l 7.approach to dyspnea
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Approach toDyspnea
Dr.Bilal Natiq Nuaman,MD
C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.
Lecturer in Iraqia Medical College
2017
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Dyspnea; Breathlessness; Shortness of
Breath(SOB)
• ‘’Dyspnea’’
Dys: difficult, painful
Pneumea:breath
• Breathlessness or dyspnea can be defined as the feeling of an uncomfortable need to breathe.
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DEFINITION OF DYSPNEA
• Clinical : A subjective experience of breathing discomfort that
consists of (qualitatively) distinct sensations that vary in
intensity.
• Physiological: The stimulation of pulmonary and extra pulmonary afferent receptors and the transmission of afferent information to the cerebral cortex, where the sensation is perceived as uncomfortable or unpleasant
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Patients perceptions:
✓ Unsatisfied inspiration
✓ Chest tightness
✓ Sensation of feeling breathless
✓ Cannot get enough air
✓ Hunger for air
✓ Incomplete exhalation
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Pathophysiology :
Respiratory diseases can stimulate breathing and dyspnea by:
➢ stimulating intrapulmonary sensory nerves (e.g. Pneumothorax, interstitial inflammation and pulmonary embolus)
➢ increasing the mechanical load on the respiratory muscles (e.g. airflow obstruction or pulmonary fibrosis)
➢ Causing hypoxia, hypercapnia or acidosis, stimulating
chemoreceptors.
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Common Pulmonary Causes
• Obstructive lung disease
• Asthma/COPD (Chronic Bronchitis ,Emphysema)
• Pneumonia
• Pulmonary embolism
• Pneumothorax
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cardiac failure can stimulate breathing and dyspnea by:
➢ pulmonary congestion reduces lung compliance and can
also obstruct the small airways.
➢ In addition, during exercise, reduced cardiac output
limits oxygen supply to the skeletal muscles, causing
early lactic acidaemia and further stimulating breathing
via the central chemoreceptors.
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Common Cardiac Causes
• Acute coronary syndromes
• CHF
• Dysrhythmias
• Valvular heart disease
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Stages of dyspnea
1-EXERTIONAL DYSPNEA- DYSPNEA DUE TO EXERCISE
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2-PND - PAROXYSMAL NOCTURNAL DYSPNEA
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3-ORTHOPNEA – SOB LYING FLAT AND BETTER SITTING UP (CHF, pregnancy, resp.muscle weakness)
4-RESTING DYSPNEA- DYSPNEA AT REST
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Common Miscellaneous Causes
• Metabolic acidosis
• Severe anemia
• Pregnancy
• Hyperthyroidsm
• Hyperventilation syndrome
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Differential diagnosis of dyspnea
Patients with breathlessness present either with
Chronic exertional dyspneaOr
Acute dyspnea,when symptoms are prominent even at rest.
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• Chronic: Dyspnea >30 daysthat develops over weeks, months or years.
• COPD
• Left ventricular failure
• Lung fibrosis
• Asthma (uncontrolled)
• Pleural effusion
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conscious level declines or if severe respiratory acidosis is
Pulmonary oedema is suggested by pink, frothy sputum and
bi-basal crackles;
asthma or COPD by wheeze and prolonged expiration;
pneumothorax by a silent resonant hemithorax; and
pulmonary embolus by severe breathlessness with normal
breath sounds.
eg swelling may suggest cardiac failure or, if asymmetrical,
venous thrombosis causing pulmonary embolism.Arterial blood gases, a chest X-ray and an ECG should beobtained to confirm the clinical diagnosis, and high concentrations of oxygen given pending results.
rgent endotracheal intubation may become necessary if the
present.
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Physical signs in dyspnic patient
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Investigations
Chest radiograph (CXR): weather cardiac or pulmonary
Cardiac Causes! Pulmonary causes!
ECG Pulmonary function test(PFT)
(abnormally significant) (abnormally significant)
Echo CT scan of chest
(abnormally significant) (abnormally significant)
Corona angiography Lung Biopsy
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CXR
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