Recommended
More Related Content
What's hot
What's hot (20)
Similar to Approach to dyspnea
Similar to Approach to dyspnea (20)
Recently uploaded
Recently uploaded (20)
Approach to dyspnea
- 1. APPROACH to DYSPNEA Moderator- Dr Yashwanth Presented by- Dr Nandan
- 2. Definition of Dyspnea A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity . The experience derives from interactions among multiple physiological, psychological, social and environmental factors and may induce secondary physiological and behaviour responses.
- 3. Terms to know Orthopnea – dyspnea occurs in supine position within 1-2 minute after assuming the position (acute LVF,mssive pleural effusion,severe CCF, respiratory muscle weakness) Platypnea – dyspnea on upright position (left atrial thrombus/tumors) Trepopnea –dyspnea in lateral decubitus (pleural effusion,DCM) Paroxysmal nocturnal dyspnea –Dyspnea occurs 2-4 hrs after the onset of sleep & takes 15 min to recover. LVF, asthsama,cardiomyopathy,atrial fibrillation
- 4. Tachypnea – increased rate of respiration Bradypnea- decreased rate of respiration Hyperventilation – increased depth of respiration Hyperpnea – increased rate and depth of respiration
- 5. Mechanism of orthopnea &PND During the day, gravitational effects may favour a loss of intravascular fluid into the inte stitial space. • When the patient is in a horizontal position, the venous return to the heart increases and left ventricle fails to cope up with extra volume of blood leading to pulmonary interstitial edema PND – similar to orthopnea + decreaed sympathetic drive during the sleep
- 6. Pathophysiology Respiratory sensations are the consequence of interactions between the efferent or outgoing motor output from the brain to the ventilatory muscles (feed-forward) and the afferent or incoming sensory input from receptors throughout the body (feedback) as well as the integrative processing of this information will be Occurring in the brain
- 7. Receptors involved in mechanism 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(hering breur reflexes) 3) Chemoreceptors - carotid arteries, aorta & reticular substance of medullaStimulated by hypoxia, excess of CO2, decrease in PH 4) Receptors in the respiratory muscle – immediate cause of appreciation of dyspnea
- 8. Pathophysiology Hypoxemia Acidosis or hypercarbia Decreased compliance Airway resistance Carotid body medullary chemoreceptors L;ung and muscle mechanorece ptors Airway receptors DYSPNEA
- 13. Causes of Acute Dyspnea Cardiovascular - Myocardial Infarction , Cardiac Tamponade, CCF Pulmonary -Pneumothorax(Tension) Pneumonia , Pulmonary Embolism, ARDS a) Lower Airway - Asthma , AE of COPD b) Upper Airway - Aspiration Anaphylaxis
- 15. Causes of Chronic Dyspnea Cardiovascular - Effusion, Cardiac Tamponade, Pericardial Constriction Systolic Dysfunction , Diastolic Dysfunction , Cardiomyopathies Valvular Stenosis , Regurgitation, Sub-Valvular Disease Coronary Artery Disease , Stable Angina , Acute Coronary Syndrome Atrial Fibrillation Bradyarrhythmia Tachyarrhythmia
- 16. Pulmonary Pleural Abnormalities - Pleural Effusions , Pleural Thickening/Masses Pulmonary Alveoli - Pneumonia, Neoplasm Pulmonary Interstitium - ILD CHF Sarcoidosis Airway Obstruction - Asthma , COPD , Bronchiectasis Pulmonary Vessels - PE , PAH Chest Wall Abnormalities - Neuromuscular Weakness ,Kyphoscoliosis , Abdominal Distention
- 17. Other causes • Anemia •Anxiety • Deconditioning • Hyperthyroidism • Metabolic Acidosis GERD
- 19. How do we APPROACH? Assess airway patency and listen to the lungs Observe breathing pattern, including use of accessory muscles Measure vital signs and pulse oximetry. Obtain any history of cardiac or pulmonary disease, or trauma. Monitor cardiac rhythm Evaluate mental status.
- 20. HISTORY Previous history Onset (IHD,pneumothorax,PE), chest pain Fever /throat pain/symptoms Cough Assosciated with sputum/blood and sounds during breathing Positional variation Indigestion/dysphagia, occupation Weight loss, decreased appetite Alcohol, anxiety, foreign body,trauma
- 21. ONSET MINUTES Pneumothorax Pulmonary edema,PE & aspiration Laringeal edema & ACS HOURS Asthma LVF Pneumonia DAYS Pneumonia ,ARDS, LVF WEEKS Pleural effusion, anemia,muscle weakness MONTHS Pulmonary fibrosis thyrotoxicosis
- 22. Past history - Asthma /Copd/CCF Personal history – Alcohol, occupation Family history - Asthma, autoimmune diseases, muscular dystrophies
- 23. Symtoms Cough - Asthma, pneumonia,COPD Severe sore throat - Epiglottitis Pleuritic chest pain - Pericarditis, pulmonary embolism, pneumothorax, pneumonia Orthopnea, nocturnal paroxysmal dyspnea, edema - Congestive heart failure
- 24. Tobacco use - Chronic obstructive pulmonary disease, congestive heart failure, pulmonary embolism Wheeze - COPD , asthmaCHF Fever - Pneumonia, broncitis,TB Hemoptysis- Pneumonia ,TB, CA,PE Indigestion, dysphagia - Gastroesophageal reflux disease, aspiration Barking cough - Croup
- 25. Post prandial - GERD, Aspiration, foreign body Nocturnal onset dyspnea- CHF, COPD, Asthma, sleepapnea,GERD
- 26. General physical examination Consciousness Physique and gait Use of accesory muscles Ptosis Pallor Icterus Clubbing Cyanosis/lymphadenopathy/ edema
- 27. Pallor Hb <13 M and <12 F Nutritional deficiency Imapired red cells production / infections Hemolytic anemia Genetic and acquired
- 28. Clubbing cardiac causes Infective endocarditis, CHD Eisenmerger syndrome Pulmonary causes Bronchiectasis,cystic fibrosis, lung abcess, crcinoma, ILD , long standing TB Thyrotoxicosis
- 29. CYANOSIS Ventilation perfusion mismatch Cyanotic congenital heart disease Reduced cardiac output
- 31. Vitals sign Pulse rate Temperature Respiratory rate Blood pressure
- 32. PULSE RATE INCREASED arrhythmias,cardiac failure,hypotension.anemia DECREASED severe hypoxia,heart blocks , MI(inferior wall)
- 33. RHYTHM regular and irregular CHARACTER Hypokinetic – mitral and aortic stenosis hyperkinetic – anemia pulsus bisferens – Aortic regurgitation pulsus paradoxus- cardiac tamponade, AE of asthama
- 34. Respiratory rate 14-18 cycles /min Tachypnea,bradypnea(alkalosis, ICT) hyperpnea(acidosis) Rhythm Cheyne stroke(hyperapnea with apnea) - cardiac failure,midbraion and upper pons
- 35. Kussmauls breathing increase in rate and depth acidosis and pontine lesion Biots breathing apnea between several shallow or few deep inspirations (meningitis)
- 36. Shape of chest wall AP to Transverse – 5:7 Flat chest 1:2 – TB Barrel chest 1:1 – COPD Pectus excavatum and carinatum
- 37. Inspection URT examination Position of trachea JVP Llymphnode enlargement Supraclavicular fullness Engorged veins Palpitations and pulsations Apical impulse
- 38. Palpation Measurements Apical impulse Vocal fremitus increased in consolidation and decreased in effusion Percussion Dull note – consolidation and collapse Hyperesonant in pneumothorax Impaired in Fibrosis
- 40. Auscultation Wheeze/Ronchi Expiratory in asthama and emphysema(polyphonic) Inspiratory in Fibrosis Crackles Fine (alveoli) and coarse (bronchus)
- 41. Bilateral crackles – LVF Expiratory – chronic bronchitis BREATH SOUNDS Tubular , Cavernous , Amphoric
- 42. Investigations CBC,LFT,RFT, S/E Spirometry, ABG ECG/2D Echo CHEST XRAY HRCT THORAX
- 45. Questions/clues for diagnosis Wheezing, pulsus paradoxus, accessory muscle use Acute asthma, COPD exacerbation
- 46. Wheezing, clubbing, barrel chest, decreased breath sounds COPD exacerbation
- 48. Edema, neck vein distension, S3 or S4 hepatojugular reflux, murmurs, rales, hypertension, wheezing Congestive heart failure, pulmonary edema
- 49. Wheezing, friction rub, lower extremity swelling PE
- 51. Stridor, wheezing, persistent pneumonia Foreign body aspiration
- 52. THANK YOU