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EVALUATION OF
DYSPNOEA
DR. PRAPULLA CHANDRA
DEFINITION OF DYSPNOEA
Dyspnoea is a subjective experience of
breathing discomfort that is comprised of
qualitatively dist...
MECHANISM OF DYSPNOEA
Receptors involved in mechanism of dyspnea
1) J receptors – alveolo-capillary junction
• Stimulated by pulmonary congestio...
COPD
Thorax is in hyperinflated position/Diaphragm
Work of breathing is high, O2 cost of breathing high
Derangement of dea...
INTERSTITIAL LUNG DISEASE
Work of breathing & O2 cost of ventilation
increased
Effort of respiratory muscles in ventilatio...
Pleural effusion & Pneumothorax
collapse of the normal lung hypoxia
muscles at mechanical disadvantage
Dyspnoea
Anemia
Ina...
PULMONARY EDEMA
alveolar & interstitial edema stimulate J-receptors
Dyspnoea
MUSCULOSKELETAL DISORDERS
Hightened motor dri...
STEPWISE APPROACH
 history
 physical examination
 investigations
 treatment
HISTORY TAKING
Onset
Position
Timing
Severity
Ppt/Relieving factors
Associated symptoms
•
Minutes
• Pneumothorax
• Pulmonary oedema
• Major pulmonary embolism
• Foreign body
• Laryngeal oedema
Hours
• Asthma
• ...
Months
• Pulmonary fibrosis
• Thyrotoxicosis
• Muscle weakness
Years
 Muscle weakness
 COPD
 Chest wall disorders
ACUTE DYSPNOEA
RESPIRATORY CAUSES
-PNEUMOTHORAX
-ACUTE ASTHMA
-ACUTE PULM.EMBOLISM
-UPPER AIRWAY OBSTRUCTION
-PULMONARY ED...
CARDIAC CAUSES
Acute MI
Acute valvular insufficiency
Aortic dissection
 Complete heart block
Pericardial tamponade
C...
CHRONIC DYSPNOEA
AIRWAYS
1. Obstructive airway disease
2. Asthma
3. Chronic bronchitis
4. Empyema
5. Cystic fibrosis
PAREN...
OTHER CAUSES
CONGESTIVE HEART FAILURE
CONSTRICTIVE PERICARDITIS
NEUROMUSCULAR DISORDERS
ANEMIA
POSITION
ORTHOPNOEA
• CCF
• LVF
• COPD
• Br.asthma
• Massive
pleural effusion
• Bil diaphragm
palsy.
• Ascites
• GERD
PLATYPNOEA
• ...
TIMING
NOCTURNAL ONSET DYSPNOEA
- CHF
- COPD
- BRONCHIAL ASTHMA
- SLEEP APNOEA
- POST NASAL DRIP
- NOCTURNAL ASP. IN GERD
PAROXYSMAL NOCTURNAL DYSPNOEA
Severe difficulty in breathing that awakens the
patient from sleep and forces him to a sitt...
POSTPRANDIAL DYSPNOEA
GERD
ASPIRATION
FOOD ALLERGY
GRADING
DYSPNOEA GRADING SCALES
Visual analogue scale
Borg scale
Bode index
Sherwood jones grading
American thoracic society ...
EXAMPLE OF A VISUAL ANALOG SCORE. THESE CAN BE ADAPTED TO ANY
SYMPTOM AND CAN BE SUPPLEMENTED WITH ANCHORING VERBAL
OR VIS...
SHERWOOD JONES GRADING
Grade 1a : housework/job with moderate difficulty
1b : with great difficulty
Grade 2a : confined to...
GRADE 1 –Dyspnoea only with unusual exertion.
GRADE 2 –Dyspnoea on doing ordinary activity
GRADE 3 –Dyspnoea on doing l...
I. Not troubled by breathlessness with
strenuous exercise.
II. Shortness of breath when hurrying or walking up a slight
hi...
0. Not troubled by breathlessness with strenuous exercise.
1. Shortness of breath when hurrying or walking up a slight hil...
PPT/RELIEVING FACTORS
 Precipitating factors :
+ exercise
+ exposure – cigarette ,allergens
+ occupational exposure
+ obesity
+ severe weight l...
ASSOCIATED SYMPTOMS
-FEVER
-CHEST PAIN
-Central chest pain
-Pleuritic chest pain
-Pericardial pain
-WHEEZE
 Chronic sputum production
 Change in the pitch of voice
 Palpitations and syncope
 Haemoptysis
 Dysphagia or odynoph...
Heart burn
Muscle weakness or myalgias
Visual disturbances & headache
Bone pain
PAST MEDICAL HISTORY
SURGICAL HISTORY
DRUG HISTORY
OCCUPATIONAL HISTORY
SMOKING HISTORY
PHYSICAL EXAMINATION
 EXAMINE NOSE
 LOOK FOR CYANOSIS
 PALLOR
 ICTERUS
 CLUBBING
 EDEMA
 CERVICAL LYMPHADENOPATHY
RAISED JVP
PERIPHERAL PULSES AND BRUITS
GOITRE
 Hypotension, tachycardia, and tachypnea : acute
pulmonary edema , ARDS
 Hypertension in a dyspnoeic patients:
hypertens...
Cardiovascular examination
Elevated neck veins, extra heart sound (S3 gallop rhythm),
and fluid retention - congestive he...
Respiratory examination
Pursed lip breathing - COPD.
A barrel chest - emphysema and cystic fibrosis.
Stridor -upper air...
The trachea may deviate away from the lesion-
tension pneumothorax or a large pleural effusion.
Unilateral dullness to p...
Neurological examination
Cranial nerve palsies associated with
dyspnoea -botulism.
Ptosis -myasthenia gravis, myotonic
d...
Pneumothorax
 Sudden-onset dyspnoea associated with unilateral chest pain may
indicate acute pneumothorax.
 On examinati...
Anaphylaxis
 Exposed to a medication, food product, or insect bite.
 Sudden-onset dyspnoea is accompanied by cutaneous
m...
Acute pulmonary embolism
Sudden dyspnoea and chest pain, associated
with tachycardia, tachypnoea, hypotension,
hypoxaemia,...
Foreign body aspiration
History of epilepsy, syncope, altered mental status (e.g.,
intoxication, hypoglycaemia), or choki...
Upper airway obstruction
Significant dyspnoea, inspiratory stridor, and
occasionally expiratory wheezing, exacerbated
by ...
Acute myocardial infarction
 Presents with central chest pain radiating to the shoulders and
neck frequently accompanied ...
Acute valvular insufficiency
 Acute dyspnoea,
 systolic murmur and signs of acute cardiovascular collapse with
hypotensi...
Congestive heart failure
 Presents with dyspnoea worsened by exertion, orthopnoea and
paroxysmal nocturnal dyspnoea, elev...
Complete heart block
 Dyspnoea with weakness, light-headedness, or syncope.
 ECG
Pericardial tamponade
 Dyspnoea accomp...
INVESTIGATIONS
CBP – Anemia , polycythemia ( ch.Hypoxemia),
BIOCHEMICAL –
- Occult renal disease
- acid – base derangement
- collagen v...
ECG - CAD, pulm HTN, arrhythymias
PFT –
- lung volume & flow rate
- DLco
- Arterial blood gases
- Cardiopulmonary exercise...
CARDIAC EVALUATION –
-ECHO
-Thallium scan
-Holter monitoring(occult ischemia
/arrythmia)
-Cardiac monitoring
-Cardiac cath...
Treat the underlying cause
Pneumothorax - closed tube thoracostomy
Foreign body removal
Asthma – bronchodilators,steroi...
TREATMENT STRATEGIES
REDUCE VENTILATORY DEMAND
DECREASE SENSE OF EFFORT
IMPROVE RESP.MUSLE FUNCTION
PULMONARY REHABILI...
REDUCE VENTILATORY DEMAND
-Treat airway disease
-Supplemental oxygen
-Opiates & sedatives.
-Exercise training.
-Cognitive ...
DECREASE SENSE OF EFFORT & IMPROVE RESP. MUSCLE
FUNCTION
-Energy conservation (walk slowly)
-Breathing strategies ( pursed...
PULMONARY REHABILITATION
PATIENT EDUCATION
EXERCISE TRAINING
OPTIMIZE BODY COMPOSITION
PSYCHOSOCIAL SUPPORT
PHYSIOLOG...
evaluation of dyspnoea
evaluation of dyspnoea
evaluation of dyspnoea
evaluation of dyspnoea
evaluation of dyspnoea
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evaluation of dyspnoea

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evaluation of dyspnoea

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evaluation of dyspnoea

  1. 1. EVALUATION OF DYSPNOEA DR. PRAPULLA CHANDRA
  2. 2. DEFINITION OF DYSPNOEA Dyspnoea is a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interaction among multiple physiological, psychological, social, and environmental factors, and it may induce secondary physiological and behavioral responses.
  3. 3. MECHANISM OF DYSPNOEA
  4. 4. Receptors involved in mechanism of dyspnea 1) J receptors – alveolo-capillary junction • Stimulated by pulmonary congestion ,oedema, micro emboli. • Responsible for rapid shallow breathing 2) Stretch receptors – thoracic cage & lung 3) Chemoreceptors - carotid arteries, aorta & reticular substance of medulla Stimulated by hypoxia, excess of CO2, decrease in PH 4) Receptors in the respiratory muscle – immediate cause of appreciation of dyspnea
  5. 5. COPD Thorax is in hyperinflated position/Diaphragm Work of breathing is high, O2 cost of breathing high Derangement of dead space ventilation & alveolar capillary gas exchange Afferent stimuli to sensorymotor cortex Dyspnoea
  6. 6. INTERSTITIAL LUNG DISEASE Work of breathing & O2 cost of ventilation increased Effort of respiratory muscles in ventilation stimulate afferent impulses DYSPNOEA
  7. 7. Pleural effusion & Pneumothorax collapse of the normal lung hypoxia muscles at mechanical disadvantage Dyspnoea Anemia Inadequate O2 delivery to respiratory muscles increased respiratory drive Dyspnoea
  8. 8. PULMONARY EDEMA alveolar & interstitial edema stimulate J-receptors Dyspnoea MUSCULOSKELETAL DISORDERS Hightened motor drive required to activate weakened respiratory muscles Dyspnoea
  9. 9. STEPWISE APPROACH  history  physical examination  investigations  treatment
  10. 10. HISTORY TAKING
  11. 11. Onset Position Timing Severity Ppt/Relieving factors Associated symptoms
  12. 12. • Minutes • Pneumothorax • Pulmonary oedema • Major pulmonary embolism • Foreign body • Laryngeal oedema Hours • Asthma • Left heart failure • Pneumonia Days • Pneumonia • ARDS • Left heart failure • Repeated pulmonary embolism Weeks • Pleural effusion • Anemia • Muscle weakness • Tumours ONSET OF DYSPNOEA
  13. 13. Months • Pulmonary fibrosis • Thyrotoxicosis • Muscle weakness Years  Muscle weakness  COPD  Chest wall disorders
  14. 14. ACUTE DYSPNOEA RESPIRATORY CAUSES -PNEUMOTHORAX -ACUTE ASTHMA -ACUTE PULM.EMBOLISM -UPPER AIRWAY OBSTRUCTION -PULMONARY EDEMA -TRAUMA -FOREIGN BODY
  15. 15. CARDIAC CAUSES Acute MI Acute valvular insufficiency Aortic dissection  Complete heart block Pericardial tamponade Congestive heart failure
  16. 16. CHRONIC DYSPNOEA AIRWAYS 1. Obstructive airway disease 2. Asthma 3. Chronic bronchitis 4. Empyema 5. Cystic fibrosis PARENCHYMAL 1. ILD 2. Malignancy -primary -secondaries PLEURAL 1. Effusion 2. Malignancy 3. Fibrosis PULM-VASCULAR DISEASE 1. A-V Malformations 2. Vasculitis 3. Veno-occlusive disease
  17. 17. OTHER CAUSES CONGESTIVE HEART FAILURE CONSTRICTIVE PERICARDITIS NEUROMUSCULAR DISORDERS ANEMIA
  18. 18. POSITION
  19. 19. ORTHOPNOEA • CCF • LVF • COPD • Br.asthma • Massive pleural effusion • Bil diaphragm palsy. • Ascites • GERD PLATYPNOEA • Left atrial myxoma • Massive pulm. Embolism • Pulm. AV fistula • Paralysis of intercostal .m • Hepato pulmonary syn. TREPOPNOEA • DISEASE OF ONE LUNG/ BRONCHUS • CCF
  20. 20. TIMING
  21. 21. NOCTURNAL ONSET DYSPNOEA - CHF - COPD - BRONCHIAL ASTHMA - SLEEP APNOEA - POST NASAL DRIP - NOCTURNAL ASP. IN GERD
  22. 22. PAROXYSMAL NOCTURNAL DYSPNOEA Severe difficulty in breathing that awakens the patient from sleep and forces him to a sitting or standing position. Almost always implies underlying heart failure
  23. 23. POSTPRANDIAL DYSPNOEA GERD ASPIRATION FOOD ALLERGY
  24. 24. GRADING
  25. 25. DYSPNOEA GRADING SCALES Visual analogue scale Borg scale Bode index Sherwood jones grading American thoracic society scaling NYHA Scale MRC Classification MMRC dyspnoea scale
  26. 26. EXAMPLE OF A VISUAL ANALOG SCORE. THESE CAN BE ADAPTED TO ANY SYMPTOM AND CAN BE SUPPLEMENTED WITH ANCHORING VERBAL OR VISUAL DESCRIPTORS AS SHOWN HERE.
  27. 27. SHERWOOD JONES GRADING Grade 1a : housework/job with moderate difficulty 1b : with great difficulty Grade 2a : confined to chair/bed but able to get up with moderate difficulty. 2b : with great difficulty Grade 3 : totally confined to chair/bed Grade 4 : moribund
  28. 28. GRADE 1 –Dyspnoea only with unusual exertion. GRADE 2 –Dyspnoea on doing ordinary activity GRADE 3 –Dyspnoea on doing less than ordinary activity. GRADE 4 –Dyspnoea at rest. NYHA SCALE
  29. 29. I. Not troubled by breathlessness with strenuous exercise. II. Shortness of breath when hurrying or walking up a slight hill. III. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace. IV. Stops for breath after walking about 100m or after a few min. or level ground. V. Too breathless to leave the house or breathless when dressing or undressing. MRC CLASSIFICATION
  30. 30. 0. Not troubled by breathlessness with strenuous exercise. 1. Shortness of breath when hurrying or walking up a slight hill. 2. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace. 3. Stops for breath after walking about 100m or after a few min. or level ground. 4. Too breathless to leave the house or breathless when dressing or undressing. MMRC SCALE
  31. 31. PPT/RELIEVING FACTORS
  32. 32.  Precipitating factors : + exercise + exposure – cigarette ,allergens + occupational exposure + obesity + severe weight loss + medication  Relieving factors : - rest - medication
  33. 33. ASSOCIATED SYMPTOMS
  34. 34. -FEVER -CHEST PAIN -Central chest pain -Pleuritic chest pain -Pericardial pain -WHEEZE
  35. 35.  Chronic sputum production  Change in the pitch of voice  Palpitations and syncope  Haemoptysis  Dysphagia or odynophagia  Vomiting and diarrhoea
  36. 36. Heart burn Muscle weakness or myalgias Visual disturbances & headache Bone pain
  37. 37. PAST MEDICAL HISTORY SURGICAL HISTORY DRUG HISTORY OCCUPATIONAL HISTORY SMOKING HISTORY
  38. 38. PHYSICAL EXAMINATION
  39. 39.  EXAMINE NOSE  LOOK FOR CYANOSIS  PALLOR  ICTERUS  CLUBBING  EDEMA  CERVICAL LYMPHADENOPATHY
  40. 40. RAISED JVP PERIPHERAL PULSES AND BRUITS GOITRE
  41. 41.  Hypotension, tachycardia, and tachypnea : acute pulmonary edema , ARDS  Hypertension in a dyspnoeic patients: hypertension-related diastolic heart failure with pulmonary oedema, hyperthyroidism, or phaeochromocytoma Pulsus paradoxus - asthma, COPD, cardiac tamponade. BLOOD PRESSURE
  42. 42. Cardiovascular examination Elevated neck veins, extra heart sound (S3 gallop rhythm), and fluid retention - congestive heart failure. Elevated neck veins, pulsus paradoxus, a pericardial knock, pericardial rub, and the Kussmaul's sign - Constrictive pericarditis and effussion An irregular or fast heart beat - a tachyarrhythmia or atrial fibrillation.  A loud S2 -PAH A systolic heart murmur- acute valvular insufficiency, mechanical valve malfunction.
  43. 43. Respiratory examination Pursed lip breathing - COPD. A barrel chest - emphysema and cystic fibrosis. Stridor -upper airway obstruction Hoarseness - in laryngitis, laryngeal tumours, vocal cord paralysis.
  44. 44. The trachea may deviate away from the lesion- tension pneumothorax or a large pleural effusion. Unilateral dullness to percussion - pleural effusion, atelectasis, foreign body aspiration, pleural tumours, or pneumonia.  Hyper-resonance - pneumothorax or severe emphysema.  Subcutaneous emphysema - pneumomediastinum
  45. 45. Neurological examination Cranial nerve palsies associated with dyspnoea -botulism. Ptosis -myasthenia gravis, myotonic dystrophy, or botulism.
  46. 46. Pneumothorax  Sudden-onset dyspnoea associated with unilateral chest pain may indicate acute pneumothorax.  On examination, breath sounds are unilaterally absent, and percussion of the ipsilateral chest may reveal tympany.  The trachea may also be deviated away from the lesion. Acute asthma  Acute-onset dyspnoea associated with wheezing and cough, especially in a person with prior history of asthma  Asthma is diagnosed based on the history and demonstration of airflow obstruction reversibility. RESPIRATORY CAUSES
  47. 47. Anaphylaxis  Exposed to a medication, food product, or insect bite.  Sudden-onset dyspnoea is accompanied by cutaneous manifestations , voice changes, a choking sensation, tongue and facial oedema, wheezing, tachycardia, and hypotension.  Nausea, vomiting, and diarrhoea Pulmonary contusion  History of trauma  may present with dyspnoea, circulatory collapse, and shock.
  48. 48. Acute pulmonary embolism Sudden dyspnoea and chest pain, associated with tachycardia, tachypnoea, hypotension, hypoxaemia, hemoptysis and calf tenderness.
  49. 49. Foreign body aspiration History of epilepsy, syncope, altered mental status (e.g., intoxication, hypoglycaemia), or choking and coughing after ingesting food (particularly nuts) may suggest foreign body aspiration. Cyanosis and stridor followed by hypotension and circulatory collapse .
  50. 50. Upper airway obstruction Significant dyspnoea, inspiratory stridor, and occasionally expiratory wheezing, exacerbated by exercise.
  51. 51. Acute myocardial infarction  Presents with central chest pain radiating to the shoulders and neck frequently accompanied by dyspnoea. ► O/E patient may be clammy and hypotensive.  S3 or S4 gallop rhythm  pulmonary rales.  characteristic ECG changes,  elevated cardiac enzymes CARDIAC CAUSES
  52. 52. Acute valvular insufficiency  Acute dyspnoea,  systolic murmur and signs of acute cardiovascular collapse with hypotension, tachycardia, and pulmonary rales.  An echocardiogram is typically required to establish the diagnosis. Aortic dissection  Dyspnoea  severe chest pain that may radiate to the back.  hypotension and absent peripheral pulses.  Emergency echocardiogram or a CT chest is used for diagnosis.
  53. 53. Congestive heart failure  Presents with dyspnoea worsened by exertion, orthopnoea and paroxysmal nocturnal dyspnoea, elevated neck veins, peripheral fluid retention, an S3 gallop rhythm, and pulmonary congestion (fine bibasal rales) .  The CXR shows characteristic signs of pulmonary venous congestion with cardiomegaly.  Echocardiography.  B-type natriuretic peptide >100 pg/ml
  54. 54. Complete heart block  Dyspnoea with weakness, light-headedness, or syncope.  ECG Pericardial tamponade  Dyspnoea accompanied by neck vein and facial engorgement, shock, peripheral cyanosis, and tachycardia.  An enlarged cardiac silhouette on CXR and a low-voltage ECG, echocardiography.
  55. 55. INVESTIGATIONS
  56. 56. CBP – Anemia , polycythemia ( ch.Hypoxemia), BIOCHEMICAL – - Occult renal disease - acid – base derangement - collagen vascular disease - thyroid disease BNP – Secreted by ventricles in response to inc. ventr . pressure . - LVF ,COR PULMONALE CXR – SPIROMETRY – (airway & parenchymal diseases)
  57. 57. ECG - CAD, pulm HTN, arrhythymias PFT – - lung volume & flow rate - DLco - Arterial blood gases - Cardiopulmonary exercise testing - bronchial challenge - maximal insp. Pressure Imaging techniques - VP scan - CT (HRCT/contrast) CT angiogram - Gallium scan - Diaphragmatic fluoroscopy BRONCHOSCOPY
  58. 58. CARDIAC EVALUATION – -ECHO -Thallium scan -Holter monitoring(occult ischemia /arrythmia) -Cardiac monitoring -Cardiac catherisation (with exercise) CARDIOPULMONARY EXERCISE TESTING ESOPHAGEAL EXAMINATION / pHmonitoring ENT examination Sleep studies Psychological assessment
  59. 59. Treat the underlying cause Pneumothorax - closed tube thoracostomy Foreign body removal Asthma – bronchodilators,steroids Anaphylaxis – adrenaline & avoidance of precipitating agent TREATMENT
  60. 60. TREATMENT STRATEGIES REDUCE VENTILATORY DEMAND DECREASE SENSE OF EFFORT IMPROVE RESP.MUSLE FUNCTION PULMONARY REHABILITATION
  61. 61. REDUCE VENTILATORY DEMAND -Treat airway disease -Supplemental oxygen -Opiates & sedatives. -Exercise training. -Cognitive behavioural therapy
  62. 62. DECREASE SENSE OF EFFORT & IMPROVE RESP. MUSCLE FUNCTION -Energy conservation (walk slowly) -Breathing strategies ( pursed lip breath) -Position ( leaning forwards) -Correct obesity / malnutrition -Inspiratory Muscle exercise -Resp . Muscle rest(nasal /transtracheal O2) -Medication (theophylline)
  63. 63. PULMONARY REHABILITATION PATIENT EDUCATION EXERCISE TRAINING OPTIMIZE BODY COMPOSITION PSYCHOSOCIAL SUPPORT PHYSIOLOGIC ASSESSMENT

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