This document discusses the approach to a patient presenting with dyspnea. It defines dyspnea and outlines its types, pathophysiology, physiological pathways, etiologies including cardiac, pulmonary, mixed and other causes. It describes the clinical features, assessment, relevant history, examinations and investigations for a patient with dyspnea. It concludes by stating that dyspnea is a common symptom that varies between individuals depending on physiological, psychological and social factors, and its management depends on identifying and treating the underlying cause.

2. APPROACH TO PATIENT WITH
DYSPNOEA
DR NIMRAH ARIF
PGR 1 MEDICAL UNIT 1

3. ‘A subjective experience of breathing discomfort that
consists of qualitatively distinct sensations that vary in
intensity’,.
Dyspnea

4. TYPES
Acute or Chronic

5. Patients perceptions:
o Unsatisfied inspiration
o Chest tightness
o Sensation of feeling breathless
o Cannot get enough air
o Hunger for air
o Incomplete exhalation

6.  Dissociation between pulmonary ventilation and respiratory drive
 Components of dyspnea
a. afferent signals
b. efferent signals
c. central information processing
 cardiovascular, respiratory system, metabolic derangements,
neuromuscular disorders or psychogenic conditions
Pathophysiology

7.  Specific acid-sensing ion channels,
 Mechanoreceptors and lung receptors.
 Chemoreceptors in the carotid bodies and medulla
 Juxtacapillary receptors are sensitive to edema
 Stretch receptors signal bronchoconstriction
Physiological pathways

8. 4 categories
1. Cardiac
2. Pulmonary
3. Mixed cardiac or pulmonary
4. Non-cardiac or non-pulmonary
ETIOLOGY

9. • CHF
• CAD
• MI (recent or past history)
• Cardiomyopathy
• Valvular dysfunction
• LVH
• Pericarditis
• Arrhythmias
CARDIAC ETIOLOGY

10.  COPD
 Asthma
 Restrictive Lung Disorders
 Hereditary Lung Disorders
 Pneumonia
 Pneumothorax
PULMONARY ETIOLOGY

11.  COPD with pulmonary HTN
 Chronic pulmonary emboli
 Pleural effusion
MIXED

12.  Acidosis
 Neuromuscular disorders
 Obesity
 Anxiety
 Chemical exposure
 Pain
 Trauma
Other causes

13.  Should be based on
1. Intensity of sensation
2. Degree of Dyspnea
3.Impact of daily activities
Assessment of patient

14. CLINICAL FEATURES
SIGNS
o Unable to complete sentences
o Tachypnea
o Increased respiratory effort
o Nasal flaring
o Use of accessory muscles
o Wheeze, Crepitation, Silent chest.
o Cyanosis
SYMPTOMS
o Shortness of breath
o Chest tightness
o Associating symptoms

15.  0. Breathlessness on strenuous exercise
 1. Breathlessness when hurrying or walking up a slight
hill.
 2. walk slower than others or stop when walking at own
pace on level ground
 3.stop after a few minutes
 4. too breathless to leave the house /on washing/dressing
GRADES OF DYSPNOEA

16.  Hypotension
 Respiratory rate >40 breaths/minute
 Altered mental status
 Hypoxia
 Cyanosis
 Stridor
 Breathing effort without air movement
 Tracheal deviation with unilateral breath sounds
 Unstable arrhythmia
Red flags for Dyspnoea

17.  Onset
 Duration
 Aggravating factors
 Relieving factors
 Associating factors
a. Sputum
b. Wheeze
c. Chest pain
d. Effort intolerance
e. Edema ,PND , Orthopnea
History

18. 1. Cardiac disease:
2. Respiratory disease:
3. Renal disease
4. Thyroid disease
MEDICAL HISTORY

19.  General appearance
 Pulsus paradoxus
 Extremities.
 Neck.
 Cardiac and pulmonary disease.
 Abdomen.
Clinical examination

20.  APPROACH TO PATIENT WITH DYSPNOEA
DR NIMRAH ARIF

21.  Full blood count
 ABGS
 Blood glucose
 Serum electrolytes
 RFTS
 Troponin
First Line Investigations

22.  Chest radiography (CXR).
 Electrocardiography (ECG)
 Cardiopulmonary exercise tests
 D-dimer
 Brain natriuretic peptide (BNP)
 Point-of-care ultrasound scans and echocardiography
 pulmonary embolism rule-out criteria
Relevant special investigations

23.  Treatment of the underlying disease
 Relieving symptoms
1. Supplemental oxygen
2. Pharmacological therapy
3. Pulmonary rehabilitation
4. Other non-pharmacological approaches.
Management

24.  Dyspnoea is a common and often distressing symptom
 Dyspnoea is symptom, and its experience is subjective
and varies greatly among individuals
 Differential experience of dyspnea among individuals
emanates from interactions among multiple
physiological, psychological, social and environmental
factors.
 The management of Dyspnoea will depend on the
underlying cause.
Conclusion

25. THANKS