Dyspnea

1. Dyspnea Victor Politi, M.D., FACP Medical Director, St. Anthony’s School of Allied Health Professions, Physician Assistant Program

3. Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.

4. Dyspnea - common complaint/symptom • “shortness of breath” or “breathlessness” • Defined as abnormal/uncomfortable breathing • Multiple etiologies - • 2/3 of cases - cardiac or pulmonary etiology

5. There is no one specific cause of dyspnea and no single specific treatment • Treatment varies according to patient’s condition • chief complaint • history • exam • laboratory & study results

6. Differential Diagnosis • Composed of four general categories • Cardiac • Pulmonary • Mixed cardiac or pulmonary • non-cardiac or non-pulmonary

7. Pulmonary Etiology • COPD • Asthma • Restrictive Lung Disorders • Hereditary Lung Disorders • Pneumonia • Pneumothorax

8. Cardiac Etiology • CHF • CAD • MI (recent or past history) • Cardiomyopathy • Valvular dysfunction • Left ventricular hypertrophy • Pericarditis • Arrhythmias

9. Mixed Cardiac/Pulmonary Etiology • COPD with pulmonary HTN and/or cor pulmonale • Deconditioning • Chronic pulmonary emboli • Pleural effusion

10. Noncardiac or Nonpulmonary Etiology • Metabolic conditions (e.g. acidosis) • Pain • Trauma • Neuromuscular disorders • Functional (anxiety,panic disorders, hyperventilation) • Chemical exposure

11. Easily Performed Diagnostic Tests • Chest radiographs • Electrocardiograph • Screening spirometry

12. In cases where test results inconclusive • complete PFTs • ABGs • EKG • Standard exercise treadmill testing/ or complete cardiopulmonary exercise testing • Consultation with pulmonologist/cardiologist may be useful

13. ABGs • Commonly used to evaluate acute dyspnea • can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia • normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea • Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing

14. PULSE OX • Rapid, widely available, noninvasive means of assessment in most clinical situations- • insensitive (may be normal in acute dyspnea) • The % of Oxygen saturation does not always correspond to PaO2 • The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels

15. ASTHMA

16. What is Asthma • A Chronic disease of the airways that may cause: • Wheezing • Breathlessness • Chest tightness • Nighttime or early morning coughing

19. The bronchospasm characteristic of the acute asthmatic attack is typically reversible. It improves spontaneously or within minutes to hours of treatment

20. Asthma can exist by itself or coexist with chronic bronchitis, emphysema, or bronchiectasis

21. Symptoms/Chief Complaint • Progressive dyspnea • Cough • Chest tightness • Wheezing/coughing

22. The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction

23. Focus of Therapy • Pharmacologic manipulation of airway smooth muscle • Do not overlook physiologic impairment caused by mucous production and mucosal edema • Bronchospasm can be reversed in minutes • Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - • may lead to atelectasis, infectious bronchitis, pneumonitis

24. Asthma Triggers • Immunologic reaction • Viral respiratory/sinus infections • change in temperature/humidity • Drugs/Chemicals - • aspirin, NSAIDS • Exercise • GE reflux • Laughing/coughing • Environmental factors - • strong odors, pollutants, dust, fumes

25. Patient Exam • Wheezing • may be audible w/o stethoscope • Use of accessory muscles of inspiration • diaphragmatic fatigue • Paradoxical respirations • - reflect impending ventilatory failure • Altered mental status - • lethargy, exhaustion, agitation, confusion

26. Patient Exam • Hypersonance to percussion • decreased intensity of breath sounds • prolongation of expiratory phase w or w/o wheezing

27. Patient Exam • The intensity of the wheeze may not correlate with the severity of airflow obstruction • “quiet chest” - very severe airflow obstruction

28. Asthma Treatment • Nebulized B-adrenergic drugs • Corticosteroids • Nebulized anticholinergics • Magnesium sulfate • Oxygen • Long acting beta-agonists • Inhaled steroids

29. Managing Asthma: • Indications of a severe attack: • Breathless at rest • hunched forward • talking in words rather than sentences • Agitated • Peak flow rate less than 60% of normal

30. Treatment Goals of Severe Asthma • Improve airway function rapidly • Avoid hypoxemia • Prevent respiratory failure and death

31. COPD

32. COPD • Hallmark symptom - Dyspnea • Chronic productive cough • Minor hemoptysis • pink puffer • blue bloater

33. COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat.

34. COPD - Physical Findings • Tachypnea • Accessory respiratory muscle use • Pursed lip exhalation • Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing

36. Dominant Clinical Forms of COPD • Pulmonary emphysema • Chronic bronchitis • Most patients exhibit a mixture of symptoms and signs

37. COPD - Advanced Dx • secondary polycythemia • cyanosis • tremor • somnolence and confusion due to hypercarbia • Secondary pulmonary HTN w or w/o cor pulmonale

38. COPD Treatment Strategy • Elimination of extrinsic irritants • bronchodilator & glucocorticoid therapy • Antibiotics • Mobilization of secretions • “respiratory vaccines” • Oxygen therapy - if oxygen saturation <90% at rest on room air

39. Spirometry

41. PNEUMONIA

42. 6th leading cause of death in the US • Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases

43. Common types of respiratory infections • Tracheobronchitis • Pneumonia • Effusions • Empyema • Abscess • Cavitary lesions • post-obstructive

44. Common Respiratory Viruses • Influenza A & B • Parainfluenza 1& 3 • Respiratory Syncytial Virus • Adenovirus • Cytomegalovirus • Herpes Simplex & Zoster/varicella • Hanta Virus Infection

45. Respiratory Syncytial Virus • Rapid diagnosis of Respiratory Syncytial Virus Infection by immunofluorescence of respiratory secretions

46. Classic Pneumonia Symptoms • Dyspnea, chills • high fever, cough/sputum • pleuritic chest pain

47. Viral Pneumonia - symptoms • Chest Pain • Fever • Dyspnea • Prodrome - malaise, upper respiratory symptoms, and other GI symptoms

48. Viral pneumonia - Clinical Findings • Minimal/variable • Chest exam - may reveal wheezing • Fine rales if heard can signify interstitial involvement • Chest x-ray - patchy densities or interstitial involvement

49. Viral pneumoniaManagement /Prophylaxis • Supportive treatment - decrease severity of symptoms • bed rest • analgesics • expectorants • Patients w/ • airway obstruction - treat w/bronchodilators • secondary bacterial infection - antibiotics

50. Atypical Pneumonia • Accounts for 25% of community acquired pneumonias • Mycoplasma/chlamyda/legionella • can case extrapulmonary manifestations - • meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia • typically bilateral infiltrates on chest x-ray • primarily effects younger persons