Dyspnea 2007

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.


More questions


Lab tests


Initial hypotheses



Observe results


Px DIES

Chronic Disease

Examine patient

PE

Refine hypotheses


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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are needed to see this picture.

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.


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Lab tests


Initial hypotheses



Observe results


Px DIES

Chronic Disease

Examine patient

PE

Refine hypotheses


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


More questions


Lab tests


Initial hypotheses



Observe results


Px DIES

Chronic Disease

Examine patient

PE

Refine hypotheses


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.


More questions


Lab tests


Initial hypotheses



Observe results


Px DIES

Chronic Disease

Examine patient

PE

Refine hypotheses




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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.



Inspection



Palpation



Percussion



Percussion



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



6060

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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Dyspnea 2007

Documents

normal dyspnea dyspnea

patient lab tests

critical care dyspnea

cause of dyspnea

dyspneic patient acquisition

episodes of dyspnea

pleasant breathing

breathing life