Dyspnea 2007

Dyspnea: The Pulmonary Perspective Section of Pulmonary and Critical Care

DYSPNEA: Breathing Life into a Complex Symptom

Maria Piedad Rosales – Natividad, MD and Patrick Gerard L, Moral, MD Section of Pulmonary and Critical Care Medicine Department of Medicine, UST Faculty of Medicine and Surgery

Definition • “a person’s uncomfortable sensation associated with breathing” • a perception by the individual and is entirely subjective • not a clinical observation, nor does it relate directly to any physiological or laboratory test • the patient’s interpretation of a reduction in pleasant breathing. Frontline Cardiopulmonary Topics / Dyspnea, 2001*

OBJECTIVES • review the different pathophysiologic events • integrate subjective and objective data in order to come up with a logical diagnosis of the cause of dyspnea • select and prioritize ancillary procedures in the diagnosis and management of the disease • apply basic pharmacologic and nonpharmacologic therapy based on etiopathogenesis of the disease

Evaluation of the Dyspneic Patient • acquisition of a detailed history describing the conditions under which the patient has been or is currently experiencing dyspnea • a physical examination • a chest radiograph • measurements of pulmonary mechanics Frontline Cardiopulmonary Topics / Dyspnea, 2001*

Patient presents with dyspnea

Initial hypotheses

ID, CC, HPI

Ask questions Px is better; no further care

Px DIES

HPI, PMH, FH. Social, ROS

Refine hypotheses

Observe results Chronic Disease

Treat patient accordingly

More questions

ECG, etc.

Select most likely diagnosis

PE

Examine patient Lab tests

Radiologic studies

Once an emergent situation has been excluded, the patient's airway, mental status, ability to speak, and breathing effort should be reevaluated. A focused history should be obtained, and a physical examination completed.

Patient presents with dyspnea

Initial hypotheses

ID, CC, HPI

Ask questions Px is better; no further care

Px DIES

HPI, PMH, FH. Social, ROS

Refine hypotheses

Observe results Chronic Disease

Treat patient accordingly

More questions

ECG, etc.

Select most likely diagnosis

PE

Examine patient Lab tests

Radiologic studies

Listening to the Patient •Getting to know the patient •Characterizing the symptom •Understanding its effects on the patient •Achieving a common perception of the problem

Getting to know the patient • • • • • • • •

Name Age Sex Race / Nationality / Ethnicity Civil Status Occupation Residence Religion

Communication

Hingal

sumisikip ang Kapos ng dibidib

hininga Nasasakal Hinahapo

Are all episodes of dyspnea pathologic?

yes

no

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Normal Dyspnea • Dyspnea may occur normally in states of intense exercise, such as running, mountain climbing, lifting, rowing, and swimming, where the stress of breathing is a direct result of intense physical effort and not a consequence of cardiopulmonary or metabolic disorder.

Key Questions • • • • • •

Quality (description, progression) Location / Radiation Severity (bearable, intolerable) Timing /Duration (acute, chronic) Setting Precipitating (body positions, exposures) Palliating (body positions, medications) • Associated symptoms (chest pain, cough)

Quality • I feel that I am suffocating • My chest feels tight • My breathing is heavy • I feel that I am smothering • My breath does not go in all the way • My breath does not go out all the way • I feel that I am breathing more

•My breathing requires effort •I cannot get enough air •I feel a hunger for air •My breathing is shallow •I feel out of breath •My chest is constricted •My breathing requires work

CHEST 2000; 118:679–690

Severity • The usual technique is to determine the amount of effort required to bring on dyspnea. – How far can the patient walk, at a normal pace (in meters) before stopping due to shortness of breath? – Can the patient walk uphill? – How many flights of stairs can the patient climb? – In conversation, can the patient finish a sentence (or word) without taking a breath? – During telephone conversations, does the patient notice shortness of breath?

• These questions should be asked at each visit to assess symptom progression or improvement.

Visual Analogue Scale No shortness of breath

100 mm line

Shortness of breath as bad as can be

Borg Scale 0 0.5 1 2 3 5

10

-

Nothing at all Very, very slight Very slight Slight Moderate Somewhat severe Severe Very Severe Very, very severe Maximal

4 6 7 8 9

Timing • Onset of dyspnea: recent or remote, • Has there been a recent change in severity? • Acute, subacute, or chronic • Recurrent or continuous

Time Course

Setting - Precipitating

Palliating

Associated Symptoms

Associated Symptoms

Key Questions • Cardiac questions – presence or absence of chest pain, orthopnea, paroxysmal nocturnal dyspnea (PND), edema, weight gain, and any cardiac medications or cardiac diagnoses of the patient.

• Pulmonary questions – presence or absence of wheezing, chest tightness, cough, sputum production, pleuritic pain, sleep patterns (apneas), and a history of tobacco smoking

• Other – history of cirrhosis, renal insufficiency, anemia, or endocrine abnormalities, all of which can be quickly reviewed.

Patient presents with dyspnea

Initial hypotheses PULMONARY

ID, CC, HPI

Ask questions Px is better; no further care

Px DIES

HPI, PMH, FH. Social, ROS

Refine hypotheses

Observe results Chronic Disease

Treat patient accordingly

More questions

ECG, etc.

Select most likely diagnosis

PE

Examine patient Lab tests

Radiologic studies

Afferent and Efferent Signals

Manning HL, Schwartzstein, RM. Mechanisms of disease: Pathophysiology of dyspnea. New Engl J Med. 1995;

Ventilatory Control Neurogenic Factors

Voluntary Control anxiety / hysteria

cortex

Pulmonary receptors sensitive to stretch and Chest wall bronchial irritation (stimulated receptors in asthma, pulmonary embolism and pneumonia)

Juxta capillary (J) receptors stimulated by pulmonary congestion (heart failure)

Muscle and joint receptors stimulated by exercise

Chemical Stimuli

Respiratory Center stimulated by increase PaCO2 and H+

Carotid and Aortic Bodies stimulated by increase PaO2 < 8kPa

Dyspnea

respiratory respiratory drives drives

cardiopulmonary system response cardiopulmonary system response

• The work of breathing must be appropriate to the task and in the context of the resultant cardiovascular and respiratory responses.

Pulmonary Sources

obstructive

Respiratory work major components: 1. resistive load

– the resistance of moving air through the airways

2. elastic load

restrictive

– the load imposed by elasticity and recoil of the lungs, thorax, and respiratory musculature

vascular

Restrictive

Obstructive

Vascular • Ventilation • No perfusion

Migration

Embolus Thrombus

Gas Diffusion • Thickness of membrane • Surface area of membrane • Diffusion coefficient of gas • CO driving pressure • RBC volume • Rate of reaction of Hgb and CO

O2 O2

O2

Patient presents with dyspnea

Initial hypotheses

ID, CC, HPI

Ask questions Px is better; no further care

Px DIES

HPI, PMH, FH. Social, ROS

Refine hypotheses

Observe results Chronic Disease

Treat patient accordingly

More questions

ECG, etc.

Select most likely diagnosis

PE

Examine patient Lab tests

Radiologic studies

Additional Data • Past Medical History – Immunizations, past ailments, allergies

• Family History – Pedigree chart, household contacts

• Social History – Smoking (pack years); substance abuse

• Occupational History – Present and previous employment

• Review of Systems – All other symptoms not referable to the pulmonary system

Tobacco Use • Pack-Year History – Pack/s of cigarettes per day x number of years – One pack: 20 cigarettes – Ex-smoker; Still smoking? – Practices: (Ilocos – placing the lit end in the mouth)

• Environmental tobacco smoke (Passive smoking) • Other tobacco products

Historical Data

C.O. complains of shortness of breath General Data Chief Complaint History Social/ Family/ Past Medical/Occupational Review of Systems

Dyspnea General Data: •42, male – cardiac, pulmonary •asian – if pulmonary, not cystic fibrosis or alpha-1 antitrypsin deficiency •politician – cardiac •Pampanga – volcanic dust exposure?

History: •progressive – cardiac, pulmonary (COPD)? •worsened with dust and heat – asthma / COPD •relieved by salbutamol– asthma, / COPD •episodic/ at rest– asthma/ COPD/ cardiac/ embolism

Dyspnea Additional history: •smoker – cardiac, pulmonary (STOP!) •obesity – cardiac, restrictive lung, embolism •hypertension– cardiac; medication exacerbates asthma •Pain reliever– drug allergy (ask about dyspnea occurring with drug intake) •Family hx – (+) asthma; PTB less likely •Politician – no other occupational risks

Dyspnea Review of Systems: •Weight gain – hypothyroid; familial; anxiety •Morning headaches– sleep apnea •Daytime somnolence– sleep apnea; work related •Cold intolerance – hypothyroidism •Morning nasal stuffiness – rhinitis •Epigastric pain – peptic ulcer; reflux; NSAID •Knee pains – osteorathritis •Edema – cardiac, obesity; DVT; cor pulmonale

Differential Diagnosis •Cardiac – Coronary Artery Disease –Dyspnea – congestive heart failure

•Bronchial asthma or COPD –Dyspnea – obstructive lung disease

•Obesity ( familial or due to hypothyroidism) –Dyspnea - restricitive

•Deep venous thromboses > embolism –Dyspnea - vascular

•Anxiety –Dyspnea - psychogenic

Anxiety symptoms may imply psychogenic causes of dyspnea, but organic etiologies always should be considered first.

Patient presents with dyspnea

Initial hypotheses

ID, CC, HPI

Ask questions Px is better; no further care

Px DIES

Chronic Disease

PE

Examine patient QuickTimeª and a YUV420 codec decompressor are needed to see this picture.

HPI, PMH, FH. Social, ROS

Refine hypotheses

Observe results

Treat patient accordingly

More questions

Lab tests

Radiologic QuickTimeª and a ECG, etc. Animation decompressor are needed to see this picture. studies

Select most likely diagnosis

Initial Assessment of Patients with Dyspnea • Assess airway patency and listen to the lungs. • Observe breathing pattern, including use of accessory muscles. • Monitor cardiac rhythm. • Measure vital signs and pulse oximetry. • Obtain any history of cardiac or pulmonary disease, or trauma. • Evaluate mental status.

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Inspection

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Palpation

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Percussion

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Percussion

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Physical Examination Pneumonia

Effusion

Pneumothorax

Atelectasis

INSPECTION (trachea)

Normal (midline)

Lagging Lagging (contralateral) (contralateral)

Lagging (ipsilateral)

PALPATION

Inc. fremiti

Dec. fremiti

Dec. fremiti

PERCUSSION

Dullness

Dullness

AUSCULTATION Inc. BS

Dec. BS

Dec. fremiti

Hyperresonance

Dec. BS

Dullness

Dec. BS

Communicating with the patient •Give reassurance •Address the needs of the patient while taking your history •Assure the patient of your availability •Emphasize the partnership in treatment

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General Data •C.O. •42 year old •Male •Married (one wife) •Asian - Filipino •Government worker •Pampanga •Roman Catholic

History •1 year before admission, he developed shortness of breath upon walking 100 meters. It would be worsened by dust exposure and heat.This would partly be relieved by intake of salbutamol by inhaler.

History •1 month before admission, he would experience dyspnea after walking 10 meters. He had occasional cough, with occasional increases in severity of the shortness of breath even at rest that would resolve spontaneously. Wheezing would occasionally be heard.

Additional Data •Past Medical History –No vaccination –Obesity - sibutramine –Hypertension on metoprolol –Osteoarthritis – on celecoxib

•Family History –(+) asthma – father; (-) PTB; Obesity – parents and siblings

•Social History –20 pack years smoker until now

•Occupational History –Politician; no previous job

Review of Systems •100 lbs weight gain in 2 years •Morning headaches •Daytime somnolence •Cold intolerance •Morning nasal stuffiness •Epigastric pain •Knee pains •Edema of both lower extremities with discoloration

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