Download - Dyspnoea TUTORIAL
GROUP A4
Tay Qin Le Low Li Tatt
Amirul Asyraf
Farah Izzati Nadiah Umar
Chua Hui Shan Magdalen
..Breathlessness..
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CASE PRESENTATION“SHORTNESS OF BREATH”
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Biodata
• Mr M• 57 y/o• Malay• Gentleman• Security Guard• Married• Kajang• Admitted: 4 August 2010
Chief Complaint
Shortness of breath for half an hour
HOPI
Intermittent SOB ?(day/night, before/after meal)
Last for half an hour Occur at rest Relieving factor: No Exacerbating factor: cold weather, lying
down, 20 feet walking
Associated symptoms
• Orthopnoea• PND(wake up 3-4 times)• Cough: productive, yellowish sputum, large
volume, bubbles, no haemoptysis, ?viscosity
• Chest pain: pleuritic chest pain with prickling in nature, chest tightness, left anterior chest wall, localised
• Wheezing while dyspnoea• Can only climb one flight of stairs• LOA, LOW(5kg in 2 weeks)• No fever
Past Medical History
• Recurrent bronchitis for 20 years and being admitted to hospital-recently admitted to HKJ 2/8/2010 and discharged on the following day
• Inhaler for 20 years (Ventoline & Bricanyl)
• No asthma• No DM, HPT• No known allergy
Family History-No significant family history except daughter has asthma since childhood
Past surgical history-do not have any surgery before.
Drug history-daun pecah kaca(Strobilanthes crispus )
Social History
Job- security guard Living environment- terrace house with
clean environment Chronic smoker Pet-No Non-alcoholic
Systemic review
General – PND CVS – orthopnoea, chest pain, no
palpitation RS – SOB, wheezing, cough, headache AS – not significant except pain at
epigastric and right hypochondriac region
US – frequency CNS & PNS – not significant MS – not significant Endocrine – not significant
Physical Examination
• General Appearance: On nasal prong, cardiac monitoring for pulse oximetry, cannula insertion at right dorsum of hand, well-hydrated
• Vital signs: RR= 26/min, HR= 92/min• RS: no clubbing, no flapping tremor, no
muscle wasting, no trachea deviation, resonance on percussion, reduced chest expansion, bibasal crepitation, reduced breath sound bilaterally, increased in AP diameter(barrel chest)
CVS: raised JVP(5 cm), apex beat not palpable, no cardiac & liver dullness, bilateral pedal edema up to mid-shin, no pallor, no jaundice, drnm
AS: tenderness at right hypochondriac and epigastric region on deep palpation
No significant finding in CNS, PNS, US, MS and Endocrine
Provisional Diagnosis: AECOPD Differential Diagnosis: CCF
SHORTNESS OF BREATH / DYSPNOEA
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Definition
Breathlessness / Dyspnoea – Awareness that an abnormal amount of works is required for breathing
....often described as SOB,inabliltiy to get enough air,suffocation,chest tightness,activities limit by exercise & heavy breathing
Orthopnoea – dyspnoea that develop when a patient is supine
Paroxysmal Nocturnal Dyspnoea – severe dyspnoea that wakes patient up from sleep to gasp for breath
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ClassificationGraded from I to IV based on the New York
Heart Association classification:
Class I – disease present but no dyspnoea or dyspnoea only on heavy exertion
Class II – dyspnoea on moderate exertion Class III – dyspnoea on minimal exertion Class IV – dyspnoea at rest
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Causes of Dyspnoea
I. Decrease O2 supply from lung dysfunction
II. Decrease O2 delivery from CVS problems
III. Decrease O2 carrying capacity in the circulation
IV. Increased O2 demand
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I. Decrease O2 supply from lung dysfunction
O2 carrying capacity is dependent on adequate air exchange in lung & to transport O2 on Hb
For adequate gas exchange, the lung need;- adequate inspiratory and expiratory forces- alveolar spaces is able to permit adequate gas exchange- vascular flow to the lung must be unobstructed
Disruption in any of above, will result in mismatches of O2 delivery and demand
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Chest mechanical abnormalities- fractured ribs, severe kyphosis/scoliosis
Airway obstruction- Epiglottic/laryngeal obstruction – Viral infection (croup), epiglottitis (Haemophilus influenzae)- Bronchial inflammation/obstruction – chronic bronchitis, lung cancers, asthma- Alveolar obstruction – pneumonia, pulmonary edema
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II. Decrease O2 delivery from CVS problems
Left ventricular failureRise of pressure in the left atrium and pulmonary capillaries leading to interstitial and alveolar oedemaLung less compliant which increase respiratory effort necessary to breathe
Cardiac failure Cardiomyopathies
- Diabetic cardiomyopathy, hypertensive cardiomyopathy
Myocardial ishemia
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III. Decrease O2 carrying capacity in the circulation
Concentration of Hb & its ability to bind & release O2 are important factors in determining available O2 in tissues
Acquired anemia – blood loss, hemolysis, underproduction
Congenital abnormalities in Hb – Thalassemia, Sickle cell
Acquired dysfunction in Hb function – Carbon monoxide poisoning
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IV. Increased O2 demand
Hyperthyroidism
Drug that produce hypermetabolic state – cocaine/ amphetamines
Generalized anxiety disorder
Panic disorder
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Causes of orthopnea Cardiac failure Uncommon-massive ascites; pregnancy;
bilat. diaphraghmatic paralysis; large Pleural Effusion; severe Pneumonia
Causes of paroxysmal nocturnal dyspnoea Left ventricular failure
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HISTORY TAKING
Evaluate patient24
Information should be obtained in patient with dyspnoea
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Relieving factors Rest Medications (physician and self-prescribed)Predisposing factors Cigarette smoking Occupational and environmental exposuresAssociated medical diseases and symptoms Pulmonary Cardiac NeuromuscularFamily history
Occurrence Rest Exertion (quantify) Position Orthopnea (dyspnea lying flat) Trepopnea (dyspnea in lateral position) Platypnea (dyspnea when upright)Other precipitating factors Environment Emotional stateChronology Duration Progression Diurnal and seasonal variations Constant or intermittent
Physical examination:
INSPECTIONLooks for signs of respiratory distressChest wall deformities
1. Respiratory rate >20 breaths per mins2. Pursed lips breathing3. Flaring of nasal alae4. Use of accessory muscle5. Subcostal & intercostal muscle retraction6. Cyanosis(severe cases)
PALPATEChest expansionbarrel chest, pigeon chest, funnel chest, kyphoscoliosisVocal fremitus
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PERCUSS Hyperresonant pneumothoraxDullFibrosis,pleural thickeningStony dullPleural effusion
AUSCULTATE
~breath sounds~added sounds-Rhonchi and
wheezing
Differential diagnosis
With wheezing?? Asthma COPD Heart failure Anaphylaxis
With crepitations?? Heart failure Pneumonia Bronchiectasis Fibrosis
Others?? Hyperresonance in
pneumothorax Stony dullness in pleural
effusion
With stridor?? Foreign body/tumor Acute epiglottitis Anaphylaxis Trauma
With chest clear?? Pulmonary embolism Hyperventilation Metabolic acidosis Anaemia Drugs eg salicylates Shock Pneumocystis pneumonia Central causes
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Investigation
Lab no use in detection of dyspnoea (great value in differential d(x) & quantify severity of underlying d/o
Pulse oxymetry measuring oxygen saturation- COPD ↓oxygen saturation
Pulmonary function test detect obstructive & restrictive of lung & chest wall; VC & (FEV1) correlate well with dyspnoea
Arterial blood gas(ABG) generally performed but limited usefulness in evaluate breathlessness; most useful for quantify severity of gas exchange abnormalities in patients with lung dysf(x
Blood test Anaemia CXRPneumothorax ECGcardiac abnormalities
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Management
Nonpharmacologic interventions-Relaxation techniques-Supportive therapy : Fans, air supply , supplementary O2
Pharmacology intervention Opiods-Morphine Anxiolytics
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DIFFERENTIAL DIAGNOSIS
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HEART FAILURE
Heart unable to maintain cardiac output to meet the demands of the body
Right heart failure – 2o to left HF, volume overload, outflow obstruction, compromised ventricular filling, etc
Left heart failure – myocardial dysfunction, vol. overload, outflow obstruction
Biventricular - myocardial dysfunction, compromised ventricular filling, arrhytmia
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SYMPTOMS
RHF Nausea, anorexia,
fatigue Dyspnoea (pl.
effusion) abdominal
distension Ankle swelling
LHF Exertional
dyspnea Orthopnea Paroxysmal
nocturnal dyspnoea
Nocturnal cough wheeze
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SIGNS
RHF JVP raised Pl. effusion Hepatomegaly Ascites Dependent pitting
oedema Fxnal tricuspid
regurgitation
LHF Resting
tachycardia Tachypnea Displaced apex
beat 3rd heart sound Basal lung
crackles Fxnal mitral
regurgitation
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INVESTIGATIONS
Blood – FBC (anemia), BUSE (poor renal fx), TFT (thyrotoxicosis)
CXR – cardiomegaly, prominent upper lobe vessel, bat’s wing, kerley B line, pl.effusion
ECG – arryhtmia, ischemia Echocardiogram – assess LV fx, valvular
abnormality, pericardial effusion
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MANAGEMENTS
Encourage bed rest during exacerbation Correction of aggravating factors –
arrythmia, anemia Low-level endurance exercise Avoid exacerbating factor e.g. NSAID (cause
fluid retention), verapamil (-ve inotrope) Stop smoking, eat less salt, maintain
optimal weight and nutrition Drug: diuretics, ACE inhibitor, β-blocker,
spironolactone, digoxin, vasodilator
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PULMONARY EMBOLISM
• Venous thrombi, usually from DVT pass into the pulmonary circulation and block blood flow to the lungs.
Risk Factors• Malignancy• Surgery• Prolonged bed rest, reduced mobility• Leg fracture• Previous thromboembolism and inherited
thrombophilia
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SYMPTOMS
• Acute breathlessness
• Pleuritic chest pain• Hemoptysis• Dizziness• Syncope
SIGN
Pyrexia Cyanosis Tachypnoea Tachycardia Hypotension Raised JVP Pleural rub Pleural effusion
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INVESTIGATION
CXR– dilated pulmonary artery, pleural effusion, wedge shape opacity or cavitation
ECG – N or tachycardia, right bundle branch block, right ventricular strain
Blood Test- the quantity plasma D-dimer level is elevated.
ABG – may show Pa O2 and PaCO2
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TREATMENT
Anticoagulant with Low Molecular Weight Heparin (LMWH).
Starting regime for warfarin 10mg on day 1 and day 2,then 5mg on the third day.
Stop heparin when INR>2 and continue warfarin for a minimum of 3 months.
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MANAGEMENT
Compression stockings to prevent further thrombsis
60% of O2 if hypoxemic Dissolution of thrombus consider for
massive embolism with hypotension – streptokinase
IV morphine - to relieve pain & anxiety IV heparin, oral warfarin or LMWH for
prevention
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PNEUMOTHORAX
Air in the pleural space. Spontaneous or as result of trauma to
the chest Spontaneous (esp. in young thin men) d/t
rupture of pleural bleb In pt. over 40 years of age usual cause is
underlying COPD Secondary pneumothorax occurs with
rupture of any pulmonary lesion situated closed to pleural surface.
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SYMPTOMS Sudden onset of dyspnea Pleuritic chest pain Pt. with asthma or COPD may present with a
sudden deterioration
SIGNS Reduced expansion Hyperresonance to percussion Diminish breath sound on the affected side. Trachea deviated away from the affected side.
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TREATMENT AND MANAGEMENT
Depend whether it is primary or secondary (underlying lung disease) pneumothorax, size and symptoms.
Pneumothorax due to trauma requires a chest drain.
Aspiration of pneumothorax - identify the 2nd intercostal space midclavicular line or 4-6th intercostal space in the midaxillary line & filtrate with 1% lidocaine down to the pleura.
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ASTHMA
• Recurrent episodes of dyspnoea, cough, and wheeze caused by reversible airway obstruction
• 3 factors contribute to airway narrowing bronchial muscle contraction mucosal swelling/ inflammation increased mucus production
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SYMPTOM intermittent dyspnoea, wheeze, cough (often
nocturnal) and sputumask about:- precipitants: cold air, exercise, allergens,
infection, drugs- Exercise: quantify the exercise tolerance- Disturbed sleep: quantify as nights per
week(sn of serious asthma)- Atopic disease: eczema, hay fever, allergy,or
family history?- The home: pets?carpet?feather pillows?- Occupation?
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SIGN tachypnoea, audible wheeze, hyper-
inflated chest, hyper-resonant percussion note, diminished air entry.
severe attack: inability to complete sentences, pulse>110bpm, RR>25/min, PEF 33-50% predicted
life-threatening attack: silent chest, cyanosis, bradycardia, exhaustion, PEF<33% of predicted, confusion
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INVESTIGATIONS
Chronic asthma -PEF monitoring -spirometry- obstructive defect ( FEV1/FVC) -CXR- hyper-inflation -skin prick test-help to identify allergens
Acute attack -PEF -sputum culture - FBC- ↑ eosinophil count -ABG analysis – N/slightly low PO2 & PCO2 -radioallergosorbent test(RAST)-↑ serum level
of total or allergen-specific IgE
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MANAGEMENT
Behaviour-stop smoking,avoid precipitants
Drugs- β2-adrenoreceptor agonists, Corticosteroids, Aminophylline, Anticholinergics
Pt. and family education about asthma
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
A term used to describe pt’s with chronic bronchitis & emphysema
Chronic bronchitisproductive cough with sputum on most days for at least 3 months for 2 consecutive years
EmphysemaDilation and destruction of alveolar septum distal to terminal bronchioles
Common progressive disorder of airway obstruction (↓FEV1 <80%, ↓FEV1/FVC <70%)
Age onset > 35 years old Smoking related
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SYMPTOMS : cough, sputum, dyspnoea, wheeze
SIGNS: Inspection:Tachypnoea; prolong
expiration; hyperinflated chest Palpation : chest expansion Percussion: Resonant @ hyperresonant Auscultation: Quiet breath sound
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GENERAL EXAMINATION
Oedema Sn(s) of CO2 retention
Warm peripheries Bounding/collapsing pulse Asterixis/Flapping tremor Papilledema Confusion(severe cases)
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• Ix: -FBC- Hb & PCV↑ Polycythaemia -CXR- hyperinflation -ECG- R atrial and ventricular hypertrophy (cor pulmonale) -Lung function test (↓FEV1 <80%, ↓FEV1/FVC <70%)
• Management : Gen.management Persuade pt to stop smoking
Specific managementControlled O2 therapy(start with 24-28%,according to ABG)Nebulizer (eg:Salbutamol ;Ipratropium Bromide)Antibiotic ( eg:Amoxicillin /Ampicillin)
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PULMONARY EDEMA
Definition : -elavation of left atrial pressure
pulmonary capillary pressure transudation of fluid into lungs (cardiogenic pulm. edema )
Etiology :
Cardiogenic Non-cardiogenic
-LVF ( eg : IHD , MI )-mitral & aortic regurgitation-arrhythmias -malignant HTN
-ARDS d/t trauma , malaria , drugs -fluid overload-neurogenic ( eg : head injury )
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Clinical Features :
Complications :
-respiratory distress respiratory arrest
Investigations :
-chest X ray –distension of upper lobe veins, bat’s wing , Kerley B lines, small pleural effusions
-ECG-evidence of MI
Symptoms Signs
-breathlessness & orthopnea-wheezing -pink frothy sputu5m
Inspection :-cyanosis-tacyhpneaPalpation :-tachycardia ;low volume pulse-pulsus alternans ( indicates LVF)Auscultations :-gallop rhythm -rhonchi &crepitations
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-Blood -ABG- evidence of hypoxemia , initially low PaCO2 then high PaCO2 d/t impaired gas exchange
-cardiac enzymes
Management :General :- Sit patient up- 60% Oxygen via facemask
Pharmacological Rx:-IV frusemide -IV dimorphine -IV antiemetic
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PLUERAL EFFUSION
Definition : Excess accumulation of fluid in pleural space .
Etiology :Tansudate ( < 30 g/l) Exudate ( > 30 g/l)
-CCF-Chronic liver disease ( cirrhosis )-nephrotic syndrome
-Infections ( bac. Pneumonia, empyema, TB )- neoplasia : bronchial carcinoma, mesothelioma-Pulmonary infarction -Sarcoidosis -Post MI syndrome -Pancreatitis -Connective tissue disease
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Other types of pleural effusion : empyema, hemothorax, chylothorax
Clinical Features :Symptoms Signs
-pleuritic chest pain -dyspnea
Inspection :-Ipsilateral reduced chest movementPalpation:-ipsilateral reduced chest expansion -reduced vocal fremitusPercussion :-stony dull to percussionAuscultation :-reduced /absent breath sound-bronchial breath sound above effusion-whispering pectoriloquy
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Investigations :1 ) imaging : CXR ( can detect radiologically if > 300ml) - loss of costophrenic angle - dense shadow over lung field with concave upper
limit2) Pleural aspiration :- protein estimation - bacteriological examination( gram stain, Ziehl Nielson stain
and culture)-cytology ( for malignant cells )- Others ( amylase, Rheumatoid factor ,glucose)
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MANAGEMENTS:
-to treat underlying cause
Symptomatic Rx :
1) Pleural aspiration – for large effusions
2) Pleurodesis
-to induce adhesions between visceral and parietal pleural.
- 2 types : chemical -eg : with talc, tetracycline, bleomycin surgical - decortication ( abrasion of pleura to
induce adhesions )
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References
Oxford Clinical Handbook 7th edition Clinical Examination by Nicholas J Talley and
Simon O’Connor http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?
book=cm&part=A1140 http://www.supportiveoncology.net/journal/
articles/0101023.pdf http://ajrccm.atsjournals.org/cgi/content/full/159/
1/321#SEC4 Davidson’s Principles & Practice of Medicine,
20th edition. Kumar & Clark, Clinical Medicine, sixth edition.
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Ventolin62
Beta-agonist – prevent bronchospasm Used in: treat or prevent airway spasms,
as well as to prevent exercise-induced asthma attacks
Used as inhaler Side effect: throat irritation, coughing,
and respiratory infections
Bricanyl63
Beta-agonist Used in: reliever medication for
asthmatic symtoms, prevention against acute exercise induced asthma attacks
Used as inhaler/injection Side effect: Tremor, palpitations,
nervousness and restlessness, headache