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Similar to breathlessness breathing deficulty. .ppt
breathlessness breathing deficulty. .ppt
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- 2. Definition • Breathlessness isan unpleasant sensation of uncomfortable, rapid or difficult breathing. People say they feel puffed, short of breath or winded. The medical term is dyspnoea. Your chest may feel tight and breathing may hurt. Everyone can experience breathlessness if they run for a bus or exert themselves to an unusual extent. But it is important to seek medical attention if you experience breathlessness, as it may be due to a serious underlying problem • Undue awareness of breathing and is normal with strenuous physical exercise • Sense of awareness of increased respiratoryeffort that is unpleasant and that is recognizedby the patient as being inappropriate • Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable need to breathe.. • 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 isnot painful in the usual sense of the word’
- 3. MRC (medicalresearch council)DyspnoeaScale 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
- 4. New York HeartAssociation(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.
- 5. Common Causes System Acutedyspnoea 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
- 6. System Chronic exertionaldyspnoea 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
- 7. History taking • Patient's details: Name Age Sex Occupation : paint sprayers, rubber industry workers are prone to lung disease Address Date of Admission
- 8. History taking • Chief Complaints oShortnessof 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 , oAggravating factors : pollen, dust, cold climate - asthma, sinusitis oRelieving factors : rest, medication
- 9. 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
- 10. 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
- 11. 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
- 12. 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
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- 14. 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
- 15. Head to ToeExamination 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 ) 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
- 16. 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
- 17. Examination Sequence 1. Notethe patient’s general appearance and demeanour. 2. Look for central cyanosis of the lipsandtongue. 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 andcervical 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. Feelthe trachea and cardiacapex 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.
- 18. Differential diagnosis Develop differentialdiagnosis in a patient with breathlessness based on history and examination
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- 20. Bedside investigations Pulse OximetryPeak Flow Rate • 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 • 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.
- 21. Radiology Chest X-Ray • Todetermine 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.
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- 23. Pharmacological • The treatmentof 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.
- 24. Oxygen Treatment • Evidencehave 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.
- 25. Non-pharmacological • There doesseem 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.
- 26. There aresome breathing control techniques that can help to reduce breathlessness. Examples include: • Relaxed, slow, deep breathing: breathe in gently through your nose and breathe out through your nose and mouth. Try to stay feeling relaxed and calm. • Paced breathing: this may help when you are walking or climbing stairs. Try to breathe in rhythm with your steps at a speed you find comfortable. • Controlled breathing. This involves using your diaphragm and lower chest muscles to breathe instead of your upper chest and shoulder muscles. Breathe gently and keep your shoulders and upper chest muscles relaxed.
- 27. Use differentcomfortable seating and standing positions when you feel breathless. Different positions suit different people but examples include: • When standing up, lean from the hips with your forearms resting on something at a comfortable height, such as a chair or kitchen work surface. • When standing put your hands on your waist or in your back pockets. • When sitting, lean forwards, resting your forearms on your knees, on the arms of a chair, or on a table. Arrange the things you use every day to make sure they are easy to reach. Try to stay active but take a rest when you feel breathless and then start again.
- 28. Avoidance/prevention • Quit smoking,alcohol • Weight loss • Regular exercise • Avoid going to areas with dust, smoke, air pollution • Cholesterol management • Bp management • Diabetes control • diet
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