A focused history should be obtained, and a physical examination completed.
Patient presents with dyspnea
More questions
ECG, etc. Radiologic studies
Lab tests
Ask questionsID, CC, HPI
Initial hypotheses
Select most likely diagnosis
Treat patient accordingly
Observe results
Px is better; no further care
Px DIES
Chronic Disease
Examine patient
PE
Refine hypotheses
HPI, PMH, FH. Social, ROS
Listening to the Patient
•Getting to know the patient•Characterizing the symptom•Understanding its effects on the patient•Achieving a common perception of the problem
Getting to know the patient• Name• Age• Sex• Race / Nationality / Ethnicity• Civil Status• Occupation• Residence• Religion
Communication
Hingal
Kapos ng hininga
Hinahapo
sumisikip ang dibidib
Nasasakal
Are all episodes of dyspnea pathologic?
yes no
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Normal Dyspnea
• Dyspnea may occur normally in states of intense exercise, such as running, mountain climbing, lifting, rowing, and swimming, where the stress of breathing is a direct result of intense physical effort and not a consequence of cardiopulmonary or metabolic disorder.
Key Questions
• Quality (description, progression) • Location / Radiation• Severity (bearable, intolerable)• Timing /Duration (acute, chronic)• Setting• Precipitating (body positions, exposures) Palliating (body positions, medications)• Associated symptoms (chest pain, cough)
Quality• I feel that I am
suffocating• My chest feels tight• My breathing is heavy• I feel that I am
smothering• My breath does not go in
all the way• My breath does not go
out all the way• I feel that I am breathing
more
•My breathing requires effort•I cannot get enough air•I feel a hunger for air•My breathing is shallow•I feel out of breath•My chest is constricted•My breathing requires work
CHEST 2000; 118:679–690
Severity
• The usual technique is to determine the amount of effort required to bring on dyspnea. – How far can the patient walk, at a normal pace (in meters)
before stopping due to shortness of breath? – Can the patient walk uphill? – How many flights of stairs can the patient climb? – In conversation, can the patient finish a sentence (or word)
without taking a breath? – During telephone conversations, does the patient notice
shortness of breath?
• These questions should be asked at each visit to assess symptom progression or improvement.
Visual Analogue Scale
100 mm line
No shortness of breath
Shortness of breath as bad as can be
Borg Scale0 - Nothing at all 0.5 - Very, very slight 1 - Very slight 2 - Slight 3 - Moderate 4 - Somewhat severe 5 - Severe 6 - 7 - Very Severe 8 - 9 - Very, very severe 10 - Maximal
Timing
• Onset of dyspnea: recent or remote, • Has there been a recent change in
severity? • Acute, subacute, or chronic• Recurrent or continuous
Time Course
Setting - Precipitating
Palliating
Associated Symptoms
Associated Symptoms
Key Questions• Cardiac questions
– presence or absence of chest pain, orthopnea, paroxysmal nocturnal dyspnea (PND), edema, weight gain, and any cardiac medications or cardiac diagnoses of the patient.
• Pulmonary questions– presence or absence of wheezing, chest tightness,
cough, sputum production, pleuritic pain, sleep patterns (apneas), and a history of tobacco smoking
• Other – history of cirrhosis, renal insufficiency, anemia, or
endocrine abnormalities, all of which can be quickly reviewed.
Patient presents with dyspnea
More questions
ECG, etc. Radiologic studies
Lab tests
Ask questionsID, CC, HPI
Initial hypotheses
Select most likely diagnosis
Treat patient accordingly
Observe results
Px is better; no further care
Px DIES
Chronic Disease
Examine patient
PE
Refine hypotheses
HPI, PMH, FH. Social, ROS
PULMONARY
Afferent and Efferent Signals
Manning HL, Schwartzstein, RM. Mechanisms of disease: Pathophysiology of dyspnea. New Engl J Med. 1995;
Ventilatory Control
Neurogenic Factors
Chemical Stimuli
Voluntary Control anxiety / hysteria
Respiratory Center stimulated by increase PaCO2 and H+
Carotid and Aortic Bodies stimulated by increase PaO2 < 8kPa
cortex
Chest wall receptors
Pulmonary receptors sensitive to stretch and bronchial irritation (stimulated in asthma, pulmonary embolism and pneumonia)
Juxta capillary (J) receptors stimulated by pulmonary congestion (heart failure)
Muscle and joint receptors stimulated by exercise
Dyspnea
• The work of breathing must be appropriate to the task and in the context of the resultant cardiovascular and respiratory responses.
respiratory drives
cardiopulmonarysystem response
respiratory drives
cardiopulmonarysystem response
Pulmonary SourcesRespiratory work major components: 1. resistive load
– the resistance of moving air through the airways
2. elastic load– the load imposed by
elasticity and recoil of the lungs, thorax, and respiratory musculature
obstructive
restrictive
vascular
Restrictive
Obstructive
Vascular
• VentilationVentilation• No perfusionNo perfusion
Embolus
Migration
Thrombus
Gas Diffusion
• Thickness of membraneThickness of membrane• Surface area of Surface area of
membranemembrane• Diffusion coefficient of Diffusion coefficient of
gasgas• CO driving pressureCO driving pressure• RBC volumeRBC volume• Rate of reaction of Hgb Rate of reaction of Hgb
and COand CO
O2O2O2
Patient presents with dyspnea
More questions
ECG, etc. Radiologic studies
Lab tests
Ask questionsID, CC, HPI
Initial hypotheses
Select most likely diagnosis
Treat patient accordingly
Observe results
Px is better; no further care
Px DIES
Chronic Disease
Examine patient
PE
Refine hypotheses
HPI, PMH, FH. Social, ROS
Additional Data• Past Medical History
– Immunizations, past ailments, allergies• Family History
– Pedigree chart, household contacts• Social History
– Smoking (pack years); substance abuse• Occupational History
– Present and previous employment• Review of Systems
– All other symptoms not referable to the pulmonary system
Tobacco Use
• Pack-Year History– Pack/s of cigarettes per day x number of
years– One pack: 20 cigarettes– Ex-smoker; Still smoking?– Practices: (Ilocos – placing the lit end in
the mouth)• Environmental tobacco smoke
(Passive smoking)• Other tobacco products
Historical Data
C.O. complains of shortness of breath
General Data
Chief Complaint
History
Social/ Family/ Past Medical/OccupationalReview of Systems
Dyspnea
General Data: •42, male – cardiac, pulmonary•asian – if pulmonary, not cystic fibrosis or alpha-1 antitrypsin deficiency•politician – cardiac•Pampanga – volcanic dust exposure?
History: •progressive – cardiac, pulmonary (COPD)?•worsened with dust and heat – asthma / COPD•relieved by salbutamol– asthma, / COPD•episodic/ at rest– asthma/ COPD/ cardiac/ embolism
Dyspnea
Additional history: •smoker – cardiac, pulmonary (STOP!)
•Family hx – (+) asthma; PTB less likely
•obesity – cardiac, restrictive lung, embolism
•hypertension– cardiac; medication exacerbates asthma
•Pain reliever– drug allergy (ask about dyspnea occurring with drug intake)
•Politician – no other occupational risks
Dyspnea
Review of Systems: •Weight gain – hypothyroid; familial;
anxiety
•Morning nasal stuffiness – rhinitis
•Morning headaches– sleep apnea•Daytime somnolence– sleep apnea;
work related•Cold intolerance – hypothyroidism
•Knee pains – osteorathritis•Epigastric pain – peptic ulcer; reflux; NSAID
•Edema – cardiac, obesity; DVT; cor pulmonale
Differential Diagnosis•Cardiac – Coronary Artery Disease–Dyspnea – congestive heart failure•Bronchial asthma or COPD–Dyspnea – obstructive lung disease•Obesity ( familial or due to hypothyroidism)–Dyspnea - restricitive•Deep venous thromboses > embolism–Dyspnea - vascular•Anxiety–Dyspnea - psychogenic
Anxiety symptoms may imply psychogenic causes of dyspnea, but organic etiologies always should be considered first.
Patient presents with dyspnea
More questions
ECG, etc. Radiologic studies
Lab tests
Ask questionsID, CC, HPI
Initial hypotheses
Select most likely diagnosis
Treat patient accordingly
Observe results
Px is better; no further care
Px DIES
Chronic Disease
Examine patient
PE
Refine hypotheses
HPI, PMH, FH. Social, ROS
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Initial Assessment of Patients with Dyspnea• Assess airway patency and listen to the
lungs.• Observe breathing pattern, including use
of accessory muscles.• Monitor cardiac rhythm.• Measure vital signs and pulse oximetry.• Obtain any history of cardiac or pulmonary
disease, or trauma.• Evaluate mental status.
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Inspection
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Palpation
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Percussion
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Percussion
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Physical Examination
INSPECTION (trachea)
PALPATION
PERCUSSION
AUSCULTATION
Pneumonia Effusion Pneumothorax Atelectasis
Normal (midline)
Lagging (contralateral)
Lagging (contralateral)
Lagging (ipsilateral)
Inc. fremiti Dec. fremiti Dec. fremiti Dec. fremiti
Dullness Dullness DullnessHyperresonance
Inc. BS Dec. BS Dec. BS Dec. BS
Communicating with the patient
•Give reassurance•Address the needs of the patient while taking your history•Assure the patient of your availability •Emphasize the partnership in treatment
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General Data
•C.O.•42 year old •Male•Married (one wife)•Asian - Filipino•Government worker•Pampanga•Roman Catholic
History
•1 year before admission, he developed shortness of breath upon walking 100 meters. It would be worsened by dust exposure and heat.This would partly be relieved by intake of salbutamol by inhaler.
History
•1 month before admission, he would experience dyspnea after walking 10 meters. He had occasional cough, with occasional increases in severity of the shortness of breath even at rest that would resolve spontaneously. Wheezing would occasionally be heard.
Additional Data•Past Medical History–No vaccination–Obesity - sibutramine–Hypertension on metoprolol–Osteoarthritis – on celecoxib•Family History–(+) asthma – father; (-) PTB; Obesity – parents and siblings•Social History–20 pack years smoker until now•Occupational History–Politician; no previous job
Review of Systems•100 lbs weight gain in 2 years•Morning headaches•Daytime somnolence•Cold intolerance•Morning nasal stuffiness•Epigastric pain•Knee pains•Edema of both lower extremities with discoloration
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