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L 5.approach to dyspnea

Jan 26, 2017

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  • Approach to Dyspnea

    Dr.Bilal Natiq Nuaman,MD C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.Lecturer in Iraqia Medical College 2016-2017

  • Dyspnea; Breathlessness; Shortness of Breath(SOB) Dyspnea

    Dys: difficult, painful Pneumea:breath

    Breathlessness or dyspnea can be defined as the feeling of an uncomfortable need to breathe.

  • DEFINITION OF DYSPNEA

    Clinical : A subjective experience of breathing discomfort that consists of (qualitatively) distinct sensations that vary in intensity.

    Physiological: The stimulation of pulmonary and extra pulmonary afferent receptors and the transmission of afferent information to the cerebral cortex, where the sensation is perceived as uncomfortable or unpleasant

  • Patients perceptions:

    Unsatisfied inspiration

    Chest tightness

    Sensation of feeling breathless

    Cannot get enough air

    Hunger for air

    Incomplete exhalation

  • Pathophysiology :

    Respiratory diseases

    stimulating intrapulmonary sensory nerves (e.g. Pneumothorax,interstitial inflammation and pulmonary embolus)

    increasing the mechanical load on the respiratory muscles (e.g.airflow obstruction or pulmonary fibrosis)

    Causing hypoxia, hypercapnia or acidosis, stimulating

    can stimulate breathing and dyspnea by:

    interstitial inflamm

    airflow obstruction

    chemoreceptors.

  • Common Pulmonary Causes Obstructive lung disease

    Asthma/COPD (Chronic Bronchitis ,Emphysema)

    Pneumonia

    Pulmonary embolism

    Pneumothorax

  • cardiac failure can stimulate breathing and dyspnea by:

    pulmonary congestion reduces lung compliance and can also obstruct the small airways.

    In addition, during exercise, reduced cardiac output limits oxygen supply to the skeletal muscles, causing early lactic acidaemia and further stimulating breathing via the central chemoreceptors.

  • Common Cardiac Causes Acute coronary syndromes

    CHF

    Dysrhythmias

    Valvular heart disease

  • Stages of dyspnea

    1-EXERTIONAL DYSPNEA- DYSPNEA DUE TO EXERCISE

    2-ORTHOPNEA SOB LYING FLAT AND BETTER SITTING UP (CHF, pregnancy, resp.muscle weakness)

    3-PND - PAROXYSMAL NOCTURNAL DYSPNEA characterized by acute shortness of breath almost always

    accompanied by coughing and wheezing. This respiratory distress usually occurs when a person is already sleep in a reclining position (HEART FAILURE-early night , ASTHMA-late night )

    4-RESTING DYSPNEA- DYSPNEA AT REST

  • Common Miscellaneous Causes Metabolic acidosis

    Severe anemia

    Pregnancy

    Hyperthyroidsm

    Hyperventilation syndrome

  • Differential diagnosis of dyspnea Patients with breathlessness present either with

    Chronic exertional dyspnea Or Acute dyspnea, when symptoms are prominent even at rest.

  • Chronic: Dyspnea >30 days that develops over weeks, months or years. COPD Left ventricular failure Lung fibrosis Asthma (uncontrolled) Pleural effusion

  • The following should be assessed and documented:Clinical assessment

    1- level of consciousness

    2-degree of central cyanosis

    3-evidence of anaphylaxis (urticaria or angioedema)

    4-patency of the upper airway

    5-ability to speak (in single words or sentences)

    6-cardiovascular status (heart rate and rhythm, blood pressure and degree of peripheral perfusion).

  • Pulmonary oedema is suggested by pink, frothy sputum and

    asthma or COPD by wheeze and prolonged expiration;pneumothorax by a silent resonant hemithorax; andpulmonary embolus by severe breathlessness with normal

    Leg swelling may suggest cardiac failure or, if asymmetrical,venous thrombosis causing pulmonary embolism.

    Urgent endotracheal intubation may become necessary if the

    bi-basal crackles;

    breath sounds.

    Arterial blood gases, a chest X-ray and an ECG should be obtained to confirm the clinical diagnosis, and high concentrations of oxygen given pending results.

    conscious level declines or if severe respiratory acidosis is present.

  • Physical signs in dyspnic patient

  • Investigations

    Chest radiograph (CXR): weather cardiac or pulmonary

    Cardiac Causes! Pulmonary causes! ECG Pulmonary function test(PFT)

    (abnormally significant) (abnormally significant)

    Echo CT scan of chest (abnormally significant) (abnormally significant)

    Coronary angiography Lung Biopsy

  • CXR

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