Approach to a patient with breathlessness

1. Shortness
of Breath
PhotobyJamesHeilman,MD/CCBY-SA3.0

2. Contents • Definition
• Grades of breathlessness
• Common causes
• History taking
• Abnormalities on physical examination
• Differential diagnosis
• Initial investigations
• Basic management

3. Definition • Undue awareness of breathing and is normal
with strenuous physical exercise
• Sense of awareness of increased respiratory
effort that is unpleasant and that is recognized
by the patient as being inappropriate
• Breathlessness or dyspnoea can be defined as the
feeling of an uncomfortable need to breathe.
• It is unusual among sensations, as it has no
defined receptors, no localized representation in
the brain, and multiple causes both in health
(e.g. exercise) and in diseases of the lungs, heart
or muscles.
• Patients use terms such as ‘shortness of breath’,
difficulty getting enough air in’, ‘tiredness’,
‘difficult, laboured, uncomfortable breathing;
it is an unpleasant type of breathing, though it is
not painful in the usual sense of the word’

4. MRC Dyspnoea Scale
Grade Degree of breathlessness related to activity
1 Not troubled by breathlessness except on strenuous exercise
2
Short of breath when hurrying on a level or when walking up
a slight hill
3
Walks slower than most people on the level, stops after a mile
(1.6 km) or so, or stops after 15 minutes walking at own pace
4
Stops for breath after walking 100 yards (90 m), or after a
few minutes on level ground
5
Too breathless to leave the house, or breathless when
dressing/undressing

5. New York Heart Association (NYHA)
Functional Classification
Grade Symptoms
Grade 1 ( Mild )
No limitation on physical activity. Ordinary physical activity doesn't
cause undue fatigue, palpitation, dyspnoea
Grade 2 ( Mild )
Slight limitation of physical activity. Comfortable at rest but
ordinary physical activity results in fatigue, palpitation, dyspnoea.
Grade 3 ( Moderate )
Marked limitation of physical activity. Comfortable at rest. Less
than ordinary activity causes fatigue, palpitation, or dyspnea.
Grade 4 ( Severe )
Unable to carry out any physical activity without discomfort.
Dyspnoea present at rest, if any physical activity is undertaken the
discomfort increases.

6. Common Causes
System Acute dyspnoea
Cardiovascular Acute pulmonary oedema
Respiratory
Acute severe asthma
Acute exacerbation of COPD
Pneumothorax
Pneumonia
Pulmonary embolus
ARDS
Inhaled foreign body
Lobar collapse
Laryngeal oedema
Others
Metabolic acidosis
Psychogenic hyperventilation

7. System Chronic exertional dyspnoea
Cardiovascular
Chronic heart failure
Myocardial ischaemia
Respiratory
COPD
Chronic asthma
Bronchial carcinoma
Interstitial lung disease
Chronic pulmonary thromboembolism
Lymphatic carcinomatosis
Large pleural effusions
Others
Severe anaemia
Obesity
Deconditioning
Common Causes

8. History taking
• Patient's details :
 Name
 Age
 Sex
 Occupation : paint sprayers,
rubber industry workers are
prone to lung disease
 Address
 Date of Admission

9. History taking • Chief Complaints
oShortness of breath for how many days
/ weeks
• History of Presenting Illness
oOnset : gradual/sudden
oProgression : worsen/better
oSeverity : NYCA/MRCA grading
oDiurnal variability : worsen at night /
morning- asthma
oPostural variability : orthopnoea , PND-
CVS
oAggravating factors : pollen, dust, cold
climate - asthma, sinusitis
oRelieving factors : rest, medication

10. History taking • Associated symptoms :
a) Cough : yes/no
oIf yes , onset/duration/progression -
chronic cough - bronchiectasis
oFrequency, severity
oDiurnal variability - might indicate
asthma
oPostural variability - might indicate
bronchiectasis
oProductive/ dry cough
b) Sputum :
oHow much? Frequency? - Copious sputum
suggestive of bronchiectasis
oColour? – White (viral) , yellowish
(bacteria), rusty (pneumonia)
oConsistency
oFoul smell? - Suggestive of bronchiectasis,
suppurative lung disease

11. History taking • Associated symptoms :
c) Haemoptysis :
oDuration, onset, progression
oAmount of blood?
oAssociated with melena or epistaxis?
oMight be due to malignancy
d) Chest pain :
oOnset, duration, progression
oSite? Bilateral/ unilateral
oType of pain
oRadiating - CVS pathology
oPain on deep inspiration, pain relief
when lie on same side- pleuritic chest
pain

12. History taking • Associated symptoms:
e) Fever :
oOnset, progression, duration
oAssociated with chills or rigor,
night sweats
oHigh / low grade
oEvening rise of temp - TB
f) Wheezing – asthma
g) Weight lost - TB, malignancy
h) Palpitation - CVS pathology
i) Sinusitis
j) Rhinitis

13. History taking • Past History :
oHistory of TB, Measle/whopping cough,
Asthma/ allergy, IHD, chest trauma/
surgery , similar complains, DM/HTN
• Personal History :
oDiet, Addiction, Bowel/Bladder
movement, Sleep, Appetite
oSmoking- highly ass with Emphysema
oAlcoholism - Aspiration Pneumonia
oLost of appetite & weight - TB,
Malignancy
• Family History :
oAsthma, TB, Cystic Fibrosis,
Malignancy
oAnyone with similar complaints

14. History taking • Social history :
oEconomic status, income, type of house,
water source, no. of people staying in
one house
oCongested homes/ low economic status -
risk of lung pathology
• Menstrual history :
oTo rule out pregnancy

15. Abnormalities on
Physical Examination

16. General Physical Examination
• BMI –
• Normal : 18.5 – 22.9 ( Asian )
18.5 – 24.9 ( Non-Asian )
• Obesity might be the cause of the
breathlessness
oExtra weight in the chest and
abdomen
Increased work load on muscles
that control breathing

17. Vital Signs :
a) Pulse Rate – Normal
(60-90 beats/min)
 Tachycardia : Pneumonia ,
Atrial Fibrillation
 Bradycardia : Myocardial
Infarction
b) Blood Pressure – Normal
(120/80 mmHg)
 Hypotension : Pneumothorax ,
Myocardial Infarction
 Hypertension : Cardiac
Failure
c) Temperature
 High : Tuberculosis,
Pneumonia
d) Respiratory Rate – Normal
(14-16 breaths/min)
 Tachypnoea : Pulmonary
Embolism , Anxiety
 Bradypnoea : Myocardial
Infarction

18. Head to Toe Examination
1. Nails and Hands
 Pallor ( Left Heart Failure ,COPD)
 Cyanosis ( Cardiac Failure , COPD , Pulmonary oedema )
 Clubbing ( Carcinoma of Bronchus , Pulmonary Fibrosis
,Bronchiectasis , Lung Abscess , Pleural Empyema )
 Koilonychia ( Anaemia )
2. Neck :
 JVP increased ( Right Heart Failure caused by Chronic
Pulmonary Hypertension in severe lung disease such as COPD )

19. Head to Toe Examination
3. Face :
 Eyes – Pallor ( Anaemia )
 Lips and Tongue – Cyanosis ( Cardiac Failure , COPD )
oIndicate poor oxygenation of blood
4. Lower limb :
 Pitting Pedal Oedema
oUnilateral – DVT
oBilateral – Congestive Heart Failure

20. Respiratory System Examination
 Auscultation
• Stridor ( Laryngeal Oedema ,
Foreign bodies )
• Diminished Vesicular Breath
Sounds ( Obesity , Pleural
Effusion , Pneumothorax , COPD ,
Lung collapse )
• Bronchial Breath Sounds ( Lung
consolidation in pneumonia )
• Vocal Resonance ( over
consolidated lung , the spoken
numbers are clearly audible but
over an effusion or collapse they
are muffled )
• Rhonchi / Wheeze ( COPD ,
Bronchial Asthma )
• Pleural Rub ( Pneumonia , TB )
• Crackles

21. Examination Sequence
1. Note the patient’s general
appearance and demeanour.
2. Look for central cyanosis of the
lips and tongue.
3. Examine the skin for rashes and
nodules.
4. Listen for hoarseness and stridor.
5. Examine the hands for finger
clubbing, peripheral cyanosis and
tremor.
6. Measure the blood pressure.
7. Examine the neck for raised JVP
and cervical lymphadenopathy.
8. Record the respiratory rate.
9. Observe the breathing pattern,
and look for use of accessory
muscles.
10. Inspect the chest front and back
for abnormalities of shape and
scars.
11. Feel the trachea and cardiac apex
beat for evidence of mediastinal
shift.
12. Percuss the chest front and back
for areas of dullness or
hyperresonance.
13. Listen to the chest front and back
for altered breath sounds and
added sounds.
Certain groups of physical signs are
typically associated with particular
pathological changes in the lungs.

22. Differential diagnosis
Develop differential diagnosis in a patient with
breathlessness based on history and
examination

23. Differential Diagnosis

24. Differential Diagnosis

25. Evaluation
Plan initial investigations and basic
management based on the differential diagnosis

26. Bedside investigations
Pulse Oximetry
• A spectrophotometric device that
measures arterial oxygen saturation by
determining the differential absorption
of light by oxyhaemoglobin and
deoxyhaemoglobin .
• This allows detection and ongoing
monitoring of hypoxaemia with
initiation of oxygen supplementation as
necessary, while undertaking diagnostic
work-up for its cause
Peak Flow Rate
• Person's maximum speed of expiration.
• Normal test results depends on age year
gender and sometimes occupation.
• Helps to differentiate between
pulmonary and cardiac causes of
dyspnoea. Low peak flow rates are
associated with obstructive lung disease
such as asthma, COPD, and cystic
fibrosis.
• Normal: 80-100 per cent of usual flow
rate.

27. Bedside investigations
Pulse Oximetry Peak Flow Rate

28. Radiology
Chest X-Ray
• To determine the lobe / area in which
the lung is affected.
• Make out any cardiomegaly in the PA
view of the x-ray
• Check for any fluid / consolidation of
the lungs.
• Check for any structural damage such
as a broken rib
Chest fluoroscopy / Sniff test
• Determines how well lungs,
diaphragm, or other parts of your
chest are working.
• Uses more radiation than a standard
chest X-ray.
• It detects the movement of the
diaphragm when the patient breathes.
• Hence able to detect any abnormal
diaphragmatic conditions.

29. Radiology
Chest X-Ray Chest fluoroscopy / Sniff test

30. Electrocardiogram
• To detect underlying causes of cardiac origin that causes breathlessness.
• Coronary artery diseases can be a major causes of breathlessness.
• If needed an angiogram can be done to make out any blockage to the
coronary arteries.

31. Lung Biopsy
• Invasive procedure.
• Involves removal of a small piece of lung tissue which can be sent for
investigations.
• Types: bronchioscopic, needle, open, video associated thoracoscopic surgery.
• Diagnose certain condition such as sarcoidosis or pulmonary fibrosis and
even lung cancers.

32. Treatment
Management of breathlessness

33. Pharmacological
• The treatment of breathlessness is complex. It depends on the
underlying causes.
• Opioids-either oral or parenteral-are now considered to be the
gold standard in reducing ventilator demand. A slow release
preparation of morphine has been found to be beneficial
• Anxiolytics such as benzodiazepines may assist in the anxiety
component of breathlessness. However, these may be poorly
tolerated in some patients, especially in those with liver
failure.
• Long acting beta agonists may be beneficial in breathlessness
due to COPD in reducing the work of breathing.
• Bronchodilators help in relaxing muscles and improving
muscle tone in the airways.

34. Oxygen Treatment
• Evidence have shown oxygen treatment is of no
use in a patient with breathlessness WITHOUT
hypoxia.
• Otherwise, high flow oxygen of >60 percent is
used except in COPD patients.

35. Non-pharmacological
• There does seem to be a relationship between anxiety
and breathlessness, however, which one comes first is
difficult to tell. Strategies such as relaxation training
and distraction do seem to help as do cognitive
behavioural therapies.
• Controlled breathing exercises and techniques such as
an upright leaning forward position and pursed lip
breathing are also beneficial therapies.
• Chest wall vibration, neuro-electrical muscle
stimulation, walking aides, and breathing training.

36. Thank you!