Breathlessness

1. BREATHLESSN
ESS
Zahra Said AL- Rashdi 86114

2. Definition
 Breathlessness= dyspnea =shortness of
breath
 The feeling of an uncomfortable need to
breathe

3. :causes
respiratory
Acute severe
asthma
Acute exacerbation
of COPD
Pneumothorax
Pneumonia
Cardiovascular
Acute pulmonary
edema
MI

4. Case 1
 A 60 yr old man presented to ER with severe
retrosternal crushing chest pain that was
radiating to the left arm and lasting for 40
mins.
 It was associated with SOB, nausea &
excessive sweating.

5.  He had similar episodes of mild chest pain
over the past 4 months when he walked at a
fast pace or climbed a flight or 2 of stairs. Each
time, the pain lasted for 1-5 minutes & was
relieved by rest. The pain has been occurring
more frequently and lasting longer over the
past 2 wks & sometimes occurring at rest

6.  . He had no prior health problems. He was not
on any regular medication & had no allergies.
He had an older brother with similar
complaints. He is married with 4 children. He
doesn’t smoke or consume alcohol.

7. Physical examination
 General examination
 Obese man
 No pallor or cyanosis
 He had no pedal edema
• Vital signs
 HR= 110
 BP= 150/90
 T= 37.2 C
 RR= 26
 O2 = 98%
• Cardiac examination
 All pulses were palpable
 JVP was normal
 Heart sounds were normal

8. DDx
 MI
 LVF
 Heart burn
 CHF
 Pericarditis

9. Investigation
 Urgent
 ECG ….. ST elevation in anterior leads
 CBC, blood glucose, & troponin … normal
 Chest x-ray was ……normal

10. Diagnosis
MI

11.  . For patients presenting to the emergency
department with chest pain suspicious for an
acute coronary syndrome (ACS), the diagnosis
of STEMI can be confirmed by the ECG.
Biomarkers may be normal early. (See
"Criteria for the diagnosis of acute myocardial
infarction" and "Initial evaluation and
management of suspected acute coronary
syndrome in the emergency department"

12. MI
 Narrowing of the coronary arteries, due to
atherosclerosis. Blood clots formed on arterial walls
roughened by plaque deposits and may block one or
more of the narrowed coronary arteries completely and
cause MI.
MI

13. Clinical features
 Crushing chest pain
radiate down the left
arm, neck & jaw
 SOB
 Dizziness
 palpitation
 Sweating
 Nausea
 Tachycardia
 Tachypnea
 SpO2 decreased
 Hypotension
 Pulmonary edema
 Raised JVP
Symptoms Signs

14. Non -modifiable
• Age
• hypercholesterolemia
• Male
• familial
Modifiable
• Smoking
• Obesity
• Lack of exercise
• DM
• HTN
Risk factors

15. Action
 arrange immediate transfer to hospital
 Attend the patient once the ambulance has been
called
 aspirin
 IV analgesia( morphine )
 sublingual GTN
 oxygen
 IV antiemetic
 Thrombolysis maybe appropriate in places when
transfer to hospital takes more than 30 min

16. Management
 Relief of ischemic pain
 Assessment of the hemodynamic state and
correction of abnormalities that are present
 Initiation of reperfusion therapy with primary
percutaneous coronary intervention (PCI) or
fibrinolysis
 Antithrombotic therapy to prevent rethrombosis
or acute stent thrombosis
 Beta blocker therapy to prevent recurrent
ischemia and life-threatening ventricular
arrhythmias (1)

17. Management post MI
 All patients who have had an acute MI should
be offered treatment with a combination of the
following drugs:
 ACE (angiotensin-converting enzyme) inhibitor
 aspirin
 beta-blocker
 statin.(2)

18. The role of GP
 Support after discharge
Returne to work
Sedentry ..4-6 weeks light ...6-8weeks
heavy..3months after uncomplicated MI
Physical activity
Sexual activity ….after 6wk
Psycological effects
Driving …..after I month (4)
 Modification of risk factors

19. Prevention
Discuss how you will counsel this patient
regarding his diagnosis and future
management plan especially with regards
to life style modifications

20.  Changing dietary regimen (omega3)
 avoid smoking
 Treat elevated blood pressure and
diabetes to normal level
 Reduce stress
 Maintain ideal body weight
 Physical activity
 Healthy diet
 Decrease total cholestrol (1)

21. keep in mind

22. ‫سوريا‬ ‫أهل‬ ‫أغث‬ ‫اللهم‬..‫سوريا‬ ‫أهل‬ ‫أغث‬ ‫اللهم‬..‫سوريا‬ ‫أهل‬ ‫أغث‬ ‫اللهم‬
‫الكرب‬ ‫عنهم‬ ‫اكشف‬ ‫اللهم‬..‫بالفـرج‬ ‫ل‬ّ‫ج‬‫ع‬ ‫اللهم‬..‫قلوبهم‬ ‫بين‬ ‫ألف‬ ‫اللهم‬..
‫العالمين‬ ‫رب‬ ‫يا‬ ‫الحق‬ ‫على‬ ‫كلمتهم‬ ‫وحد‬ ‫اللهم‬...

23. Case 2
 An 60-year obese old man is brought
into the ER in the early hours of the
morning with acute shortness of breath.
He is pale, clammy, sweaty and very
distressed. This associated with
Palpitation & cough with pink frothy
sputum. He had episodes of difficulty
breathing on exertion & when lying
down. He is a known case of
uncontrolled diabetes & hypertension.
He had a previous MI. He had a strong
FHx of heart disease. He was not
smoker or alcohol consumer.

24. Physical examination
 General examination
 BMI =27
 HR =120
 RR =29
 T = 37.4C
 BP = 100/60
 SpO2 = 90%
 Central & peripheral cyanosis
 Cardiovascular and Respiratory
examination
 Inspection
 Use of accessory muscles
 Raised JVP
Palpation
– Shifted apex to
anterior axillary line
– Heave on LV area
– Trachea not deviated
Auscultation
– S3
– Fine crackles over
bases
– Wheeze
Percussion
– dullness

25. DDx
 Asthma
 COPD
 Pneumonia
 Pulmonary embolism
 Pulmonary edema

26. Inv investigation
 Chest x-ray
 Arterial blood gases
 Chest x-ray
 ECG
 Echocardiogram
 BNPs

27. Diagnosis
Pulmonary
edema

28. pulmonary edema
A pathological condition defined by the presence of large amounts
of fluid in pulmonary alveoli and in pulmonary interstitium that
interfere with blood oxygenation.
causes
left ventricular
failure
Mitral stenosis
Hypertensive
crisis
Severe
ARDS
Aspirin overdose
Pulmonary
embolism
Acute Renal failure
Respiratory failure
cardiogenic Non- cardiogenic

29. Clinical features
Dyspnea
Chest pain
Cough with pink frothy
sputum
Orthopnea
Paroxysmal nocturnal
dyspnea
Palpitation
Tachypnea
Tachycardia
Cyanosis
Pallor
Fine crackles
Wheezing
Gallop rhythm
Raised JVP
Pitting edema

30. Management
 O2 mask
 A loop diuretic (e.g., furosemide) and GTN (Preload
reducers)
 Nitroprusside and ACEI…. Decrease pre & after –
load
 Continuous ECG Monitoring
 Analgesia
 CPAP – continuous positive airway pressure. (5)

31. Complication
prevention
 Treat risk factors
 Following healthy diet
 Physical exercise

32. References;
 1.3 Drug therapy after an MI (up to date)
 MI - secondary prevention (update(up to
date)
 Shared Learning: NICE MI guidance -
Omega 3 intake
 Oxford handbook of clinical practice