Approach to patient with DYSPNOEA

1. Approach to patient with DYSPNOEA Sadaf Zaman 31st Jan 07

2. DYSPNOEA Dyspnoea is defined as unpleasant subjective awareness of sensation of breathing.

3. CAUSES of Acute Dyspnoea CVSAcute pulmonary oedema(LVF) Myocardial ischemia(angina equivalent) RESP Acute severe asthma Acute exacerbation of COPD Pneumothorax Pneumonia Pulmonary embolus ARDS Inhaled foreign body Lobar collapse Laryngeal oedema(anaphylaxis) OthersMetabolic acidosis (DKA ,lactic acidosis,uraemia,overdose of salicylate) Psychogenic hyperventilation (anxiety or panic-related)

4. CAUSES of Chronic Dyspnoea CVS Chronic heart failure Myocardial ischemia RESP COPD Chronic asthma Bronchial carcinoma Interstitial lung disease Chronic pulmonary thromboembolism Lymphatic carcinomatosis Large pleural effusion Others Severe anaemia Obesity

5. CAUSES of Chronic Dyspnoea chest wall pathology Kyphoscoliosis rib fractures / flail chest sternal compression Diaphragmatic causes tense ascites (causing diaphragmatic compression) diaphragmatic palsy Neurological causes ALS,MS,progressive diseases of nerves and muscles affecting respiratory muscles

6. HISTORY The development of the dyspnoea: When did it start?  was it years, months, weeks or hours ago (acute/chronic) Rate of onset ? : steady progession, attacks, acute exacerbations Frequency of the symptom: Episodic:asthma,heartfailure Constant:COPD How does the dyspnoea affect dailyactivities?(severity)

7. Severity Scale of Dyspnea New York Heart Association Classification (NYHA) CLASS 1 no limitation during ordinary activity CLASS 2slight limitation during ordinary activity CLASS3 marked limitation of normalactivities without symptoms at rest CLASS 4unable to undertake physical activitywithout symptoms maybe present at rest

8. Severity Scale of Dyspnea Grade Degree Characteristics 0 None Only with strenuous activity 1 Slight When hurrying on level ground or climbing a slight incline 2 Moderate Needs to walk more slowly than others of the same age or has to stop for breath when walking at own pace on level ground 3 Severe Stops for breath after 100 yards or after a few minutes 4 Very severe Housebound or dyspnea when dressing or undressing

9. Affecting Factors Provokingfactors: Dust,smoke,cold weather, feather,any allergy, H/O smoking Relieveing factors: rest,sitting upright, more pillow,bronchodilators

10. Associated symptoms Cough Pneumonia Asthma CCF COPD Interstitial lung disease Fever pneumonia causing exacerbation of asthma / COPD Orthopnoeaheart failure &PND

11. Associated symptoms Chestpain Pleuritic Pulmonary embolism (PE) Pneumonia, Pneumothorax Angina Myocardial ischemia

12. Contributing Factors Medicines: B-blockers causing bronchospasm Previous medications for asthma / COPD Age:Children; suspect foreign body. Elderly; suspect malignancy History of other disease: Diabetes, renal, anaemia Post –op or bed-bound patient suspect pulmonary embolism Anxiety: Causes the patient to hyperventilate

13. Key Questions for Dyspnea Evaluation

14. Assess severity of condition by Respiratory effort, use of accessory muscles Level of consciousness Degree of central cyanosis Patency of upper airway Evidence of anaphylaxis (urticaria/ angio-oedema) Ability to speak (single words or sentences) CVS status Heartratetachycardia (LVF,Pulmonary embolism,pneumonia, acute asthma) High BP (causing LVF) low BP (shock in pulmonary embolism)

15. GPE Vitals Cyanosis Anaemia Clubbing (malignancy,ILD) Barrel chest (COPD) Kyphoscoliosis (restrictive lung disease) Pursing of lips (COPD)

16. Cardiovascular System Signs of heart failure: Raised JVP Oedema of the body Enlarged liver or spleen. Engorged veins on the neck or upper chest (cor pulmonmale) Patient sitting and leaning forward S3 , soft S1 Leg swelling; cardiacfailure (or venous thrombosis) LVH : S4, Apical impulses Pulmonaryhypertension: Loud P2, Right ventricular heave

17. Respiratory system Inspection Resp rate and pattern of breathing Decreased chest expansion Accessory muscle use Shape of the chest (e.g.Barrel: Asthma) Palpation Trachea (deviated in pnumothorax,pleural effusion,fibrosis) Chestexpansion(decreased in COPD) Vocal fermitus (increased in consolidaion & decreased in effusion or pneumothorax Palpate the chest for subcutaneous emphysema and crepitus Percussion Percuss for dullness, an indication of consolidations or effusions. Hyper-resonance suggests pneumo-thorax or emphysema.

18. Respiratory system Auscultation Wheeze -Asthma,COPD,heart failure, anaphylaxis Stridor -upper airway obstruction Foreign body or tumour, acute epiglottitis,anaphylaxis, Bronchial breathing -Pneumonia Crepitations - Heart failure,pneumonia,bronchiectasis,fibrosis Chest clear - Pulmonary embolism,hyperventilation,anaemia, metabolic acidosis (may cause air hunger) Absentbreathsounds - Pneumothorax, pleural effusion

19. INVESTIGATIONS Labs Hb: Anaemia, polycythemia WBCs: Pneumonia LFT , RFT (systemic causes) ECG ACS,PE,cor-pulmonale, metabolic abnormalities ABG,s Respiratory failure

20. INVESTIGATIONS Pulse oximeter detects oxygen saturation Spirometry Measurements of Forced vital capacity (FVC) Forced expiratory volume in one second (FEV1) to diagnose both Obstructive (decreased FEV1 and decreased FEV1/FVC ratio) & Restrictive (decreased FVC and normal or increased FEV1/FVC ratio) lung disease.

21. INVESTIGATIONS CXR Cardiomegaly, pulmonary vascular congestion and pulmonary edema, CCF, pulmonary infiltrates and atelectasis, interstitial lung diseases, hyperinflation, COPDand asthma, and pulmonary hypertension

22. PLEURAL EFFUSION

23. COPD

24. PNEUMOTHORAX

25. PNEUMOTHORAX

26. PNEUMONIA

27. BRONCHOGENIC CARCINOMA

28. Dyspnea on Echocardiography • Causes of Dyspnea on ECHO Left ventricular (LV) systolic dysfunction LV diastolic dysfunctionAortic and mitral valve disease Congenital heart diseaseTumorsPericardial diseasesPulmonary hypertensionMyocardial ischemia

29. PULMONARY EMBOLISM D-dimers Doppler ultrasound of leg CT pulmonary angiogram / V/Q scan CXR Normal or non-specific changes Focal infiltrates, segmental collapse, raised hemidiaphragm, pleural effusion ECG Sinus tachycardia RVH and strain RBBB T wave inversion S1Q3T3 pattern - rare

30. PULMONARY EMBOLISM

31. ECG IN PULMONARY EMBOLISM

32. V/Q SCAN

33. Right ventricular hypertrophy

35. GENERAL MANGEMENT • Oxygen • Prop up • Morphine 10mg with antiemetic(caution in COPD ,liver failure)

36. ASTHMA / COPD Assess severity of attack Bronchodilators Nebulization with salbutamol / ipratropium bromide Steroids(hydrocortisone/prednisolone) Theophylline MgSO4 1.2-2g iv over 20min CXR to exclude pneumothorax Antibiotics

37. HEART FAILURE Diuretics (frusemide 40-80mg iv slow) Nitrates ;GTN 2 tabs SL start nitrate infusion if systolic >100mmHg Digoxin if AF

38. PULMONARY EMBOLISM Heparin unfractioned 10,000U iv bolus then 15-25U/kg/h LMW 175U/kg/24hr SC continued for 5 days or until INR>2 Inotropic supportif in shock Warfarin10mg/24hr PO continued for 6 wks if cause is known or for 3-6 months if there is no obvious cause Vena caval filters if patient develop embolism despite anticoagulation

39. PNEUMOTHORAX Percutaneous needle aspiration Mild to moderate pneumothorax(upto 2.5 litre) Spontaneous pneumothorax Chest drain Underlying lung disease Tension pneumothorax PLEURAL EFFUSION Aspiration if symptomatic Treat the cause

40. CHEST INTUBATION

41. PNEUMONIA Assess severity “CURB score” Antibiotics IV fluids (if dehydration,shock) Analgesia for pleuritic pain

42. Mechanical Ventilation Intubation & assisted ventilation The last resort Indications for assisted ventilation Repiratory arrest Deterioration in ABG,s Exhaustion,confusion,drowsiness Coma

43. If you have built castles in the air, put the foundations under them.

44. THANKS