approach to a patient with dyspnoea

1. APPROACHAPPROACH TO THETO THE
PATIENTPATIENT WITHWITH
DYSPNOEADYSPNOEA
Dr. AL TARIQUE
IMO, Department of Medicine,
EMCH

2. DEFINITIONDEFINITION
A subjective experience of breathing
discomfort that consists of qualitatively
distinct sensations that vary in intensity.
(American Thoracic Society )
Other definitions describe it as "difficulty in
breathing, disordered or inadequate
breathing, uncomfortable awareness of
breathing. And It may be acute or chronic.

3. Some definitionsSome definitions
 TrepopnoeaTrepopnoea :Breathlessness when lying on:Breathlessness when lying on
one side as a result of ipsilateral pulmonaryone side as a result of ipsilateral pulmonary
disease . Causes are dilateddisease . Causes are dilated
cardiomyopathy, pleural effusion.cardiomyopathy, pleural effusion.
 OrthoponeaOrthoponea : Breathlessness when lying: Breathlessness when lying
flat. Ex : Left Ventricular Failure, diaphramaticflat. Ex : Left Ventricular Failure, diaphramatic
weakness, massive pleural effusion, hugeweakness, massive pleural effusion, huge
ascitis, any severe lung disease.ascitis, any severe lung disease.
 Breathlessness during swimming isBreathlessness during swimming is
characteristic of bilateral diaphragmcharacteristic of bilateral diaphragm
paralysisparalysis..

4. Continue ….Continue ….
 PlatypnoePlatypnoeaa : Breathlessness on sitting up.: Breathlessness on sitting up.
Ex : right to left shunt, ASD, or large intraEx : right to left shunt, ASD, or large intra
pulmonary shunt, pericardial effusion, liverpulmonary shunt, pericardial effusion, liver
cirrhosis.cirrhosis.
 PNDPND : Breathlessness that wakes the patient: Breathlessness that wakes the patient
from sleep. Ex : Left Ventricular failure.from sleep. Ex : Left Ventricular failure.
Bronchial Asthma.Bronchial Asthma.

5. Etiology / Differential DiagnosisEtiology / Differential Diagnosis
(Dyspnoea)(Dyspnoea)
 Composed of four general categoriesComposed of four general categories
CardiacCardiac
PulmonaryPulmonary
Mixed cardiac or pulmonaryMixed cardiac or pulmonary
non-cardiac or non-pulmonarynon-cardiac or non-pulmonary

6. Pulmonary EtiologyPulmonary Etiology
 AsthmaAsthma
 COPDCOPD
 PneumoniaPneumonia
 PneumothoraxPneumothorax

7. Cardiac EtiologyCardiac Etiology
 CHFCHF
 CADCAD
 CardiomyopathyCardiomyopathy
 Valvular dysfunctionValvular dysfunction
 PericarditisPericarditis
 ArrhythmiasArrhythmias

8. Mixed Cardiac/Pulmonary EtiologyMixed Cardiac/Pulmonary Etiology
 COPD with pulmonary HTN and/orCOPD with pulmonary HTN and/or
cor pulmonalecor pulmonale
 Chronic pulmonary emboliChronic pulmonary emboli
 Pleural effusionPleural effusion

9. Noncardiac or Nonpulmonary EtiologyNoncardiac or Nonpulmonary Etiology
 It is a normal symptom of heavy exertionIt is a normal symptom of heavy exertion
Normal pregnancy (around 2/3rd
)
 Metabolic acidosisMetabolic acidosis
 PainPain
 TraumaTrauma
 Neuromuscular disordersNeuromuscular disorders
 FunctionalFunctional (anxiety, panic disorders, hyperventilation)(anxiety, panic disorders, hyperventilation)
 Chemical exposureChemical exposure
Obesity
Psychogenic

10. Life Threatening Causes of DyspneaLife Threatening Causes of Dyspnea
 Pulmonary EmbolismPulmonary Embolism
 Tension PneumothoraxTension Pneumothorax
 Severe metabolic acidosisSevere metabolic acidosis
 Pulmonary EdemaPulmonary Edema
 Status asthmaticusStatus asthmaticus
 Hypercapneic Respiratory FailureHypercapneic Respiratory Failure
 Severe upper airway obstructionSevere upper airway obstruction
 ARDSARDS

11. Causes of episodic / intermittentCauses of episodic / intermittent
breathlessnessbreathlessness
 AsthmaAsthma
 Pulmonary OedemaPulmonary Oedema
 AnginaAngina
 Pulmonary EmbolismPulmonary Embolism
 Hypersensitivity PneumonitisHypersensitivity Pneumonitis
 VasculitisVasculitis
 Hyperventilation SyndromeHyperventilation Syndrome

12. CLINICAL FEATURESCLINICAL FEATURES
SympTomSSympTomS ::
a.a. Shortness of breathShortness of breath
b.b. Chest tightnessChest tightness
C.C. Associating symptomsAssociating symptoms
SIgNS :SIgNS :
a.a. Patient breaks up sentence to pause for breathPatient breaks up sentence to pause for breath
b.b. TachypnoeaTachypnoea
c.c. Increased respiratory excursionsIncreased respiratory excursions
d.d. Nasal flaringNasal flaring
e.e. CyanosisCyanosis
f.f. Accessory muscle useAccessory muscle use ::
1)1) Chest and abdominal muscle useChest and abdominal muscle use
2)2) Neck muscle use (Scalene,Sternocleidomastoid)Neck muscle use (Scalene,Sternocleidomastoid)

13. HISToRyHISToRy
 Onset, duration, preceding factors,
aggravating factors.
 Associating features-
Sputum
wheeze
Chest pain
Effort intolerance etc.

14. Breathlessness:Mode of
onset,duration and progression
Minute:Minute:
Pulmonary thromboembolism,pneumothorax,Asthma,Pulmonary thromboembolism,pneumothorax,Asthma,
Inhaled foreign body, Acute left ventricular failure.Inhaled foreign body, Acute left ventricular failure.
Hours to day:Hours to day:
Pneumonia, Asthma, Exacerbation of COPDPneumonia, Asthma, Exacerbation of COPD
Weeks to month:Weeks to month:
Anaemia, Pleural effusion, Respiratory neuromuscularAnaemia, Pleural effusion, Respiratory neuromuscular
disorder.disorder.
Months to year:Months to year:
COPD, Pulmonary fibrosis, Pulmonary tuberculosis.COPD, Pulmonary fibrosis, Pulmonary tuberculosis.
It is a common medical emergency and can arise from aIt is a common medical emergency and can arise from a
variety of conditions which require totally different initialvariety of conditions which require totally different initial
treatment.treatment.

15. MRC Breathlessness Scale
Grade Degree of dysponea
1 Breathless when hurrying on the level or
walking up a slight hill
2 Breathlessness when walking with people of
own age or on level ground
3 Walks slower than peers or stops when
walking on the flat at own pace
4 Stops after walking 100 meters or a few
minuters on the level
5
[5b]
Too breathless to leave the house
Too breathless to wash or dress

16. CoNT.CoNT.
KNowN RESpIRAToRy dISEASE:
1. Previous acute exacerbation of COPD
requiring hospital management
2.2. Previous lung function test and arterialPrevious lung function test and arterial
blood gas analysis:blood gas analysis:
3.3. RequirementRequirement for home nebulizedfor home nebulized
bronchodialator and/or oxygen therapy.bronchodialator and/or oxygen therapy.
 KNowN CARdIAC dISEASE
1. CoRoNARy dISEASE
2. myoCARdIAL oR vALvE dISEASE
 RISK FACToRS FoR vENoUS
THRomboEmboLISm

17. APPROACH TO THE PATIENTAPPROACH TO THE PATIENT
 The initial approach for evaluation begins byThe initial approach for evaluation begins by
assessment of the airway, breathing, andassessment of the airway, breathing, and
circulation followed by a medical history andcirculation followed by a medical history and
physical examinationphysical examination
Physical findingsPhysical findings::
 General appearance: Speak in full sentences?
Accessory muscles? Color?
 BP-
 Nose and sinus examNose and sinus exam
 Fluid status exam :Fluid status exam :
Jugular Venous DistentionJugular Venous Distention
Hepatojugular ReflexHepatojugular Reflex
Peripheral EdemaPeripheral Edema

18. CONT.CONT.
 Respiratory ExamRespiratory Exam
I.I. Increased AP Chest diameterIncreased AP Chest diameter
II.II. Wheezing, stridorWheezing, stridor
III.III.CracklesCrackles
IV.IV.CyanosisCyanosis
V.V. ClubbingClubbing
VI.VI.Accessory muscle use (Neck, chest,Accessory muscle use (Neck, chest,
abdomen)abdomen)
VII.VII.Speaking in phrases to catch breathSpeaking in phrases to catch breath

19. CONT.CONT.
 Cardiac AuscultationCardiac Auscultation
I.I. TachycardiaTachycardia
II.II. 33rdrd
HS (Gallup Rhythm)HS (Gallup Rhythm)
III.III.Cardiac MurmurCardiac Murmur
 Psychomotor examPsychomotor exam
I.I. AnxietyAnxiety

20. INVESTIGATIONSINVESTIGATIONS
FIRST LINE (INITIAL) INV :FIRST LINE (INITIAL) INV :
 CHEST X-RAYCHEST X-RAY
 ARTERIAL BLOOD GASES AND pHARTERIAL BLOOD GASES AND pH
 FULL BLOOD COUNTFULL BLOOD COUNT
 ECGECG
 TSH levelTSH level
 BLOOD GLUCOSEBLOOD GLUCOSE
 SODIUM ,POTASSIUM AND CREATININESODIUM ,POTASSIUM AND CREATININE
 BIOMARKERS:BIOMARKERS:
 D-dimer if pulmonary embolism isD-dimer if pulmonary embolism is
suspectedsuspected
 Troponin if acute coronary syndrome isTroponin if acute coronary syndrome is
suspectedsuspected
 BNP( brain natriuretic peptide) if heartBNP( brain natriuretic peptide) if heart
failure is suspectedfailure is suspected

21. CONT.CONT.
SECOND LINE INV.( WHEN STABLE):SECOND LINE INV.( WHEN STABLE):
 LUNG FUNCTION TESTSLUNG FUNCTION TESTS
(SPIROMETRY)(SPIROMETRY)
 Cardiopulmonary exercise testingCardiopulmonary exercise testing
( CPET)IF difficult to differentiate cardiac( CPET)IF difficult to differentiate cardiac
or respiratory cause.or respiratory cause.

22. CAUSE OF BREATHLESSNESS WITH A NORMAL CXRCAUSE OF BREATHLESSNESS WITH A NORMAL CXR
 Airway disease(Asthma, upper airway obstruction,Airway disease(Asthma, upper airway obstruction,
Bronchiolitis)Bronchiolitis)
 Pulmonary vascular disease(pulmonaryPulmonary vascular disease(pulmonary
embolism,Idiopathic pulmonary hypertension,embolism,Idiopathic pulmonary hypertension,
Intrapulmonary shunt,)Intrapulmonary shunt,)
 Early parenchymal disease(Sarcoid, InterstitialEarly parenchymal disease(Sarcoid, Interstitial
pneumonia, Infection-Viral)pneumonia, Infection-Viral)
 Cardiac disease(Angina, Arrhythmia)Cardiac disease(Angina, Arrhythmia)
 Neuromuscular diseaseNeuromuscular disease
 Metabolic acidosisMetabolic acidosis
 AnaemiaAnaemia
 ThyrotoxicosisThyrotoxicosis

23. DIFFERENTIATION BETWEEN CARDIAC
AND PULMONARY DYSPNEA
• Careful history: Dyspnea of lung disease
usually more gradual in onset
than that of heart disease; nocturnal
exacerbations common with each.
• Examination: Usually obvious evidence of
cardiac or pulmonary disease.
Findings may be absent at rest when
symptoms are present only with
exertion.

24. Cont ….Cont ….
Brain natriuretic peptide (BNP): Elevated in cardiac but not
pulmonary
dyspnea.{BNP <50ng/l makes cardic failure unlikly }
• Pulmonary function tests: Pulmonary disease rarely
causes dyspnea
unless tests of obstructive disease (FEV1, FEV1/FVC) or
restrictive
disease (total lung capacity) are reduced (<80%
predicted).
• Ventricular performance: LV ejection fraction at rest
and/or during
exercise usually depressed in cardiac dyspnea.

25. MANAGEMENTMANAGEMENT
A.A. Immediate ABC Management :Immediate ABC Management :
a)a) Emergency Airway ManagementEmergency Airway Management
b)b) Emergency Breathing ManagementEmergency Breathing Management
c)c) Emergency Circulation ManagementEmergency Circulation Management
B.B. Obtain initial vital signs :Obtain initial vital signs :
a)a) Temperature, Blood Pressure, and PulseTemperature, Blood Pressure, and Pulse
b)b) Respiratory Rate and OxygenRespiratory Rate and Oxygen
SaturationSaturation

26. CONT.CONT.
C.C. Immediately triage unstable patientsImmediately triage unstable patients ::ifif
a)a) HypotensionHypotension
b)b) Altered Level of ConsciousnessAltered Level of Consciousness
c)c) Hypoxia (decreased Oxygen Saturation)Hypoxia (decreased Oxygen Saturation)
d)d) ArrhythmiaArrhythmia
e)e) Stridor or other signs of upper airwayStridor or other signs of upper airway
obstructionobstruction
f)f) Unilateral breath sounds or other PneumothoraxUnilateral breath sounds or other Pneumothorax
signssigns
g)g) Respiratory Rate >40 breaths per minuteRespiratory Rate >40 breaths per minute
h)h) Accessory muscle use with retractionsAccessory muscle use with retractions
i)i) CyanosisCyanosis

27. CONT.CONT.
D.D. Initial management of acute distressInitial management of acute distress
a)a) Obtain Intravenous Access (when appropriate)Obtain Intravenous Access (when appropriate)
b)b) Administer High Flow OxygenAdminister High Flow Oxygen
c)c) Evaluate and treat Hypoxia if presentEvaluate and treat Hypoxia if present
d)d) Consider Pulmonary Embolism DiagnosisConsider Pulmonary Embolism Diagnosis
E.E. Initiate disease specific managementInitiate disease specific management
a)a) Emergency Management of Acute severe AsthmaEmergency Management of Acute severe Asthma
b)b) COPD Exacerbation ManagementCOPD Exacerbation Management
c)c) Acute Pulmonary Edema ManagementAcute Pulmonary Edema Management
d)d) Tension Pneumothorax -Needle ThoracentesisTension Pneumothorax -Needle Thoracentesis

28. Palliative care
Along with the measure above, systemic
immediate release(IR) opioids are
beneficial in reducing the symptom of
shortness of breath due to both cancer
and non cancer causes.
There is a lack of evidence to recommend
midazolam, nebulised opioids, the use of
gas mixtures, or cognitive-behavioral
therapy