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Dr . M.Shahparianpour

chronic dyspne a. Dr . M.Shahparianpour. There are no precise data on the prevalence of dyspnea . The actual scope of the problem varies among clinical settings and patient subgroups . Population-based surveys have estimated the prevalence to be between 17% and 38%

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Dr . M.Shahparianpour

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  1. chronic dyspnea Dr .M.Shahparianpour

  2. There are no precise data on the prevalence of dyspnea. The actual scope of the problem varies among clinical settings and patient subgroups. Population-based surveys have estimated the prevalence to be between 17% and 38% In an ambulatory setting the prevalence of dyspnea was 3.7% Morbidity associated with dyspnea can range from minor to disabling

  3. For a dyspneic patient presenting to the office, the initial goal is to determine the severity of the dyspneaand the need for urgent intervention such as intubation. The clinical approach to the patient depends on the acuteness of the problem.

  4. The patient who has chronic shortness of breath may be more difficult to diagnose because the dyspnea typically develops over weeks to months, patients alter their activities in response to the dyspnea so the severity may not apparent, and dyspnea is frequently out of proportion to any physiologic impairment that is found

  5. Definition: Dyspnea is defined as an awareness of difficulty in breathingIt is therefore a symptom, usually described by the patient as “short of breath,” whether the sensation is due to actual difficulty in breathing or is essentially an awareness of hyperventilation. If the symptom becomes striking, it always companies with dilatation of nares, cyanosis, use of accessory muscles of respiration and abnormalities of respiratory rate, depth or rhythm.

  6. Definition: • Chronic dyspnea: Dyspnea lasting > 1 month • 2/3 cause: Cardiopulmonary disease • Accurate diagnosis is essential because treatment is different • 85% causes: • Asthma, Congestive heart failure(CHF), Chronic obstructive pulmonary disease(COPD), pneumonia, Cardiac ischemia, Interstitial lung disease(ILD), psychogenic

  7. Definition • Synthetic sensation (like thirst) • Patient’s description: • A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity • I can’t not get enough air • My chest feels tight • Air hunger

  8. Etiology • Respiratory diseases • Circulatory diseases • Poisoning • Hematology • Neuropsychogenic factors

  9. Respiratory dyspnea • Caused by abnormal ventilation and gas exchange, reduction in ventilatory capacity, hypercapnia and hypoxemia resulting from respiratory disease. • Three clininal types: Inspiratorydyspnea Expiratory dyspnea Mixed dyspnea

  10. Inspiratory dyspnea • Tends to occur primarily when there is obstruction ( such as inflammation, edema, tumor and foreign body) in larynx, trachea and major bronchi. • Characterized by the depression sigh, in which visible indrawing over the sternal notch, the supraclavioular spaces, the intercostal spaces and the epigastrium in the inspiration can be seen. • Often accompanied by a coarse, low pitched inspiratory wheezing and dry cough.

  11. Expiratory dyspnea • Expiratory dyspnea is due to the decrease of lung elasticity and spasm narrowing of the bronchioles and smaller bronchi as in emphysema, bronchial asthma and asthmatic bronchitis. • Expiration is prolonged and laboured with wheezing.

  12. Mixed dyspnea • Occurs with the extensive lung disease, such as severe pneumonia, pulmonary fibrosis, massive atelectasis, pleural effusion and pneumothorax. • Results in the decrease of ventilators and gas exchange capacity. • Breathing is difficult during both inspiration and expiration.

  13. Cardiac dyspnea Cardiac dyspnea is usually attributable to pulmonary vascular congestion resulting from the left and/or right heart failure.

  14. Cardiac dyspnea • In Left-sided heart failure, compliance is reduced, and therefore, ventilation is decreased to the edematous lung regions and vital capacity reduced. • Alveoli are stiff and more work is needed to overcome elastic recoil, the high alveolar pressure will stimulate stretch receptor and initiate the inflation reflex resulting in early turning off of inspiration and an increase in respiratory rate.

  15. Cardiacdyspnea • The dyspnea caused by right-sided heart failure is less severe than that one caused by left-sided. • Mechanism: (1) The pressure of right atrial and superior vena cava is the natural stimulus of respiratory center. (2) The decrease of oxygen content and the accumulation of the acid metabolites, such as lactic, stimulate respiratory center. (3) The restriction of the respiratory movement caused by enlargement of liver resulting from congestion, ascites and pleural effusion.

  16. Cardiacdyspnea Symptoms of congestive heart failure can cause orthopnea and paroxysmal nocturnal dyspnea when elevated-filling pressure is present.

  17. orthopnea • Orthopnea is difficulty in breathing in the supine position, this may be relived by sitting up, which reduces the degree of pulmonary congestion by pooling blood in the lower extremities and lowering left ventricular filling pressures, improving the diaphragmatic movement, increasing vital capacity.

  18. paroxysmal nocturnal dyspnea • Symptoms: The patient awakes short of breath at night, but often obtain relief by sitting up for a period of time. In the most advanced cases, the patients become acutely dyspneic, cyanotic and very frequently produce foamy sputum tinged with blood. • Signs: Moist rales at the both lung bases, tachycardia, wheezing and bronchospasm, the markedly accentuated second heart sound in the pulmonic area.

  19. paroxysmal nocturnal dyspnea • Mechanism: Supine posture for sleep results in resorbtion of extracellular fluid into the intravascular space, causing arise in filling pressure. • The paroxysmal dyspnea is termed as cardiac asthma. It can be seen in the hypertensive heart disease and coronary heart disease.

  20. Toxicdyspnea • In the metabolic acidosis (uremia and diabetic ketosis), the acid metabolites stimulate the respiratory center, causing deep and regular respiration with snoring. • The overdose of morphine and pentobarbital can depress respiratory center causing deep respiration or Cheyne-Stokess respiration

  21. Neuro-Psychogenicdyspnea • In patients suffering from cerebrovascular diseases (intracranial hemorrhage, elevated intracerebral pressure), the respiratory center loses the blood supply or is compressed. The respiration becomes deep, slow and irregular. • In some cases the dyspnea may be psychogenic, which is characterized by repetitive deep, sighing respiration with numbness of extremities or lips, cheiropedal spasm. • These are also manifestations of acute hypocapnia and respiratory alkalosis.

  22. Hematologicaldyspnea • In severe anemia, sulfhemoglobinemia, methaemoglobinemia or carbon monoxide poisoning the decrease of oxygen-carrying capacity and oxygen content develop abnormal respiration and increased heart rate. • The respiration rate also increases in shock which stimulates respiration center because of hypotension.

  23. Accompanied Symptom • Paroxysmal dyspnea with wheezing. • Dyspnea with chest pain. • Dyspnea with fever. • Dyspnea with cough and purulent sputum. • Dyspnea with coma.

  24. Paroxysmal dyspnea with wheezing It is present in bronchial asthma and cardiac asthma. Paroxysmal severe dyspnea is often seen in acute larynx edema, foreign body in bronchi, massive pulmonary embolism, and spontaneous pneumothorax.

  25. Dyspnea with chest pain. It is frequently observed in lobar pneumonia, pulmonary infarction, spontaneous pneumothorax, acute exudative pleurisy, acute myocardial infarction, and bronchial carcinoma.

  26. Dyspnea with fever. It is commonly noted in pneumonia, lung abscess, pulmonary tuberculosis, pleurisy, acute pericarditis, and nervous system diseases.

  27. Dyspnea with cough and purulent sputum. It is often present in chronic bronchitis, obstructive pulmonary emphysema with infection, purulent pneumonia, and lung abscess; Dyspnea with large amount of foamy sputum is often seen in acute left ventricular heart failure and organophosphorus poisoning.

  28. Dyspnea with coma. It suggests cerebral hemorrhage, meningitis, pneumonia with shock, uremia, diabetic ketoacidosis, and acute poisoning.

  29. Introduction • Peak incidence: 55-69 y/o • Common cause: • COPD • Heart failure • Evaluation: • History • PE • Laboratory test • Spirometry • Image

  30. Differential Diagnosis • Underlying cause of dyspnea cannot be determined by duration or severity • 2/3 causes: pulmonary or cardiac disorder

  31. Differential Diagnosis • 85% causes: • Asthma • CHF • Pneumonia • Cardiac ischemia • ILD • Psychogenic conditions [Generalized anxiety disorder(GAD), Panic disorder, Post-traumatic stress disorder(PTST)]

  32. Differential Diagnosis • Cause of 1/3 patients: multifactorial • Persistent breathlessness despite maximal therapy: Decondition or emotion

  33. Clinical Assessment • 81% accurate diagnosis • History • PE • CXR

  34. the initial physician impression of the etiology of dyspnea based on the history alone was correct only 66% of the time in one study

  35. Patients may have difficulty describing the exact sensation of their dyspnea. They should be questioned about the onset, frequency and duration of breathlessness, as well as triggers and strategies that provide relief

  36. Intermittent dyspnea is more likely caused by reversible events, such as: bronchoconstriction, pleural effusion, CHF, or even chronic recurrent thromboemboli

  37. Progressive dyspnea more likely stems from: COPD, neuromuscular disorders, or interstitial lung disease

  38. Clinical Assessment • Asthma: • Intermittent breathlessness • Triggering factors • Allergic rhinitis • Nasal polyps • Prolonged expiration • Wheezing

  39. Clinical Assessment • COPD: • Significant tobacco consumption • Barrel chest • Prolonged expiration • Wheezing

  40. COPD diagnosis • Severe COPD: • PE: Barrel chested appearance, Hyperresonance on percussion • CXR: Hyperinflation • PFT: most useful comfirmation

  41. Clinical Assessment • CHF: • History of Hypertension, Conronary arter disease(CAD) or Diabetes mellitus(DM) • Orthopnea • Paroxysmal nocturnal dyspnea(PND) • Pedal edema • Jugular vein distention • S3 gallop • Bibasilar rales • Wheezing

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