Transcript Dyspnea
Dyspnea Victor Politi, M.D., FACP Medical Director, St. Anthony’s School of Allied Health Professions, Physician Assistant Program • Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases. • Dyspnea - common complaint/symptom • “shortness of breath” or “breathlessness” • Defined as abnormal/uncomfortable breathing • Multiple etiologies • 2/3 of cases - cardiac or pulmonary etiology • There is no one specific cause of dyspnea and no single specific treatment • Treatment varies according to patient’s condition • • • • chief complaint history exam laboratory & study results Differential Diagnosis • Composed of four general categories • • • • Cardiac Pulmonary Mixed cardiac or pulmonary non-cardiac or non-pulmonary Pulmonary Etiology • • • • • • COPD Asthma Restrictive Lung Disorders Hereditary Lung Disorders Pneumonia Pneumothorax Cardiac Etiology • • • • • • • • CHF CAD MI (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Pericarditis Arrhythmias Mixed Cardiac/Pulmonary Etiology • COPD with pulmonary HTN and/or cor pulmonale • Deconditioning • Chronic pulmonary emboli • Pleural effusion Noncardiac or Nonpulmonary Etiology • • • • • Metabolic conditions (e.g. acidosis) Pain Trauma Neuromuscular disorders Functional (anxiety,panic disorders, hyperventilation) • Chemical exposure Easily Performed Diagnostic Tests • Chest radiographs • Electrocardiograph • Screening spirometry • In cases where test results inconclusive • • • • complete PFTs ABGs EKG Standard exercise treadmill testing/ or complete cardiopulmonary exercise testing • Consultation with pulmonologist/cardiologist may be useful ABGs • Commonly used to evaluate acute dyspnea • can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia • normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea • Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing PULSE OX • Rapid, widely available, noninvasive means of assessment in most clinical situations• insensitive (may be normal in acute dyspnea) • The % of Oxygen saturation does not always correspond to PaO2 • The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels ASTHMA What is Asthma • A Chronic disease of the airways that may cause: • • • • Wheezing Breathlessness Chest tightness Nighttime or early morning coughing The bronchospasm characteristic of the acute asthmatic attack is typically reversible. It improves spontaneously or within minutes to hours of treatment • Asthma can exist by itself or coexist with chronic bronchitis, emphysema, or bronchiectasis Symptoms/Chief Complaint • • • • Progressive dyspnea Cough Chest tightness Wheezing/coughing • The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction Focus of Therapy • Pharmacologic manipulation of airway smooth muscle • Do not overlook physiologic impairment caused by mucous production and mucosal edema • Bronchospasm can be reversed in minutes • Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks • may lead to atelectasis, infectious bronchitis, pneumonitis Asthma Triggers • • • • Immunologic reaction Viral respiratory/sinus infections change in temperature/humidity Drugs/Chemicals • aspirin, NSAIDS • • • • Exercise GE reflux Laughing/coughing Environmental factors • strong odors, pollutants, dust, fumes Patient Exam • Wheezing • may be audible w/o stethoscope • Use of accessory muscles of inspiration • diaphragmatic fatigue • Paradoxical respirations • - reflect impending ventilatory failure • Altered mental status • lethargy, exhaustion, agitation, confusion Patient Exam • Hypersonance to percussion • decreased intensity of breath sounds • prolongation of expiratory phase w or w/o wheezing Patient Exam • The intensity of the wheeze may not correlate with the severity of airflow obstruction • “quiet chest” - very severe airflow obstruction Asthma Treatment • • • • • • • Nebulized B-adrenergic drugs Corticosteroids Nebulized anticholinergics Magnesium sulfate Oxygen Long acting beta-agonists Inhaled steroids Managing Asthma: • Indications of a severe attack: • • • • • Breathless at rest hunched forward talking in words rather than sentences Agitated Peak flow rate less than 60% of normal Treatment Goals of Severe Asthma • Improve airway function rapidly • Avoid hypoxemia • Prevent respiratory failure and death COPD COPD • • • • • Hallmark symptom - Dyspnea Chronic productive cough Minor hemoptysis pink puffer blue bloater COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat. COPD - Physical Findings • • • • Tachypnea Accessory respiratory muscle use Pursed lip exhalation Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing Dominant Clinical Forms of COPD • Pulmonary emphysema • Chronic bronchitis • Most patients exhibit a mixture of symptoms and signs COPD - Advanced Dx • • • • secondary polycythemia cyanosis tremor somnolence and confusion due to hypercarbia • Secondary pulmonary HTN w or w/o cor pulmonale COPD Treatment Strategy • • • • • • Elimination of extrinsic irritants bronchodilator & glucocorticoid therapy Antibiotics Mobilization of secretions “respiratory vaccines” Oxygen therapy - if oxygen saturation <90% at rest on room air Spirometry PNEUMONIA • 6th leading cause of death in the US • Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases Common types of respiratory infections • • • • • • • Tracheobronchitis Pneumonia Effusions Empyema Abscess Cavitary lesions post-obstructive Common Respiratory Viruses • • • • • • • Influenza A & B Parainfluenza 1& 3 Respiratory Syncytial Virus Adenovirus Cytomegalovirus Herpes Simplex & Zoster/varicella Hanta Virus Infection Respiratory Syncytial Virus • Rapid diagnosis of Respiratory Syncytial Virus Infection by immunofluorescence of respiratory secretions Classic Pneumonia Symptoms • Dyspnea, chills • high fever, cough/sputum • pleuritic chest pain Viral Pneumonia - symptoms • • • • Chest Pain Fever Dyspnea Prodrome - malaise, upper respiratory symptoms, and other GI symptoms Viral pneumonia Clinical Findings • Minimal/variable • Chest exam - may reveal wheezing • Fine rales if heard can signify interstitial involvement • Chest x-ray - patchy densities or interstitial involvement Viral pneumonia Management /Prophylaxis • Supportive treatment - decrease severity of symptoms • bed rest • analgesics • expectorants • Patients w/ • airway obstruction - treat w/bronchodilators • secondary bacterial infection - antibiotics Atypical Pneumonia • Accounts for 25% of community acquired pneumonias • Mycoplasma/chlamyda/legionella • can case extrapulmonary manifestations • meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia • typically bilateral infiltrates on chest x-ray • primarily effects younger persons Atypical Pneumonia Treatment • • • • Antibiotics Macrolides fluroquinolones doxycycline Bacterial pneumonia • 3.3 million cases yearly in US • responsible for 10% of hospital admissions • unilateral infiltrate on x-ray • high mortality in elderly population • most common cause pneumococcal followed by haemophilus influenza • Pneumococcus pneumonia accounts for up to 90% of all bacterial pneumonias • Patients with a chronic Dx are at an increased risk of contracting pneumonia Bacterial pneumonia presentation • • • • • • • • acute shaking - chills tachypnea tachycardia malaise anorexia myalgias flank or back pain vomiting Lab Tests • • • • • • • WBC Chest X-ray Pulse Ox ABGs Sputum exam Blood cultures pleural fluid exam Pneumothorax Causes of Spontaneous Pneumothorax • • • • • Pleural blebs Bullae Emphysema Interstitial lung disease Alpha 1 antitrypsin deficiency Traumatic and Iatrogenic Causes • • • • Penetrating wounds Line placements Lung biopsies Mechanical ventilation Two most common symptoms • Dyspnea • Chest pain Physical Examination • Decreased breath sounds • hyperresonance to percussion • decreased tactile fremitus • In patients with emphysema - clinical findings may be subtle Chest X-ray to Confirm Dx • 500ml of air required to visualize pneumothorax on x-ray • Characterized by • hyperlucency and lack of lung markings at the periphery of the lung and appearance of fine line that represents the retraction of the visceral from the parietal pleura Treatment Options • Observation - if pneumothorax involves < 15-20% of hemithorax and patient relatively asymptomatic • Tube thoracostomy • Simple Aspiration Pulmonary Embolism PE History • PE is so common and deadly that the dx should be considered in any patient who presents with chest symptoms that cannot be proven to have another cause PE Risk Markers • • • • • • • • Hypercoagulable states Prior hx of DVT or PE Recent surgery or pregnancy Prolonged immobolization Underlying malignancy smoking birth control pills trauma Classic triad of signs/symptoms Hemoptysis Dyspnea Chest Pain • These symptoms are not sensitive or specific and occur in fewer than 20% of patients diagnosed with PE PE Physical Exam • Massive PE causes hypotension due to acute cor pulmonale • Physical findings in early submassive PE may be completely normal • Initially, abnomal findings are absent in most patients with PE Massive PE - Signs/Symptoms • • • • • • • Tachypnea -96% Rales - 58% Accentuated second heart sound - 53% Tachycardia - 44% Fever - 43% S3 or S4 gallop - 34% signs/symptoms suggestive of thrombophlebitis - 32% • Lower extremity edema - 24% • Cardiac murmur - 23% • Cyanosis - 19% Massive PE Diagnostic Studies • • • • • • • • VQ scan Pulmonary angiography CT Echocardiography (TEE) Pulmonary artery catheterization Diagnostic algorithm D-dimer blood gases increased A-a gradient A-a gradient A-a gradient = predicted pO2 – observed PO2 PAO2 = (FIO2 X 713) – (PaCO2/0.8) at sealevel PAO2 = 150-(PaCO2/0.8) at sealevel on room air Normal range 10-15mm > 30 years of age Normal range 8mm < 30 years of age Increased A-aDO2=diffusion defect Right to left shunt V/Q mismatch Examples • A doubel overdose brings two 30 yr old patients to the ED. Both have ingested substantial amounts of barbiturates and diazepam. Blood gases drawn on room air revealed these values: • patient 1- pH =7.18, PCO2 = 70mmHg, PO2=50mmHg, HCO3=24mEq/L; • patient2- pH =7.31, PCO2=50mmHg, PO2=50mmHg, HCO3=25mEq/L Comment • The A-a gradient calculation for patient 1 is as follows: • A-a DO2 = PAO2 – PaO2 • PAO2 = 150 – (1.25x PCO2) • PAO2 = 150 – (1.25x 70) • PAO2 = 62 • A-a =62 – 50 • A-a = 12 Comment • The calculation reveals a normal gradient, indicating that the etiology for hypoxemia and hypoventilation is extrinsic to the lung itself. Comment • The A-a gradient calculation for patient 2 is as follows: • PAO2 = 150 – (1.25 x PCO2) • PAO2 = 150 – (1.25 x 50) • PAO2 = 150 – 63 • PAO2 = 87 • Therefore, A-a = 87 – 50 =37 (an abnormally increased gradient) Comment • We can be reasonably confident that patient 1 suffered hypoventilation due to the effect of the ingested drugs on the brain stem. • Temporary mechanical ventilation restored this patient’s gas exchange. Comment • Patient 2, on the other hand, had an increased A-a gradient, indicating a lung problem in addition to any central cause for hypoventilation. • The chest x-ray film revealed that this patient’s overdose was complicated by aspiration pneumonitis and that the patient required treatment with antibiotics in addition to mechanical ventilation. Treatment Strategies • • • • • • Fluid administration anticoagulation Vena caval interruption Thrombolytics oxygen pulse ox CHF Left sided Failure • Blood/fluid back-up into the lungs result in • • • • • SOB Fatigue Cough (especially at night) PND orthopnea Right sided Failure • Build-up of fluid in the veins • Edema of feet, legs and ankles • may effect liver/portal circulation and 3rd spacing into soft tissue/ascites/pleural effusion Causes of CHF • Variety of cardiac diseases • Most common cause of CHF - CAD • other causes - valvular heart dx, HTN,cardiomyopathies, myocarditis, renal dx,fluid overload,liver dx w/loss of protein and osmotic forces,high altitude and many others Physical Findings • • • • • • • • • Peripheral edema JVD tachycardia tachypnea, using accessory muscles of respiration Skin - diaphoretic/cold/gray/cyanotic Wheezing/rales on ausculation Apical impulse displaced laterally ascites hepatosplenomegaly Diagnostic Work-Up • • • • • • • History Physical exam EKG Echo Chest x-ray BNP ABG/pulse ox Treatment • • • • • • • • • Diuretics Digitalis Peripheral vasodilators/NTG Positive inotropic agents ACE inhibitors Beta blockers Oxygen MS04 BNP Questions ?