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; and
pulmonary 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
