Dr. Ghulam Hussain Baloch Associate Professor of Medicine Approach to Dyspnea Dr. Ghulam Hussain Baloch Associate Professor of Medicine LUMHS, Jamshoro

Definition Awareness of his own breath

Hyperventilation Signing breath In ability to take deep breath

Orthopnea dyspnea on recumbence

Dyspnea Definitions Dyspnea of exertion (DOE) Orthopnea Exertion-induced SOB Orthopnea Recumbent-induced SOB Paroxysmal nocturnal dyspnea (PND) Sudden SOB after recumbent

PND (Cardiac Asthma) Sever breathness at night relieved when patient sits up

Case 1 73 y/o F presents to the ED with complaints of SOB for the last 2 days

Case 2 28 year male presented with high grade fever, cough on examination bronchial breathing Diagnosis Investigation & Mangement

Dyspnea Rapid Assessment ABC’s Mental status Presence of cyanosis

Dyspnea Initial Interventions IV assess Pulse oximetry; supplemental O2 Cardiac monitor

What Are the Indications for Airway Management? Secure & maintain patency Protection AMS or altered gag C-spine Oxygenation Ventilation Treatment – Suction, medications

Dyspnea History Prolonged questioning can be counterproductive Yes/No questions if significantly dyspneic Unlike pain, severity of dyspnea = severity of disease What does patient mean by SOB? How long has SOB been present? Is it sudden or gradual Does anything make it better or worse?

Dyspnea History Has there been similar episodes? Are there associated symptoms? What is the past medical Hx? Smoking Hx? Medications?

Cause Acute Bronchial asthma Pneumonia Pneumothorax thromboembolic disease Cardiac Pulmonary oedema Non cardiac pulmonary oedema psychogenic

Chronic Pulmonary Cause 1. COPD Chronic Bronchial Asthma Emphysema Chronic Bronchitis 2. Restrictive Lung Disease Sarcoidosis Rheumatoid lung fibrosing alveolitis Pneumoconosis

Dyspnea Etiologies

Dyspnea Etiologies: Pulmonary Causes

Dyspnea Common Pulmonary Causes Obstructive lung disease Asthma/COPD Pneumonia Pulmonary embolism Pneumothorax

Dyspnea Common Pulmonary Causes Obstructive lung disease Asthma/COPD Pneumonia Pulmonary embolism Pneumothorax

Dyspnea Etiologies: Nonpulmonary Causes

Dyspnea Common Cardiac Causes Acute coronary syndromes CHF Dysrhythmias Valvular heart disease

Dyspnea Common Cardiac Causes Acute coronary syndromes CHF Dysrhythmias Valvular heart disease

Dyspnea Common Miscellaneous Causes Metabolic acidemias Severe anemia Pregnancy Hyperventilation syndrome

Dyspnea Physical Examination: Vital Signs BP  if dyspnea significant  = life-threatening problem Pulse Usually  Bradycardia - severe hypoxemia Respiratory rate Sensitive indicator of respiratory distress DANGER = > 35-40 bpm or < 10-12 bpm

Dyspnea Physical Examination: Observation Ability to speak Patient position Cyanosis Central vs. peripheral (acrocyanosis) Mental status Altered MS - hypoxemia/hypercapnia

Dyspnea Physical Examination Pulmonary Use of accessory muscles Intercostal retractions Abdominal-thoracic discoordination Presence of stridor Cardiac Check neck for presence of JVD Signs of severe respiratory distress

Dyspnea Physical Examination: Pulmonary Inspection Use of accessory muscles Splinting Intercostal retractions Percussion Hyper-resonance vs. dullness Unilateral vs. bilateral

Dyspnea Physical Examination: Pulmonary Auscultation Air entry Stridor = upper airway obstruction Breath sounds Normal Abnormal Wheezing, rales, rhonchi, etc. Unilateral vs. bilateral

Dyspnea Physical Examination: Cardiac Neck ? JVD Auscultation Abnormal S2 splitting Present of S3 and/or S4 Rubs Murmurs

What does clubbing suggest? Chronic Hypoxemia

Pneumonia 1.Fever with chills 2.Pleuratic chest pain 3. purulent sputum 4. History of upper respiratory symptoms 5.signs of consolidation 6.x-ray chest 7. CBC 8. Blood culture 9. ABG acute bronchial asthma age startedat childhood

2. Acute Bronchial Asthma 1.Age start in young age 2. Family History 3. H/O Allergic Rhinitis 4.Physical exam 5.barrel shape chest 6.X-ray chest 7. ABG

Pneumothorax 1.Suden chest pain 2. dyspnea,caugh 3. H/O asthma 4.COPD 5.Examination, trachea, shifted to opposite side absent breath sound 6 x-ray chest

3. Acute Pulmonary edema Previous H/O Heart Disease Hyperthyroidism Rheumatic Heart disease (ms) Sign of LVF Tachycardia Pulses alternan Basal criptation ECG change X-ray Chest ( cardiomegaly) Echo

Pulmonary Embolism History of prolonged remobilization pelvic surgery contraceptive pills cyanosis ECG x-ray chest ABG ECHO PIQ study

Case 1 History Symptoms started 2 days ago Onset gradual and progressive Exertion makes it worse New onset (+) chest pain, cough, DOE, PND No past medical Hx No medications or smoking Hx

Case 1 Physical Examination Moderate respiratory distress, talks in partial sentences, prefers to sit in ED cart BP = 190/110 mmHg; HR = 118 /min; RR = 36 bpm; afebrile; SpO2 = 85% HEENT: no angioedema Lungs: rales & wheezing bilaterally Cardiac: (+) JVD; (+) S3 Skin: no rashes Extremities: no edema

Case 1 What are likely etiologies for this patient’s dyspnea? Heart failure ? ACS

Dyspnea Diagnostic Adjuncts What study will most patient’s with dyspnea get? CXR Indicated in most cases of dyspnea, especially new-onset

Case 1

Dyspnea Diagnostic Adjuncts What other non-laboratory study would you like? ECG Indicated if cardiac etiology suspected or cardiac history

Case 1

Dyspnea Diagnostic Adjuncts What lab tests might be useful in dyspnea workup? ABG If any question about ventilatory or acid-base status Beware of interpretation of (A–a)O2 Troponin How would it be helpful in our patient? B-type natriuretic protein (BNP) Laboratory studies based on suspected etiology of dyspnea

Dyspnea Treatment Cornerstone of Rx Assuring oxygenation/ventilation Supplemental O2 PaO2 > 60 mm Hg; SpO2 > 90% Specific Rx depends on working diagnosis

Dyspnea Special Considerations: Pediatrics Common upper airway problems Infection Croup Retropharyngeal abscess Epiglottitis Foreign body aspiration

Dyspnea Special Considerations: Pediatrics Common lower airway problems Anaphylaxis Asthma Bronchiolitis Bronchopulmonary dysplasia Cystic fibrosis Foreign body aspiration Pneumonia

Dyspnea Special Considerations: Pregnant Patient Venous thrombosis/pulmonary embolism 3/1000 pregnancis Risk continues to the postpartum period Heparin outpatient treatment of choice Asthma Rule of 1/3 Rx same as non-pregnant patient Pulmonary edema Preeclampsia Postpartum cardiomyopathy

Case Conclusion Diagnosis = CHF & subacute MI Treatment IV nitroglycerin IV furosemide Reassessment – much improved