dyspnea slmc bgc pg

7/27/2019 Dyspnea Slmc Bgc Pg

1/38

Noble Approach to Patients withDyspnea


2/38

bad breeze (Latin)

Breathlessness

Shortness of breath

Difficulty of breathing

Disordered /inadequate breathing

Uncomfortable awareness of breathing

Air hunger


3/38

Dyspnea Correlates with increased

prevalence of cardiac andpulmonary diseases

Predictor of hospitalization inpxs with chronic lung dse; moreclosely related with survivalthan FEV1

More closely associated withcardiac mortality than angina

Sensation or perception?

Acute or chronic?

O n e o f t h e m o s t c o m m o n d i s tr es s i n g s y m p t o m s o f a

pat ient .


4/38

Population Prevalence of

Dyspnea (%)

References

Cancer (mixed) 10-70 Solano 2006 AIDS 11-62 Solano 2006Lung cancer (primary or metastatic)

62-95 Currow 2010

Heart Disease 60-88 Solano 2006COPD 90-95 Solano 2006Renal Disease 11-62 Solano 2006Stroke 37 Addington-Hall

1995 ALS 47-50 Obrien 1992,

Hicks 1993Dementia 70 Lloyd Williams

1996No cardiorespiratorydisease

45-81 Currow 2010


5/38

a subjective experience of

breath ing d i s c o m f o r t

that consists of qualitativelydistinct

sensations that vary in intensity.

derives from interactions from multiple

physiological, psychological, social and

environmental factors, and may induce

secondary physiological and behavioral

responses.

dyspnea per se can only be perceived by

the person experiencing it.

DYSPNEA1. DEFINITION2. MECHANISMS

UNDERLYINGDYSPNEA

3. DYSPNEAMEASUREMENT

4. EVALUAITON ANDTREATMENT

Acute vsChronic

5. RESEARCHPRIORITIES

ATS Statement Mechanisms, Assessment, and Management of Dyspnea :1999 and 2011 update


6/38

Dyspnea --Uncomfortable in work of breathing

Tachypnea -- RR > normal

Hyperpnea (Tidal volume x RR) > normal; pH = normal

Hyperventilation (Tidal volume x RR) > demands; pH =

Dyspnea of exertion (DOE) -- Exertion-induced SOB

Orthopnea -- Recumbent-induced SOB

Paroxysmal nocturnal dyspnea (PND) -- Sudden SOBafter recumbent


UNDERLYINGDYSPNEA



Acute vsChronic



7/38


8/38

DOMAINS OF DYSPNEA MEASUREMENT

Sensory-perceptual experience : what breathing feelslike; single item ratings of intensity eg Borg, VAS

Affective distress : how distressing breathing feels; multiitem scales of emotional responses such as anxiety

Symptom impact or burden : how dyspnea affectsfunctional ability, QOL; MRC, multidimensional scales of QOL


UNDERLYINGDYSPNEA


4. EVALUATION ANDTREATMENT



9/38


UNDERLYINGDYSPNEA





10/38


UNDERLYINGDYSPNEA




Visual Analog Scale


11/38

QUESTIONNAIRESDYSPNEA1. DEFINITION2. MECHANISMS

UNDERLYINGDYSPNEA





12/38

Modified Medical Research Council (MRC) Scale

0. I only get breathless with strenuous exercise

1. I get short of breath when hurrying on the level or walking up aslight hill

2. I walk slower than people of the same age on the levelbecause of breathlessness or have to stop for breath whenwalking at my own pace on the level

3. I stop for breath after walking about 100 yards or after a fewminutes on the level

4. I am too breathless to leave the house or I am breathlesswhen dressing


UNDERLYINGDYSPNEA





13/38


UNDERLYINGDYSPNEA





14/38


15/38

CLUES from HISTORY AND PE

Restricted thoracic motion : air hunger

Bronchoconstriction: chest tightness

COPD: increased effort to breathe

Heart failure: air hunger; suffocation

Cardiovascular deconditioning: heavybreathing


UNDERLYINGDYSPNEA





16/38

EVALUATION OF ACUTE DYSPNEADYSPNEA1. DEFINITION2. MECHANISMS

UNDERLYINGDYSPNEA





17/38


UNDERLYINGDYSPNEA




Run thru thechecklist!


18/38

TWO MAJOR CATEGORIES

Acute : new onset of breathing discomfortfor whom the underlying cause of dyspnea has not yet been determined

Chronic : those with knowncardiovascular, respiratory, or neuromuscular diseases who areexperiencing worsening dyspnea


UNDERLYINGDYSPNEA





19/38


UNDERLYINGDYSPNEA





20/38

EVALUATION OF ACUTE DYSPNEADYSPNEA1. DEFINITION2. MECHANISMS

UNDERLYINGDYSPNEA




CARDIOVASCULARSYSTEM

Acute myocardialischemia

Heart Failure Cardiac

Tamponade

RESPIRATORYSYSTEM Bronchospasm Pulmonary

Embolism Pneumothorax Pulmonary

infection Upper Airway

Obstruction Aspiration Anaphylaxis


21/38

LAB WORK-UPS FOR ACUTE DYSPNEA

CXR, ABG, ECG

SOB Panel

D Dimer high negative predictive value

NT ProBNP

Myoglobin

Troponin


UNDERLYINGDYSPNEA





22/38


UNDERLYINGDYSPNEA



5. RESEARCHPRIORITIES 301 patients in the ER with DOB

Increased sensitivity by 5%Specificity not significantly improved.

Acad Emer Med 2009


23/38


Plasma BNP

With chronic and advanced HF, ventricular cells arerecruited to secrete ANP and BNP in response to highventricular filling pressures plasma concentrations

of both hormones increased in patients withsymptomatic or asymptomatic LV dysfunction

Meta analysis: BNP testing at ED in patients withdyspnea can reduce length of stay in the hospital Lam

et.al, Ann of Int Med 2010


UNDERLYINGDYSPNEA





24/38


Plasma BNP


UNDERLYINGDYSPNEA





25/38


UNDERLYINGDYSPNEA





26/38

EVALUATION OF CHRONIC DYSPNEA

LAB TESTING CBC, glucose, BUN,creatinine, electrolytes, Ca, P, TSH

PFT spirometry, bronchoprovocationtesting, lung volumes, lung diffusion,maximal inspiratory pressure, MVV

IMAGING CXR, CT

Others Echocardiography,Cardiopulmonary Exercise Testing, EMG-NCV


UNDERLYINGDYSPNEA





27/38

TREATMENT primary focus to optimizetreatment of underlying disease

Oxygen advanced heart or lung disease; relatedto changes in chemoreceptor stimulation

Heliox helium with decreased density mixedwith gas decreased resistance to airflow,decreased WOB, decreased severity of hyperinflation, inc exercise capacity, dec dyspnea;?long term studies


UNDERLYINGDYSPNEA


4. EVALUATiON ANDTREATMENT



28/38


UNDERLYINGDYSPNEA





29/38

Pharmacologic therapy

OPIOIDS can reduce breathlessness inadvanced COPD, ILD, CA, chronic HF

Nebulized opioids not superior tooral/parenteral

NEBULIZED FUROSEMIDE dec breathlessnessinduced in healthy volunteers, vagal afferent

Possible benefit in COPD, but no benefit in CA patients

Still with insufficient data


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES


30/38


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES


31/38

Other agents: Anxiolytics, Antidepressants,Phenothiazines, NaHCO3, inhaled topical

anesthetics lack data

PULMONARY REHABILITATION esp in patientswith chronic lung disease reduction inexertional dyspnea during exercise and improvedexercise tolerance.

Other nonpharmacologic approaches: chest wallvibration, cool air, noninvasive ventilation

Alternative/complementary medicine:acupuncture, yoga training


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES


32/38


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES


33/38

New treatments and larger clinical trials treatment of dyspnea per se?

Standardized instruments for measuring dyspnea

Neuromodulation, neuroimaging and centralprocessing of dyspneic sensations and associatedunpleasantness.

Interdisciplinary approaches to research indyspnea


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES


34/38


UNDERLYINGDYSPNEA



5. RESEARCH

PRIORITIES

PatientEducation


35/38

Summary and Recommendations

When developing a differential diagnosis, use aconstruct that distinguishes respiratory ssystemdyspnea fro cardiovascular dyspnea. Also takeinto account chronic conditions contributing todyspnea.

Inquire about the quality of patient s breathingdiscomfort, use assessment tools.

Plasma BNP may be helpful in establishing or excluding the dx of heart failure as cause of dyspnea.


36/38

Summary and Recommendations

History and PE lead to accurate diagnoses of patients in 2/3of cases. CXR and spirometry to screen. CT for ILD, occultemphysema, chronic thromboembolic disease.

CPET is a useful study in patients in whom the cause of their breathing discomfort remains elusive after standard testing, inpatients whom deconditioning is a serious consideration, andin patients who appear to have breathing discomfort out of proportion to their physiologic derangements.


37/38


38/38

dyspnea slmc bgc pg

Documents