Approach toDyspnea

Dr.Bilal Natiq Nuaman,MD

C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.

Lecturer in Iraqia Medical College

2017

Dyspnea; Breathlessness; Shortness of

Breath(SOB)

• ‘’Dyspnea’’

Dys: difficult, painful

Pneumea:breath

• Breathlessness or dyspnea can be defined as the feeling of an uncomfortable need to breathe.

DEFINITION OF DYSPNEA

• Clinical : A subjective experience of breathing discomfort that

consists of (qualitatively) distinct sensations that vary in

intensity.

• Physiological: The stimulation of pulmonary and extra pulmonary afferent receptors and the transmission of afferent information to the cerebral cortex, where the sensation is perceived as uncomfortable or unpleasant

Patients perceptions:

✓ Unsatisfied inspiration

✓ Chest tightness

✓ Sensation of feeling breathless

✓ Cannot get enough air

✓ Hunger for air

✓ Incomplete exhalation

Pathophysiology :

Respiratory diseases can stimulate breathing and dyspnea by:

➢ stimulating intrapulmonary sensory nerves (e.g. Pneumothorax, interstitial inflammation and pulmonary embolus)

➢ increasing the mechanical load on the respiratory muscles (e.g. airflow obstruction or pulmonary fibrosis)

➢ Causing hypoxia, hypercapnia or acidosis, stimulating

chemoreceptors.

Common Pulmonary Causes

• Obstructive lung disease

• Asthma/COPD (Chronic Bronchitis ,Emphysema)

• Pneumonia

• Pulmonary embolism

• Pneumothorax

cardiac failure can stimulate breathing and dyspnea by:

➢ pulmonary congestion reduces lung compliance and can

also obstruct the small airways.

➢ In addition, during exercise, reduced cardiac output

limits oxygen supply to the skeletal muscles, causing

early lactic acidaemia and further stimulating breathing

via the central chemoreceptors.

Common Cardiac Causes

• Acute coronary syndromes

• CHF

• Dysrhythmias

• Valvular heart disease

Stages of dyspnea

1-EXERTIONAL DYSPNEA- DYSPNEA DUE TO EXERCISE

2-PND - PAROXYSMAL NOCTURNAL DYSPNEA

3-ORTHOPNEA – SOB LYING FLAT AND BETTER SITTING UP (CHF, pregnancy, resp.muscle weakness)

4-RESTING DYSPNEA- DYSPNEA AT REST

Common Miscellaneous Causes

• Metabolic acidosis

• Severe anemia

• Pregnancy

• Hyperthyroidsm

• Hyperventilation syndrome

Differential diagnosis of dyspnea

Patients with breathlessness present either with

Chronic exertional dyspneaOr

Acute dyspnea,when symptoms are prominent even at rest.

• Chronic: Dyspnea >30 daysthat develops over weeks, months or years.

• COPD

• Left ventricular failure

• Lung fibrosis

• Asthma (uncontrolled)

• Pleural effusion

conscious level declines or if severe respiratory acidosis is

Pulmonary oedema is suggested by pink, frothy sputum and

bi-basal crackles;

asthma or COPD by wheeze and prolonged expiration;

pneumothorax by a silent resonant hemithorax; and

pulmonary embolus by severe breathlessness with normal

breath sounds.

eg swelling may suggest cardiac failure or, if asymmetrical,

venous thrombosis causing pulmonary embolism.Arterial blood gases, a chest X-ray and an ECG should beobtained to confirm the clinical diagnosis, and high concentrations of oxygen given pending results.

rgent endotracheal intubation may become necessary if the

present.

Physical signs in dyspnic patient

Investigations

Chest radiograph (CXR): weather cardiac or pulmonary

Cardiac Causes! Pulmonary causes!

ECG Pulmonary function test(PFT)

(abnormally significant) (abnormally significant)

Echo CT scan of chest

(abnormally significant) (abnormally significant)

Corona angiography Lung Biopsy

CXR