1. ASSITANT PROFESSOR EAST MEDICAL WARD MAYO HOSPITAL,LAHORE
DR.IMRAN MEHFOOZ KHAN
ASSITANT PROFESSOR
EAST MEDICAL WARD
MAYO HOSPITAL,LAHORE

2. Breathlessness (LVF)

3. Case history
A 70 years old lady presented with the complaint of shortness of breath for the last 6 months. This complain has been progressive . Initially breathlessness was on exertion only but now she feels breathless on lying in bed without three pillows . She also wakes up from sleep a number of times at night.
She lives on second floor and has to climb a flight of 10 stairs . Recently she has started to experience chest discomfort along with breathlessness.
WHAT IS THE DIAGNOSIS?

4. Heart failure
Heart failure is a complex syndrome resulting from structural or functional cardiac disorder that impairs the ability of heart to act as a pump to support physiologic circulation and is characterized by symptoms such as breathlessness and fatigue and signs of fluid retention.
Symptoms;
left ventricular failure (LVF) may result in dyspnea ,orthopnea , paroxysmal nocturnal dyspnea , nocturnal cough or fatigue.
Signs;
Hypotension
Tachycardia
Third heart sound
Edema
Bibasal crepitations/crackles

5. NYHA classification of heart failure
Class 1 – no limitations
Class 2 – slight limitation of physical activity
Class 3 – marked limitation of physical activity
Class 4 – symptoms at rest

6. Definitions Breathlessness/dyspnea;
Undue awareness of breathing . It is normal with strenuous physical exercise.
Hypoapnea;
Shallow breathing or low respiratory rate.
Orthopnea;
Breathlessness on lying flat.
Paroxysmal nocturnal dyspnea;
Breathlessness that wakes up the patient from sleep.
Tachypnea;
Increased rate of breathing.
Hyperventilation;
Inappropriate overbreathing

7. History Mode of onset Duration Progression Variability
Aggravating /relieving factors
Severity
Associated symptoms

8. Mode of onset , duration and progression of breathlessness
In minutes;
Pulmonary thromboembolism
Pneumothorax
Acute pulmonary edema
Acute attack of asthma
Inhaled foreign body
In hours/day;
Pneumonia
Exacerbation of COPD

9. Mode of onset , duration and progression of breathlessness
Weeks to months;
Pleural effusion
Anemia
Pulmonary tuberculosis
Months to years;
COPD
Pulmonary fibrosis
Congestive cardiac failure

10. Severity of breathlessness: medical research council (MRC) classification
Grade 1;
breathless when hurrying on the level ground or walking up a slight hill
Grade 2;
breathless when walking with people of own age on level ground
Grade 3;
has to stop because of breathlessness when walking on level ground at own pace

11. Associated symptoms No chest pain; Pleuritic chest pain;
Pulmonary edema
Metabolic acidosis
Anemia
Pleuritic chest pain;
Pneumonia
Pneumothorax
Pulmonary embolism
Rib fracture

12. Associated symptoms Central chest pain; Wheeze cough;
Myocardial infarction leading to acute left ventricular failure
Massive pulmonary embolism/infarction
Wheeze cough;
Asthma
Chronic obstructive pulmonary disease

13. Causes of heart failure
Ischemic heart disease
Hypertension
Valvular heart disease. Aortic stenosis.
Arrhythmias – AF
Cardiomyopathy
Myocarditis
Pericardial disease
High output failure – thyrotoxicosis, anemia.

14. Differential diagnosis
Cardiac causes;
Left ventricular failure
Mitral valve disease
Congestive cardiac failure
Cardiomyopathy
Pericardial effusion
Respiratory causes;
Airway:
Foreign body
Asthma
COPD
Bronchiectasis
Lung cancer

15. Differential diagnosis
Parenchymal:
Pulmonary fibrosis
Tuberculosis
Pneumonia
Pulmonary circulation:
Pulmonary thromboembolism
Pulmonary hypertension
Pleural:
Pneumothorax
Effusion
Chest wall:
Kyphoscoliosis
Neuromuscular:
Myasthenia gravis
Guillian barre syndrome

16. THANKYOU