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Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro
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Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Dec 19, 2015

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Page 1: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Approach to Dyspnea

Dr. Ghulam Hussain Baloch

Associate Professor of Medicine

LUMHS, Jamshoro

Page 2: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Definition

Awareness of his own breath

Page 3: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Hyperventilation Signing breath In ability to take deep breath

Page 4: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Orthopnea dyspnea on recumbence

Page 5: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaDefinitions Dyspnea of exertion (DOE)

Exertion-induced SOB

Orthopnea Recumbent-induced SOB

Paroxysmal nocturnal dyspnea (PND) Sudden SOB after recumbent

Page 6: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

PND (Cardiac Asthma)

Sever breathness at night relieved when patient sits up

Page 7: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1

73 y/o F presents to the ED with complaints of SOB for the last 2 days

Page 8: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 2

28 year male presented with high grade fever, cough on examination bronchial breathing

a) Diagnosis

b) Investigation & Mangement

Page 9: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaRapid Assessment ABC’s

Mental status

Presence of cyanosis

Page 10: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaInitial Interventions IV assess

Pulse oximetry; supplemental O2

Cardiac monitor

Page 11: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

What Are the Indications for Airway Management? Secure & maintain patency Protection

AMS or altered gag C-spine

Oxygenation Ventilation Treatment – Suction, medications

Page 12: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaHistory Prolonged questioning can be counterproductive

Yes/No questions if significantly dyspneic Unlike pain, severity of dyspnea = severity of disease

What does patient mean by SOB?

How long has SOB been present? Is it sudden or gradual

Does anything make it better or worse?

Page 13: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaHistory Has there been similar episodes?

Are there associated symptoms?

What is the past medical Hx? Smoking Hx? Medications?

Page 14: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Cause

Acute Bronchial asthma Pneumonia Pneumothorax thromboembolic disease Cardiac Pulmonary oedema Non cardiac pulmonary oedema psychogenic

Page 15: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Chronic

Pulmonary Cause1. COPD Chronic Bronchial Asthma Emphysema Chronic Bronchitis 2. Restrictive Lung Disease Sarcoidosis Rheumatoid lung fibrosing alveolitis Pneumoconosis

Page 16: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaEtiologies

75%

10% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Respiratory Cardiac Other

Page 17: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaEtiologies: Pulmonary Causes

Page 18: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaCommon Pulmonary Causes Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax

Page 19: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaDyspneaCommon Pulmonary Causes Obstructive lung disease

Asthma/COPD

Pneumonia

Pulmonary embolism

Pneumothorax

Page 20: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaEtiologies: Nonpulmonary Causes

Page 21: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaCommon Cardiac Causes Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease

Page 22: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaCommon Cardiac Causes Acute coronary syndromes

CHF

Dysrhythmias

Valvular heart disease

Page 23: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaCommon Miscellaneous Causes Metabolic acidemias

Severe anemia

Pregnancy

Hyperventilation syndrome

Page 24: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination: Vital Signs BP

if dyspnea significant = life-threatening problem

Pulse Usually Bradycardia - severe hypoxemia

Respiratory rate Sensitive indicator of respiratory distress DANGER = > 35-40 bpm or < 10-12 bpm

Page 25: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination: Observation

Ability to speak

Patient position

Cyanosis Central vs. peripheral (acrocyanosis)

Mental status Altered MS - hypoxemia/hypercapnia

Page 26: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination

Pulmonary Use of accessory muscles Intercostal retractions Abdominal-thoracic discoordination Presence of stridor

Cardiac Check neck for presence of JVD

Signs of severe respiratory distress

Page 27: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination: Pulmonary Inspection

Use of accessory muscles Splinting Intercostal retractions

Percussion Hyper-resonance vs. dullness Unilateral vs. bilateral

Page 28: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination: Pulmonary Auscultation

Air entry Stridor = upper airway obstruction

Breath sounds Normal Abnormal

Wheezing, rales, rhonchi, etc.

Unilateral vs. bilateral

Page 29: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaPhysical Examination: Cardiac Neck

? JVD

Auscultation Abnormal S2 splitting Present of S3 and/or S4 Rubs Murmurs

Page 30: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

What does clubbing suggest?

Chronic Hypoxemia

Page 31: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Pneumonia

1.Fever with chills2.Pleuratic chest pain3. purulent sputum4. History of upper respiratory symptoms 5.signs of consolidation 6.x-ray chest 7. CBC 8. Blood culture 9. ABG acute bronchial asthma age startedat

childhood

Page 32: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

2. Acute Bronchial Asthma

1.Age start in young age

2. Family History

3. H/O Allergic Rhinitis

4.Physical exam

5.barrel shape chest

6.X-ray chest

7. ABG

Page 33: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Pneumothorax

1.Suden chest pain

2. dyspnea,caugh

3. H/O asthma

4.COPD

5.Examination, trachea, shifted to opposite side

absent breath sound

6 x-ray chest

Page 34: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

3. Acute Pulmonary edema

a) Previous H/O Heart Disease b) Hyperthyroidism c) Rheumatic Heart disease (ms)Sign of LVFa) Tachycardia b) Pulses alternanc) Basal criptationd) ECG changee) X-ray Chest ( cardiomegaly)f) Echo

Page 35: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Pulmonary Embolism

a) History of prolonged remobilization b) pelvic surgery c) contraceptive pills d) cyanosis e) ECG f) x-ray chestg) ABGh) ECHOi) PIQ study

Page 36: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1History

Symptoms started 2 days ago Onset gradual and progressive Exertion makes it worse New onset (+) chest pain, cough, DOE, PND No past medical Hx No medications or smoking Hx

Page 37: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1Physical Examination Moderate respiratory distress, talks in partial

sentences, prefers to sit in ED cart BP = 190/110 mmHg; HR = 118 /min; RR =

36 bpm; afebrile; SpO2 = 85% HEENT: no angioedema Lungs: rales & wheezing bilaterally Cardiac: (+) JVD; (+) S3 Skin: no rashes Extremities: no edema

Page 38: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1

What are likely etiologies for this patient’s dyspnea?

Heart failure ? ACS

Page 39: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaDiagnostic Adjuncts What study will most patient’s with dyspnea

get?

CXR Indicated in most cases of dyspnea, especially new-

onset

Page 40: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1

Page 41: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaDiagnostic Adjuncts What other non-laboratory study would you

like?

ECG Indicated if cardiac etiology suspected or cardiac history

Page 42: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

Case 1

Page 43: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaDiagnostic Adjuncts

What lab tests might be useful in dyspnea workup? ABG

If any question about ventilatory or acid-base status Beware of interpretation of (A–a)O2

Troponin How would it be helpful in our patient?

B-type natriuretic protein (BNP) Laboratory studies based on suspected etiology

of dyspnea

Page 44: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaTreatment Cornerstone of Rx

Assuring oxygenation/ventilation Supplemental O2

PaO2 > 60 mm Hg; SpO2 > 90%

Specific Rx depends on working diagnosis

Page 45: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaSpecial Considerations: Pediatrics Common upper airway problems

Infection Croup Retropharyngeal abscess Epiglottitis

Foreign body aspiration

Page 46: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaSpecial Considerations: Pediatrics Common lower airway problems

Anaphylaxis Asthma Bronchiolitis Bronchopulmonary dysplasia Cystic fibrosis Foreign body aspiration Pneumonia

Page 47: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

DyspneaSpecial Considerations: Pregnant Patient Venous thrombosis/pulmonary embolism

3/1000 pregnancis Risk continues to the postpartum period Heparin outpatient treatment of choice

Asthma Rule of 1/3 Rx same as non-pregnant patient

Pulmonary edema Preeclampsia Postpartum cardiomyopathy

Page 48: Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro.

CaseConclusion Diagnosis = CHF & subacute MI

Treatment IV nitroglycerin IV furosemide

Reassessment – much improved