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Diagnosis of Dyspnea

Diagnosis of Dyspnea. Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency Medicine University Hospitals Case Medical Center. 2010-11. Dyspnea. Dyspnea – from Latin ‘dyspnoea’. Dyspnea (also SOB, air hunger ) subjective symptom of breathlessness .

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Diagnosis of Dyspnea

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  1. Diagnosis of Dyspnea • Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency Medicine University Hospitals Case Medical Center 2010-11 Dyspnea DyspneaDyspnea

  2. Dyspnea – from Latin ‘dyspnoea’ • Dyspnea (also SOB, air hunger) • subjective symptom of breathlessness. • normal in heavy exertion • pathological if it occurs in unexpected situations. DyspneaDyspnea

  3. Definition • Dyspnea: unpleasant, subjective sensation of abnormal respiration. • Labored breathing - physical presentation of respiratory distress/ dyspnea • Many causes April, 99 2 DyspneaDyspnea

  4. Descriptors of Dyspnea • Dyspnea on Exertion (DoE) • Dyspnea after Eating (PPD) • Nocturnal Dyspnea • Paroxysmal nocturnal dyspnea • Dyspnea in Pregnancy (hormonal, mechanical) DyspneaDyspnea

  5. What is respiratory distress? • Vague term meaning “not breathing well”. A constellation of signs including: • using accessory muscles of respiration • tachypnea • Gasping • Panting • restlessness • Sometimes, also confusion (hypoxemia) • Somnolence (hypercarbia) DyspneaDyspnea

  6. Respiratory Definitions • Eupnea - normal breathing • Bradypnea - decreased breathing rate • Tachypnea – breathing very fast. Pt not always aware of it. • Apnea – not breathing at all • Hyperpnea - faster and/or deeper breathing • Hyperventilation - rapid breathing with hypocarbia DyspneaDyspnea

  7. Goals of this presentation • Discuss dyspnea & its differential diagnosis • Discuss pathophysiology • Discuss diagnostic tests for dyspnea April, 99 DyspneaDyspnea

  8. My Philosophy of teaching: • Me: make it as simple as you can. No simpler. • You: Interact, ask questions. You will stay awake ;). • No question is dumb, and the answer will be just in front of you. DyspneaDyspnea

  9. Principles of Emergency Medicine • “Air goes in and out.” • “Blood goes round and round.” • “All bleeding stops eventually.” • “All else is details.” • But…the devil is in the details. DyspneaDyspnea

  10. What is NOT Dyspnea? • Not the O2 saturation of Hemoglobin • Not the total amount of O2 attached to Hemoglobin • Not the amount of O2 in solution in the blood (the PaO2) • Not the respiratory rate, (not all tachypnea is dyspnea) • But: a subjective sensation of air hunger. DyspneaDyspnea

  11. Case 1 • 47 y/o man c/o dyspnea. SOB, worse on exertion • Also admits to mild left sided CP, maybe respirophasic. • Onset 5-7 days ago. Getting slightly worse • What else do you want to know? • What’s your current differential? • Admit or Discharge? DyspneaDyspnea

  12. Case 1 – additional history • PMHx: none. No asthma • SHx: Tobacco Smoker. Social drinker. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works at a desk. • ROS: needs to see a dentist. No palpitations. No edema. No PND, nor orthopnea. Otherwise negative. • What else do you want to know? DyspneaDyspnea

  13. Case 1 • V/S: T=36.9; P=85; RR=20; BP 128/79 • HEENT: nl • CHEST: WD, nl excursion, lungs hard to hear, but no rales, ronchi, wheezes. • Cor: RRR w/o RMG. • Abd: soft & NT, well muscled. • Extr/MS/Neuro/Skin: all wnl. • How will you approach this? DyspneaDyspnea

  14. Approach to the patient with shortness of breath, or respiratory distress: the emergency approach. DyspneaDyspnea

  15. 1: Degree of urgency • Is the patient going to live long enough to give you a history? • If not, intervene. • If yes, try to make a diagnosis. DyspneaDyspnea

  16. 2. Assess patient. • Is the patient actively trying to breath?  look for mechanical obstruction. Correct it. • Is patient hypoxic? If yes,  increase FiO2 • Is the patient not able to breathe adequately? If no,  supplement respiratory efforts. DyspneaDyspnea

  17. 3. Locate the problem • Causes of air hunger: • mechanical, • metabolic, • cerebral, • Psychological DyspneaDyspnea

  18. 4. Correct it • Topic for another lecture • After the (correct) diagnosis is made, treatment is (relatively) simple DyspneaDyspnea

  19. Suspicion • You don’t have to know all the diagnoses, but you do have to evaluate threat to life • Know when & how to intervene. • Understand your tools. • Understand your available interventions. • Know when to get help DyspneaDyspnea

  20. Ask (yourself) questions. • Can the chest wall support breathing? • Are there barriers preventing the air getting through the airway to the blood? • Are there metabolic reasons to increase respiratory rate? • Is enough blood, of good quality, going round and round?  if not, assist circulation DyspneaDyspnea

  21. What is the purpose of respiration: • Gas exchange • To assist in balancing blood (body) pH • Lesser extent: temperature regulation / cooling the body • Cellular respiration vs Organism respiration DyspneaDyspnea

  22. Abnormal atmosphere • CO: even small amounts of CO can bind with hemoglobin in place of O2 and prevent O2 binding (competitive inhibition) 300 times more tightly than O2 • Methemoglobinemia occasionally causes dyspnea; usually just tachypnea • Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow. DyspneaDyspnea

  23. Other substances • can injure the airways directly • Noxious / toxic gases – work in many different ways and levels. • Allergens – immune system modulated • Particulates – “smothering” • Irritants – cause bronchospasm DyspneaDyspnea

  24. Mechanical Airway Obstruction • External: gagging, strangulation, smothering • Internal: food bolus, other mechanical airway obstructions: peanuts, beads, • Internal growths: tumors, infections, abscesses • Encroachment on the airway • Internal substances: pus, blood, mucus, transudates DyspneaDyspnea

  25. Muscular / Chest Wall system • Diaphragm • Chest wall muscles • Accessory muscles such as supraclaviculars, neck muscles. • Myesthenia, paralysis other muscular causes • Increased muscle tension. DyspneaDyspnea

  26. Air to blood interface: • Mechanical filling of alveoli • Lack of surfactant: alveoli collapse with exhalation • Abnormalities (thickening) of alveolar membranes, • Interstitium (tissues between the alveolus and the capillary endothelium) • Capillary endothelium • Blood: enough of it, flowing well enough DyspneaDyspnea

  27. Causes of dyspnea • Psychogenic • Hypoxic • Metabolic • Pulmonary • Cardiogenic • Hematologic • Any others? DyspneaDyspnea

  28. Tools to evaluate dyspnea • Suspicion / Clinical knowledge. “If you don’t think of it, you will never find it.” • History • PE including • Vital Signs, pulse ox, PEF • Formal Studies April, 99 DyspneaDyspnea

  29. What other tools? • PEF • ABG • Other blood tests • CXR • EKG • CT • UltraSound DyspneaDyspnea

  30. Additional items of history • Cough • Vomiting • Temporal relationship  What does that mean? • Circadian variations DyspneaDyspnea

  31. Cough • What good is a cough? • What bad is a cough? • Central & peripheral triggers • Air travels in excess of 150 kilometers per second during a cough • can denude respiratory epithelium • exposed basement membranes stimulate future antigenic response DyspneaDyspnea

  32. Aphorism • Coughing till you vomit is bronchospasm till proven otherwise. Consider cardiac. • Vomiting AND THEN coughing -> think aspiration DyspneaDyspnea

  33. Vital Signs • What are the VS? • Normal vs Stable • How do they change over time? • What does this tell you? DyspneaDyspnea

  34. Vital Signs • The meaning of each value depends on its context. • A slowing respiratory rate in a bad asthmatic may mean he is about to die. • A slowing respiratory rate in an anxious bystander may mean he is getting better. DyspneaDyspnea

  35. Vital Signs: • Respiratory rate: Do it yourself! • Temp. Don’t trust the Triage Temps. • HR, BP. What do they tell you about the RR? DyspneaDyspnea

  36. Pulse Ox • What is a dangerous level? Why? • When is the pulse ox normal and the patient about to die? Why? • When is the pulse ox bad and the patient is fine? Why? DyspneaDyspnea

  37. VS - Combinations: • High RR, HR, BP • Discussion • Low RR, HR, BP • Discussion • High RR, HR, low BP • Discussion DyspneaDyspnea

  38. Focused exam • Accessory muscles • Facial expression, color. • Chest wall, lungs, heart, abd & extr. • (Discussion) DyspneaDyspnea

  39. Physical Exam • Observation • Auscultation – with and without a stethoscope. Where? • Palpation – what & where & why? • Scratch test • The REST of the exam – habitus, edema, muscle wasting, lots more. DyspneaDyspnea

  40. Scratch Test • Place stethoscope on mediastinum, gently scratch the anterior chest wall alternate sides, equidistant from the stethoscope. One side may not transmit sounds as well as the other. • What would the scratch test tell you? April, 99 DyspneaDyspnea

  41. Pathophysiology • chemoreceptors, mechanoreceptors, lung receptors • 3 components that contribute to dyspnea: afferent signals, efferent signals, and central information processing. • brain compares the afferent and efferent signals, and a "mismatch" results in the sensation of dyspnea. DyspneaDyspnea

  42. Afferent neurons • chemoreceptors • carotid bodies, Various brain organs, juxtacapillary (J) receptors, • chest wall and its musclesMuscle spindles sense stretch • Lung parenchymal tissues, DyspneaDyspnea

  43. Efferent signals • motor neurons of respiratory muscles. • Diaphragm, intercostal, abdominal muscles, accessory muscles. DyspneaDyspnea

  44. Central Processing • Objective data • Subjective data • Psychiatric is a diagnosis of exclusion DyspneaDyspnea

  45. Grade 0 1 2 3 4 Degree of dyspnea no dyspnea except with strenuous exercise Only when walking up incline or hurryingl Slow on level, or stops after 15 minutes stops few minutes of walking on the level minimal activity such as getting dressed, too dyspneic to leave the house MRC Breathlessness Scale The Modified Borg Scale April, 99 DyspneaDyspnea

  46. Causes of dyspnea • 4 general categories: • cardiac, • pulmonary, • mixed cardiac or pulmonary, • Non-cardiac, non-pulmonary DyspneaDyspnea

  47. Asthma Pneumonia Pleural effusion Pneumothorax Interstitial Lung disease COPD Psychogenic Pericardial effusion Cardiac ischemia CHF Dysrhythmia Mechanical obstruction Anemia Common specific disease entities DyspneaDyspnea

  48. Blood tests • ABG • Vidas d-Dimer • BNP • Basic Metabolic Panel • Cardiac Enzymes • What else, and why? DyspneaDyspnea

  49. Chest radiography (CXR) • Insufficient by itself • Do your own read: the radiologist may not know what you are looking for and may overlook the most important clue. • Look for pneumothorax, aortic dissection, pneumonia, pleural effusions, sub-segmental atelectasis, pulmonary infiltrates or an elevated hemi-diaphragm April, 99 DyspneaDyspnea

  50. CXR 1 DyspneaDyspnea

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