Medical descriptions on respiratory system

1. Acute breathlessness
Prepared by Viphavadi Boon

2. DyspneaDyspnea 2
April, 99 2
Definition
• Dyspnea: unpleasant, subjective
sensation of abnormal respiration.
• Labored breathing - physical presentation
of respiratory distress/ dyspnea
• Many causes

3. DyspneaDyspnea 3
Descriptors of Dyspnea
• Dyspnea on Exertion (DoE)
• Dyspnea after Eating (PPD)
• Nocturnal Dyspnea
• Paroxysmal nocturnal dyspnea
• Dyspnea in Pregnancy
(hormonal, mechanical)

4. DyspneaDyspnea 4
April, 99
MRC Breathlessness Scale
• Grade
• 0
• 1
• 2
• 3
• 4
• Degree of dyspnea
• no dyspnea except with strenuous exercise
• Only when walking up incline or hurryingl
• Slow on level, or stops after 15 minutes
• stops few minutes of walking on the level
• minimal activity such as getting dressed,
• too dyspneic to leave the house
The Modified Borg Scale

5. DyspneaDyspnea 5
Causes of dyspnea
• 4 general categories:
• cardiac,
• pulmonary,
• mixed cardiac or pulmonary,
• Non-cardiac, non-pulmonary

6. DyspneaDyspnea 6
Common specific disease entities
• Asthma
• Pneumonia
• Pleural effusion
• Pneumothorax
• Interstitial Lung disease
• COPD
• Psychogenic
• Pericardial effusion
• Cardiac ischemia
• CHF
• Dysrhythmia
• Mechanical obstruction
• Anemia

7. Asthma

8. Definitions
GINA 2017, Box 5-1 (3/3)
Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the history of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and cough that vary over time and in intensity,
together with variable expiratory airflow limitation. [GINA 2017]
COPD
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable
disease that is characterized by persistent respiratory symptoms and airflow limitation
that is due to airway and/or alveolar abnormalities usually caused by significant
exposure to noxious particles or gases. [GOLD 2017]
Asthma-COPD overlap [not a definition, but a description for clinical use]
Asthma-COPD overlap (ACO) is characterized by persistent airflow limitation with
several features usually associated with asthma and several features usually associated
with COPD. Asthma-COPD overlap is therefore identified in clinical practice by the
features that it shares with both asthma and COPD.
This is not a definition, but a description for clinical use, as asthma-COPD overlap
includes several different clinical phenotypes and there are likely to be several different
underlying mechanisms.
UPDATED
2017

9. © Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2017, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset  Before age 20 years  After age 40 years
Pattern of symptoms  Variation over minutes, hours or days
 Worse during the night or early morning
 Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
 Persistent despite treatment
 Good and bad days but always daily
symptoms and exertional dyspnea
 Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function  Record of variable airflow limitation
(spirometry or peak flow)
 Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms
 Normal  Abnormal
Past history or family history  Previous doctor diagnosis of asthma
 Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
 Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
 Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course  No worsening of symptoms over time.
Variation in symptoms either
seasonally, or from year to year
 May improve spontaneously or have
an immediate response to
bronchodilators or to ICS over weeks
 Symptoms slowly worsening over time
(progressive course over years)
 Rapid-acting bronchodilator treatment
provides only limited relief
Chest X-ray  Normal  Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of
both
Could be ACO
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO
UPDATED
2017

10. © Global Initiative for Asthma
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
Empiric treatment with
ICS and prn SABA
Review response
Diagnostic testing
within 1-3 months
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Treat for alternative diagnosisTreat for ASTHMA
Clinical urgency, and
other diagnoses unlikely
YES
YES
YES NO
NO
NO
NO
YES
YES
NO
© Global Initiative for AsthmaGINA 2017, Box 1-1 (4/4)

11. © Global Initiative for Asthma
GINA assessment of asthma control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
GINA 2017 Box 2-2B (1/4)
Level of asthma symptom control

12. © Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2017, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset  Before age 20 years  After age 40 years
Pattern of symptoms  Variation over minutes, hours or days
 Worse during the night or early morning
 Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
 Persistent despite treatment
 Good and bad days but always daily
symptoms and exertional dyspnea
 Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function  Record of variable airflow limitation
(spirometry or peak flow)
 Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms
 Normal  Abnormal
Past history or family history  Previous doctor diagnosis of asthma
 Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
 Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
 Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course  No worsening of symptoms over time.
Variation in symptoms either
seasonally, or from year to year
 May improve spontaneously or have
an immediate response to
bronchodilators or to ICS over weeks
 Symptoms slowly worsening over time
(progressive course over years)
 Rapid-acting bronchodilator treatment
provides only limited relief
Chest X-ray  Normal  Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of
both
Could be ACO
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO
UPDATED
2017

14. Stepwise management -
pharmacotherapy
*Not for children <12 years
**For children 6-11 years, the
preferred Step 3 treatment is
medium dose ICS
#For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
 Tiotropium by mist inhaler is
an add-on treatment for
patients ≥12 years with a
history of exacerbations
GINA 2017, Box 3-5 (2/8) (upper part)
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Considerlow
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
PREFERRED
CONTROLLER
CHOICE
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
UPDATED
2017

15. © Global Initiative for Asthma
Stepwise management – additional components
GINA 2017, Box 3-5 (3/8) (lower part)
REMEMBER
TO...
SLIT: sublingual immunotherapy
• Provide guided self-management education
• Treat modifiable risk factors and comorbidities
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who
have exacerbations despite ICS treatment, provided FEV1 is 70% predicted
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
UPDATED
2017

16. COPD Definition
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► Chronic Obstructive Pulmonary Disease (COPD) is a
common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and
airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure to
noxious particles or gases.

17. COPD Etiology, Pathobiology &
Pathology
© 2017 Global Initiative for Chronic Obstructive Lung Disease

18. Classification of severity of airflow
limitation
© 2017 Global Initiative for Chronic Obstructive Lung Disease

19. ABCD Assessment Tool
© 2017 Global Initiative for Chronic Obstructive Lung Disease

20. Pharmacologic Therapy
© 2017 Global Initiative for Chronic Obstructive Lung Disease

21. Pharmacologic Therapy
© 2017 Global Initiative for Chronic Obstructive Lung Disease

22. Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease

23. Non-Pharmacologic Treatment -
Summary
© 2017 Global Initiative for Chronic Obstructive Lung Disease

24. Non-Pharmacologic Treatment –
Summary (continued)
© 2017 Global Initiative for Chronic Obstructive Lung Disease

25. Pulmonary edema

26. DyspneaDyspnea 26
Pulmonary edema:
• Basic problem: Heart stretches so far it can’t contract
well. (Falls off Frank Starling Curve)
• Cardiac oxygen demand exceeds availability.
• Air can’t cross the air-blood interface.
• Fluid seeps from the blood into the alveoli.
• Surfactant gets diluted.
• Caused by cardiac and vascular derangements.
• Vicious cycle.

28. DyspneaDyspnea 28
Pulmonary edema:
• Symptoms:
• Sudden onset; respiratory distress,
• Rales, ronchi. Foamy sputum. Sometimes
blood tinged.
• Blood pressure high (vasoconstriction) usually
240/120.
• If onset between 4 pm and 8 pm, likely to be
associated with acute MI.

29. DyspneaDyspnea 29
Pulmonary edema
• Treatment: increase airway pressure, to force
fluids back into the vascular system, (BVM
with patient effort, CPAP or intubation)
increase FiO2, dilate blood vessels and reduce
systemic blood pressure (which reduces the
work of the heart and reduces oxygen
demand). Get excess fluid off via kidneys (if
working), via bleeding (bloodletting) or
sequester fluid (tourniquets).

31. Pulmonary Embolus

33. Classical history
• pleuritic chest pain
• Haemoptysis and SOB
• Risk factors ( long haul flights, recent surgery,
immobility)

35. Classical examination findings
• CVS: tachycardia, JVP distension, RV heave,
loud P2, right S4
• Respiratory system: tachypnoea, clear chest
• Calves: look for DVT
• SBP < 90/ pulselessness/ persistent
bradycardia= “massive PE”

36. Investigaton findings
• D-dimer(if low Wells score) raised
• CT Pulmonary angiogram
• ECG: tachcardia, RV strain (T wave inversion in
chest and inferior leads), RBBB, right axis
deviation, S1Q3T3 pattern rare
• ABG: hypoxia, hypocapnia
• CXR: maybe wedge opacity, regional
oligaemia, enlarged pulmonary artery,
effusion

37. Definitive management
• Treatment dose LMWH
• Thrombolysis if massive PA

39. The end