DR.IMRAN MEHFOOZ KHAN

ASSITANT PROFESSOR

EAST MEDICAL WARD

MAYO HOSPITAL,LAHORE

Breathlessness (LVF)

Case history A 70 years old lady presented with the complaint of shortness of breath for the last 6 months. This complain has been progressive . Initially breathlessness was on exertion only but now she feels breathless on lying in bed without three pillows . She also wakes up from sleep a number of times at night.

She lives on second floor and has to climb a flight of 10 stairs . Recently she has started to experience chest discomfort along with breathlessness.

WHAT IS THE DIAGNOSIS?

Heart failure Heart failure is a complex syndrome resulting from structural or functional

cardiac disorder that impairs the ability of heart to act as a pump to support physiologic circulation and is characterized by symptoms such as breathlessness and fatigue and signs of fluid retention.

Symptoms;

left ventricular failure (LVF) may result in dyspnea ,orthopnea , paroxysmal nocturnal dyspnea , nocturnal cough or fatigue.

Signs; Hypotension

Tachycardia

Third heart sound

Edema

Bibasal crepitations/crackles

NYHA classification of heart failure

Class 1 – no limitationsClass 2 – slight limitation of physical

activityClass 3 – marked limitation of physical

activityClass 4 – symptoms at rest

Definitions Breathlessness/dyspnea;

Undue awareness of breathing . It is normal with strenuous physical exercise.

Hypoapnea;

Shallow breathing or low respiratory rate. Orthopnea;

Breathlessness on lying flat. Paroxysmal nocturnal dyspnea;

Breathlessness that wakes up the patient from sleep.

Tachypnea;

Increased rate of breathing. Hyperventilation;

Inappropriate overbreathing

History

Mode of onsetDurationProgressionVariabilityAggravating /relieving factorsSeverityAssociated symptoms

Mode of onset , duration and progression of breathlessness In minutes;

Pulmonary thromboembolism Pneumothorax Acute pulmonary edema Acute attack of asthma Inhaled foreign body

In hours/day; Pneumonia Exacerbation of COPD

Mode of onset , duration and progression of breathlessness Weeks to months;

Pleural effusion Anemia Pulmonary tuberculosis

Months to years; COPD Pulmonary fibrosis Congestive cardiac failure

Severity of breathlessness:medical research council (MRC) classification Grade 1;

breathless when hurrying on the level ground or walking up a slight hill

Grade 2;

breathless when walking with people of own age on level ground

Grade 3;

has to stop because of breathlessness when walking on level ground at own pace

Associated symptoms

No chest pain; Pulmonary edema Metabolic acidosis Anemia

Pleuritic chest pain; Pneumonia Pneumothorax Pulmonary embolism Rib fracture

Associated symptoms

Central chest pain;Myocardial infarction leading to acute

left ventricular failureMassive pulmonary

embolism/infarctionWheeze cough;

AsthmaChronic obstructive pulmonary disease

Causes of heart failure Ischemic heart disease Hypertension Valvular heart disease. Aortic stenosis. Arrhythmias – AF Cardiomyopathy Myocarditis Pericardial disease High output failure – thyrotoxicosis, anemia.

Differential diagnosis Cardiac causes;

Left ventricular failure

Mitral valve disease

Congestive cardiac failure

Cardiomyopathy

Pericardial effusion

Respiratory causes; Airway:

Foreign body

Asthma

COPD

Bronchiectasis

Lung cancer

Differential diagnosis Parenchymal:

Pulmonary fibrosis

Tuberculosis

Pneumonia

Pulmonary circulation: Pulmonary thromboembolism

Pulmonary hypertension

Pleural: Pneumothorax

Effusion

Chest wall: Kyphoscoliosis

Neuromuscular: Myasthenia gravis

Guillian barre syndrome

THANKYOU