The presentation covers clinical aspects in a patient of breathlessness and wheezing. It includes thorough history taking and clinical examination. A part of respiratory physiology and sounds heard on auscultation are also covered. Gradings of dysnea are explained.

1. Approach to
Breathlessness
Bhoopendra Kumar
3432 (8th Semester MBBS)

2. What is Dyspnea/Breathlessness?
• Dyspnea is the unusual and uncomfortable awareness of difficult or labored
breathing
• Normal resting patients are unaware of the act of breathing
• It is subjective and its quality is unique
• ~ 95% of cases are due to one of five major causes: cardiac (e.g., CHF),
pulmonary (e.g., COPD, asthma, ILD), psychogenic factors, GERD, and
deconditioning
• Dyspnea is termed acute if it develops over hours to days and chronic when it
occurs for more than four to eight weeks.

3. Some Distinct Terms
Orthopnea:
Dyspnea upon lying in the supine position. Characteristic of CHF and, in rare
cases, of bilateral diaphragmatic paralysis
Trepopnea:
Dyspnea upon lying in the lateral decubitus position. Most often occurs in
patients with CHF
Platypnea:
Dyspnea upon assuming the upright position
Bendopnea:
Dyspnea when leaning forward

4. Bendopnea. Do you want to check JVP?

5. Dysnea happens when a mismatch occurs
between afferent and efferent signaling.
As the brain receives afferent ventilation
information, it is able to compare it to the
current level of respiration by the efferent
signals.
If the level of respiration is inappropriate
dysnea might occur

7. History In A Case Of Dyspnea
• Duration, onset, course and progression
• Grade
• Associated symptoms: Substernal chest pain with myocardial ischemia; fever, cough, and sputum
with respiratory infections
• Positional variation of dyspnea (othopnea, platypnea, trepopnea) or PND
• Seasonal and diurnal variation: Intermittent dyspnea in asthma and COPD
• Smoking and environmental exposure history
• Tuberculosis: Past history/contact history/family history
• Socio-economic status

8. mMRC Grading

9. NYHA Grading

10. Approach To Dyspnea

11. General Physical Examination
• Built and appearance (BMI for objective assessment)
• Neck circumference
• Laryngeal length
• Vitals with oxygen saturation (SpO2)
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
• JVP
• Single breath count

12. RESPIRATORY TRACT EXAMINATION
• Upper respiratory tract examination: Nasal cavity, oral cavity and
pharynx

13. Respiratory System Examination
INSPECTION-
• Shape of the chest and movement of the chest (symmetry?)
• Position of trachea
• Position of apical impulse
• Chest deformities, use of accessory muscles, dilated veins, scars or sinuses, indrawing of
intercostal spaces, visible fullness
• Paradoxical breathing
• Lower chest indrawing (Hoover’s sign)

14. Barrel shaped chest

15. Trail’s sign

16. PALPATION-
• Any local rise of temperature or tenderness
• Confirming the findings of inspection
• Vocal fremitus
• Measurements: AP diameter, transverse diameter, chest circumference, hemithorax
measurements, expansion
Respiratory System Examination

17. Assessment of position of trachea

19. Vocal fremitus

20. Golden rule of Respiratory Examination
Always examine the NORMAL side first

21. Percussion

22. Respiratory System Examination
AUSCULTATION-
• Air entry and character of breath sounds
• Intensity of breath sounds
• Any added sounds
• Vocal resonance

23. Auscultation of chest

25. Approach To Dyspnea

27. Chest Xray- PA View
Full blood count with ESR
Blood chemistry- LFT/ LFT
HIV, Anti-HCV, HBsAg
ANA, RF
Mantoux testing
Sputum AFB, GeneXpert
Diagnostic thoracocentesis
TO SEND:

28. FIRST INVESTIGATION?

29. NORMAL CXR-PA VIEW

30. Approach to wheezing
BHOOPENDRA KUMAR
3432
8TH SEMESTER MBBS

31. Wheezing
Wheezing is a high pitched, continuous and musical sound that originates from oscillations in
narrowed airways.
Heard more commonly during expiration
Sign of lower airway obstruction

32. Types of Wheeze
Monophonic Wheeze: Single Pitch, produced in larger airways during expiration
Polyphonic Wheeze: Multi- Pitch Sound, widespread narrowing or various levels of narrowing.

33. Causes
Bronchial Asthma
LRTI: Increased sensitivity of respiratory tract after infection
Bronchiolitis: in the first 2 years
Topical Eosinophilia: frequent in adults
Hypersensitivity Pneumonitis
Inhaled Foreign bodies
Enlarged mediastinal LN, CF, Pulmonary Hemosiderosis.

34. Episodic vs multi trigger wheeze
Episodic Wheeze:
• wheeze in response to viral cold
• normal between episodes
Multitrigger Wheeze:
•Triggered by infection, exercise, allergen
•Symptoms may be present between episodes
•Likely to be asthmatic

35. History
Age: more common in children
Onset
Progression
Duration
Aggravating Factors
Relieving factors
Severity: altered sleep, awakening, night cough

36. Associated Symptoms: Breathing difficulty, cough.
Possible Triggers: Active/Passive Smoking, Pets, Pollen, Dust, Mites, Humidity, Smoke from
kitchen
Any history of allergy/itching/sneezing
Food Allergy
Family history of asthma, allergy

37. Examination
Normal/Drowsy/Irritable
Vitals:
• Pulse- Bounding pulse in asthma due to CO2 trapping
• Tachypnoea
• Temperature- Fever

38. Head to Toe Examination:
1. Clubbing – Bronchiectasis, CF
2. Cyanosis -- Severe Asthma
3. Lymphadenopathy- Infections
4. Face– Allergic Shiners, Transverse crease on nose, Dennie Morgan fold
5. Cushingoid facies- long term steroid therapy

39. Respiratory System
Barrel Shaped Chest
Harrison sulcus
Chest wall expansile movement diminshed bilaterally
Accessory muscles of respiration working
Lower chest indrawing
Hyper resonant percussion note
Cardiac dullness obliterated
Upper border of liver dullness at a lower position

40. Diagnosis and investigation
Clinical
Recurrent attacks of wheezing or spasmodic cough suggest asthma
Bronchodilator response
CBC
Absolute Eosinophil count
Chest Xray
PFT and Spirometry

41. Chest X-ray
Asthma- bilateral and symmetrical air trapping
Bronchiolitis- Hyperinflation of chest with scattered areas of infiltration

42. Thank You