Pulmonary Medicine Department Dyspnea Pulmonary Medicine Department Ain Shams University http://telemed.shams.edu.eg/moodle5

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

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

Factors contribute to the production of dyspnea Increase in the work of breathing Airway obstruction  pulmonary compliance Restricted chest expansion Increase in pulmonary ventilation  Dead space Severe hypoxemia Metabolic acidosis Hyperventilation syndrome Weakens of the respiratory muscles Multiple factors

Dyspnea How short of breath is the patient? Grade When does it comes? Exertional/ Rest Does it comes in attack? Paroxysmal Does he have attacks of breathlessness at night? Does he have to sit up or can he sleep lying down? Orthopnea

Dyspnea Exertional Paroxysmal Mild, moderate or severe. Paroxysmal Cardiac / bronchial asthma Others?(e.g. Carcinoid, Uremic asthma) Orthopnea (advanced CHF, COPD or asthma- massive ascites, late months of pregnancy) At rest

American Thoracic Society Grade of Breathlessness Scale Degree Description None Not troubled with breathlessness except with strenuous exercise. 1 Slight Troubled by shortness of breath when hurrying on level ground or walking up a slight hill. 2 Moderate Walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at own pace on level ground. 3 Severe Stops for breath after walking approximately 100 yards or after a few minutes on level ground. 4 Very Severe Too breathless to leave the house or breathless when dressing and undressing.

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

Pulmonary Etiology COPD Asthma Restrictive Lung Disorders Pneumonia Pneumothorax Pulmonary embolism

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

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

Asthma Cardiac Bronchial Age History Time of attack Duration Usually old Usually young History Cardiac disease Chest disease Time of attack 2 hours after sleep Early morning Duration Minutes Up to hours Expectoration Minimal, but if APO occurs pink frothy Viscid mucoid (mucous pellet) O/E ± Valve lesion Fine basal crepitations ± Wheezes Inspiratory + expiratory sibilant ronchi TTT Diuretics Bronchodilators

Non cardiac or Non pulmonary Etiology Metabolic conditions (e.g. acidosis) Pain Trauma Neuromuscular disorders Functional (anxiety, panic disorders, hyperventilation) Chemical exposure

Dyspnea Acute onset Dyspnea (1-2 hours) Pneumothorax Asthma Pulmonary embolism APO FB

Dyspnea of slow onset Wheeze Interstitial lung disease Bronchiectasis No Wheeze Occupational history ± Crackles ++ ± Pleurisy ± Hemoptysis Sputum++ ± Sputum Smoker Atopic? Interstitial lung disease Bronchiectasis Pulmonary embolism Asthma Pneumoconiosis COPD

Easily Performed Diagnostic Tests Chest radiographs Electrocardiograph Screening spirometry

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

ASTHMA  Work of breathing Hypoxemia

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

COPD Airway obstruction pulmonary compliance  Dead space  Work of breathing Airway obstruction pulmonary compliance  pulmonary ventilation  Dead space Severe hypoxemia

Dominant Clinical Forms of COPD Pulmonary emphysema Chronic bronchitis

Pneumothorax  pulmonary ventilation  Dead space Severe hypoxemia

Pulmonary Embolism Dead space (V/Q mismatch) →  pulmonary ventilation

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