Acute Dyspnea First Revision

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ACUTE DYSPNEATEAM 6

HOFILENA, MARIE CHIN

ILAGAN, JONATHANISLA, FROELAN

KHADKA,UMESH

JATTURAWUTTICHAI,NUTTORN

LAOHASINNURAK,NONLAPHAN

MOHAMED, MOHAMED HUSSEIMAMNUAYNGERNTRA,AMONTHEP

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OUTLINE ACUTE DYSPNEA

I. SYNOPSIS/ DEFINITION

II. EPIDEMIOLOGY

III. MECHANISM OF SHORTNESS OF BREATH

IV. DIFFERENTIAL DIAGNOSIS

V. RED FLAGS

VI. DIAGNOSTIC/LABORATORY

VII. DIFFENTIALS

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OUTLINE ACUTE DYSPNEA

VIII. HX OF PRESENT ILLNESS

IX. PHYSICAL EXAMINATION

X. ALGORITHM

XI. HYPOTHETICAL CASE

XII. EVIDENCE BASED MEDICINE

XIII. REFERENCES



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Acute DyspneaThe American Thoracic Societydefines dyspnea as a "subjective

experience of breathing discomfortthat consists of qualitatively distinctsensations that vary in intensity.

Harrisons Principle of Internal Medicine 18th edition



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Epidemiology

Shortness of breath is the primary reason 3.5% of people present tothe emergency department in the United States. Of theseapproximately 51% are admitted to hospital and 13% are dead withina year.



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Anatomy

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Overview of Respiratory muscles

Google image



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Anatomy of the Lungs

Google images



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Mechanisms of shortness of Breath

Desciptor Clinical example Pathophysiology

Chest tightness or constriction Asthma, CHF Bronchoconstriction, Interstitialedema

Increase work or effort of breathing Asthma, neuromuscular disease,

chest wall restriction

Airway obstruction, neuromuscular

disease

Air hunger need to breath,urge to

breathe

CHF, Pulmonary embolism, asthma,

pulmonary fibrosis

Increase drive to breathe

Inability to get a deep breath,

unsatisfying breath

Moderate to severe

asthma,pulmonary fibrosis, chest

wall disease

Hyperflation and restricted tidal

volume

Heavy breathing,rapid breathing,

breathing more

Sedentary status in healthy

individual or patient with

cardiopulmonary disease

Deconditioning

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Differential Diagnosis

Respiratory :- Acute exacerbation of asthma, and COPD,pnemothorax, pulmonary embolism, foreign body, pleuraleffusion

Cardiovascular :- Coronary artery disease ( angina and MI),congestive heart failure, arrhythmia, pericardial disease,

anemia , Pulmonary HPN Psychogenic:- Panic attack, hyperventilation

Others :- severe pain, poisoning ( OP, CO ),



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Asthma

Characterized by inflammatory hyperactivity of the respiratory

tree to various stimuli, resulting in reversible airways obstruction.

symptoms :- wheeze, chest tightness, breathlessness and cough.

Severe attack :- use of accessory muscle of respiration, diminishedbreath sound, loud wheezing, hyperresonence, intercostalretraction.



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Asthma

reduction in FEV1

Diagnosis is supported by increase FEV1 of < 12% and 200 cc after 2-4 puffs of short acting bronchodilator.



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Chronic Obstructive Pulmonary Disease ,COPD

Include chronic bronchitis and emphysema

Both are nonreversible obstruction of the airways ( unlike asthma )

Cigarette smoking represents the most significant risk factor for COPD

Use of accessory respiratory muscle, hyperinflated barrel shaped chest,cyanosis, Hyper resonance , reduced breath sound, prolonged expiration

Clubbing is not a feature of COPD.Decreased FEV1

Chronic bronchitis : Blue blotters

Emphysema : Pink puffer



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Pleural effusion

dyspnea usually develop > 0.5-1L of fluid, pluritic chest pain,

medistinal shifting ,decreased expansion of chest , stony dull ,absent breath sound and vocal resonance

Pneumothorax

medistinal shifting , hyperresonence , decreased breath soundand vocal fremitus



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Pulmonary embolism

tachycardia, hypotension, JVP, rightventricular gallop rhythm, loudP2, severe cyanosis,

Pulmonary Hypertension

Elevation of the mean pulmonary arterial pressure

> 25 mm hg at rest ( normal mean 15 ( 25/8) mm hg. dyspnea , syncope, edema, loud S2 ;esp P2 component, sign of Rt.

Heart failure( inc. JVP, hepatomegaly, pulsatile liver, pedal edemaetc.)



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Red Flags

Altered mental status.

Stridor and breathing effort without air movement.(suspectupper airway obstruction)

R/R > 40/min

cyanosis

Unilateral tracheal deviation.(suspect tension pnemothorax) Low 02 saturation.

Diaphoresis ( asthma )

Pulsus paradoxus



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Diagnostics

chest x-ray

Electro cardiogram

Spirometry

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Diagnostics

a D-dimer test may be done to detect clot formation ifpulmonary embolism is suspected.

Bronchoscopy: may be done in severe cases or to ruleout airway obstruction

PFT (pulmonary function test)

echocardiogram for suspected cardiac temponade

CTscan




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laboratory

Laboratory tests may include:-

CBC

ABG

blood carbon monoxide levels, and renal functionstudies. Blood oxygen saturation is measured usingan infrared light sensor device on the finger. (PulseOximeter)

Creatinine sodium potassium and glucose




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Risk Factors for dyspnea

Exposure to toxic irritants such as tobacco smoke

Industrial toxins

Obesity

Inhaling organic and inorganic dusts

Toxic fumes

Environmental pollutants

Irritant gases .



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Acute Dyspnea Differentials

Acute asthmaCOPD exacerbationPneumonia

Congestive heart failurePulmonary embolismPneumothorax




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Acute Dyspnea Differentials

EpiglottitisBronchiolitis

HyperventilationForeign body aspirationCongestive heart failure




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Comprehensive adult health history

7 component:1.Identifying data and source of the history: reliability2.Chief complaint(s)

3.Present illness

4.Past history

5.Family history

6.Personal and social history

7.Review of systems



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History Acute Dyspnea

1. Emphasize Coexisting caediac and pulmonary s/sx. Determineonset, duration, and occurrence at rest or exertion.

2. Chest pain during dyspnea may be caused by coronary or pleuraldisease, depending on the quality and description of the pain.

3. Sudden shortness of breath at rest is suggestive of pulmonaryembolism or pneumothorax.

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History Acute Dyspnea

4. Chest pain is almost universal in spontaneous pneumothorax,while dyspnea is the second most common symptom.

5. Consider spontaneous pneumothorax in patients with COPD, cysticfibrosis, or acquired immunodeficiency syndrome.

6. Inquire about indigestion or dysphagia, which may indicategastroesophageal reflux or aspiration.



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Skin

Rashes

Lumps

Itching Dryness

Color changes

Hair and nail

changes

General

Weight loss or gain

Fatigue

Fever or chills Weakness

Trouble sleeping

General

Weight loss or gain

Fatigue

Fever or chills Weakness

Trouble sleeping

Head

Headache

Head injury

Dizziness lightheadedness

Respiratory

Cough

Sputum

Coughing up blood

Shortness of breath

Wheezing

Painful breathing

Respiratory

Cough

Sputum

Coughing up blood

Shortness of breath

Wheezing

Painful breathing



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EYES

Vision Loss/Changes Glasses or contacts

Pain

Redness

Blurry or double vision

Flashing lights

Specks

Glaucoma

Cataracts

Last eye exam

Ears

Decreased hearing Ringing in ears

Earache

Discharge

Vertigo

Nose

Stuffiness

Discharge

Itching

Hay fever

Nosebleeds

Sinus pain



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Throat/Mouth/Pharynx

Bleeding

Dentures

Sore tongue Dry mouth

Sore throat

Hoarseness

Thrush

Non-healing sores

Neck

Lumps

Swollen glands

Pain

Stiffness

Cardiovascular

Chest pain or discomfort

Tightness

Palpitations

Shortness of breath with

activity

Difficulty breathing lying

down

Swelling

Sudden awakening from

sleep with shortness ofbreath

Cardiovascular

Chest pain or discomfort

Tightness

Palpitations

Shortness of breath with

activity

Difficulty breathing lying

down

Swelling

Sudden awakening from

sleep with shortness ofbreath



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Gastrointestinal

Swallowing difficulties

Heartburn

Change in appetite Nausea

Change in bowel habits

Rectal bleeding

Constipation Diarrhea

Yellow eyes or skin

Vascular

Calf pain with walking

Leg cramping

varicose veins

swelling w redness or

tenderness change in fingertips or toes

during cold weather

Urinary

Frequency

Urgency

Burning or pain Blood in urine

Incontinence

Change in urinary

strength



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PHYSICAL EXAMINATIONACUTE DYSPNEA



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PHYSICAL EXAMINATION ACUTE DYSPNEA

1. Begin during interview of the patient.

2. Inability to speak in full sentences before stopping to get deepbreath?

3. Evidence of increased work of breathing? indicative of

increased airway resistance or stiffness of the lungs and the chestwall.

4. VS



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5. During general examination, signs of anemia ( pale conjunctivae),cyanosis, and cirrhosis ( spider angiomata, gynecomastia) shouldbe sought.

6. Chest: symmetry of movement; percussion (dullness is indicativeof pleural effusion; hyperresonance is a sign emphysema); and

auscultation (wheezes, rhonchi, prolonged expiratory phase, anddiminished breath sounds are clues to D/O of the airways; ralesuggest interstitial edema or fibrosis).



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7. Cardiac: focus on signs of elevated right heart pressures, leftventricular dysfunction, and valvular diseases.

8. Abdomen: patient in the supine position, physician should notewhether there is paradoxical movement of the abdomen: inwardmotion during inspiration is a sign of diaphragmatic weakness,

and rounding of the abdomen during exhalation is suggestive ofpulmonary edema.



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9. Clubbing of digits may be an indication of interstitial pulmonaryfibrosis, and joint swelling or deformation as well as changesconsistent with raynauds disease may be indicative of a collagen-vascular process that can be associated with pulmonary disease.



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10. Patients with exertional dyspnea should be asked to walk underobservation in order to reproduce the symptoms.



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Adapted from MA Gillette, RM Schwartzstein, in SH Ahmedzai, MF, Muer [eds].

Supportive Care in Respiratory Disease. Oxford, UK, Oxford University Press, 2005



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Case A 75-year-old man with presents with a 1-day history of dyspnea,

rightsided chest pain, and cough with rustcolored sputum. Furtherhistory reveals subjective fever and chills.

His physical activity level has diminished over the last 2 days. Physicalexamination reveals the patient to be mildly tachypneic and afebrilebut in no acute distress.

Cardiac examination is without significant findings. There are cracklesand a friction rub in the right anterior lung field.

Laboratory examination demonstrates a mild leukocytosis and a Pao2of 60 mm Hg.



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Hypothetical Case

I. Chief Complaint- Difficulty of breathing.

II. Hx of Present Illness- While walking, the patient presented withdifficulty of breathing with right sided chest pain. He also complain ofcoughing with rust colored sputum, thus leading to consultation. Hisphysical activity level has diminished over the last 2 days

. III. Past Hx- (-) DM, No known HPN,

V. Family Medical Hx- Parents are both hypertensive, No knowncancer, DM, allergy, TB, thyroid problem or genetically transmitteddisease among family members



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Hypothetical Case Continuation

VI. Personal/Social Hx-He is a engineer, smoker for 20 pack years,Goes to catholic church every Sunday, drinks alcohol (beer)occasionally, and once a week.

VII. Physical Exam Findings- Febrile, ambulatory with the ff : VitalsSigns: BP: 90/60mmHg, RR: 32 T: 38 degree celsius HR:126beats per

minute

HEENT: Normal JVP, No cervical lymphadenopathy, No thryromegaly,(-) anecteric sclera,(-) carotid bruits

Chest/Lungs: symmetrical, Increased tactile fremitus right, (+)retractions, (-) lag, (-) spider angiomas, dullness on the right side,(+)

crackles, (-) wheezes



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Continuation

VII. Physical Exam Findings:

Heart: adynamic precordium; apex beat at 4th to 5th ICS LMCL, (-)thrills, normal S1 and S2, No murmurs

Abdomen: abdominal girth normal, flat, (-) caput medsau;normoactive bowel sounds, soft, non tender tymphanic, noorganomegaly, normal bowel movements

Extremities: (-) deformities, (-) clubbing, (-) cyanosis, with the ffpulses:

DP PT P F B R

R ++ ++ ++ ++ ++ ++

L ++ ++ ++ ++ ++ ++



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Continuation

Rectal: (-) anal tag, good sphincter tone, rectal vault not collapse,(-) hemorrhoids nor mass noted; brownish stool in tactating finger.

Neurologic Exam:

Cerebrum: conscious, oriented to 3 spheres

Cerebellum : (-) nystagmus ; can do heel to shin test ; intactRombergs test ; can do rapid alternating movements ; can dofinger to nose test



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Cranial nerves :

I can smell coffee

II, III pupils equally reactive to light

III, IV, VI intact extraoccular muscles

V intact corneal reflex , bilateral ; intact masseter muscle contraction

VII (-) facial asymmetry

VIII can hear, bilateral

IX, X intact gag reflex

XI can shrug shoulders , bilateral

XII - tongue midline on protrusion

(-) Babinski ;(-) nuchal rigidity( -) Brudzinski (-) Kernigs sign Dermatomal test :equal and intact on all levels Motor Sensory DTR



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Hypothetical Case

II. Primary Working Impression: Community Acquired Pneumonia,COPD

III. Laboratory Examinations:ECG, ABG, CBC, Creatinine, Chest Xray



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Laboratory Results

Sinus Tachycardia ECG

ABG: pH increased

PCO2 decreased

HCO3 normal

Repiratory Alkalosis

CBC: increased neutrophil count

Creatinine: Normal

Chest Xray: Right upper lobe consolidation



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Final Diagnosis:

Community Acquired Pneumonia Right Upper Lobe Moderate Risk



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Evidence-Based Medicine



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We ask this question during our meeting ingroup.

How wouldapprehensiveness affect

the patient suffering fromdyspnea?



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Acute Dyspnea First Revision

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