evaluation of dyspnoea

EVALUATION OF DYSPNOEA DR. PRAPULLA CHANDRA

DEFINITION OF DYSPNOEA

Dyspnoea is a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interaction among multiple physiological, psychological, social, and environmental factors, and it may induce secondary physiological and behavioral responses.

MECHANISM OF DYSPNOEA

Receptors involved in mechanism of dyspnea1) J receptors – alveolo-capillary junction

• Stimulated by pulmonary congestion ,oedema, micro emboli.

• Responsible for rapid shallow breathing

2) Stretch receptors – thoracic cage & lung

3) Chemoreceptors - carotid arteries, aorta & reticular substance of medulla

Stimulated by hypoxia, excess of CO2, decrease in PH

4) Receptors in the respiratory muscle – immediate cause of appreciation of dyspnea

COPD

Thorax is in hyperinflated position/Diaphragm

Work of breathing is high, O2 cost of breathing high

Derangement of dead space ventilation & alveolar capillary gas exchange

Afferent stimuli to sensorymotor cortex

Dyspnoea

INTERSTITIAL LUNG DISEASE

Work of breathing & O2 cost of ventilation increased

Effort of respiratory muscles in ventilation stimulate afferent impulses

DYSPNOEA

Pleural effusion & Pneumothorax

collapse of the normal lung hypoxia

muscles at mechanical disadvantage

Dyspnoea

Anemia Inadequate O2 delivery to respiratory muscles

increased respiratory drive

Dyspnoea

PULMONARY EDEMA alveolar & interstitial edema stimulate J-receptors

Dyspnoea

MUSCULOSKELETAL DISORDERS Hightened motor drive required to activate

weakened respiratory muscles

Dyspnoea

STEPWISE APPROACH

history

physical examination

investigations

treatment

HISTORY TAKING

Onset Position Timing Severity Ppt/Relieving factors Associated symptoms

•

Minutes• Pneumothorax

• Pulmonary oedema

• Major pulmonary embolism

• Foreign body

• Laryngeal oedema

Hours

• Asthma

• Left heart failure

• Pneumonia

Days• Pneumonia

• ARDS

• Left heart failure

• Repeated pulmonary embolism

Weeks• Pleural effusion

• Anemia

• Muscle weakness

• Tumours

ONSET OF DYSPNOEA

Months• Pulmonary fibrosis

• Thyrotoxicosis

• Muscle weakness

Years Muscle weakness

COPD

Chest wall disorders

ACUTE DYSPNOEA

RESPIRATORY CAUSES -PNEUMOTHORAX

-ACUTE ASTHMA

-ACUTE PULM.EMBOLISM

-UPPER AIRWAY OBSTRUCTION

-PULMONARY EDEMA

-TRAUMA

-FOREIGN BODY

CARDIAC CAUSES

Acute MI Acute valvular insufficiency Aortic dissection Complete heart block Pericardial tamponade Congestive heart failure

CHRONIC DYSPNOEA

AIRWAYS 1. Obstructive airway disease 2. Asthma 3. Chronic bronchitis 4. Empyema 5. Cystic fibrosis

PARENCHYMAL

1. ILD 2. Malignancy -primary -secondaries

PLEURAL

1. Effusion 2. Malignancy 3. Fibrosis

PULM-VASCULAR DISEASE

1. A-V Malformations 2. Vasculitis 3. Veno-occlusive disease

OTHER CAUSES

CONGESTIVE HEART FAILURE CONSTRICTIVE PERICARDITIS NEUROMUSCULAR DISORDERS ANEMIA

POSITION

ORTHOPNOEA

• CCF• LVF• COPD• Br.asthma• Massive pleural effusion• Bil diaphragm palsy.• Ascites• GERD

PLATYPNOEA • Left atrial myxoma• Massive pulm. Embolism• Pulm. AV fistula• Paralysis of intercostal .m• Hepato

pulmonary syn.

TREPOPNOEA

• DISEASE OF ONE LUNG/ BRONCHUS• CCF

TIMING

NOCTURNAL ONSET DYSPNOEA

- CHF - COPD - BRONCHIAL ASTHMA - SLEEP APNOEA - POST NASAL DRIP - NOCTURNAL ASP. IN GERD

PAROXYSMAL NOCTURNAL DYSPNOEA

Severe difficulty in breathing that awakens the patient from sleep and forces him to a sitting or standing position.

Almost always implies underlying heart failure

POSTPRANDIAL DYSPNOEA

GERD ASPIRATION FOOD ALLERGY

GRADING

DYSPNOEA GRADING SCALES

Visual analogue scale Borg scale Bode index Sherwood jones grading American thoracic society scaling NYHA Scale MRC Classification MMRC dyspnoea scale

EXAMPLE OF A VISUAL ANALOG SCORE. THESE CAN BE ADAPTED TO ANY SYMPTOM AND CAN BE SUPPLEMENTED WITH ANCHORING VERBALOR VISUAL DESCRIPTORS AS SHOWN HERE.

SHERWOOD JONES GRADING

Grade 1a : housework/job with moderate difficulty

1b : with great difficulty

Grade 2a : confined to chair/bed but able to get up with moderate difficulty.

2b : with great difficulty

Grade 3 : totally confined to chair/bed

Grade 4 : moribund

GRADE 1 –Dyspnoea only with unusual exertion.

GRADE 2 –Dyspnoea on doing ordinary activity

GRADE 3 –Dyspnoea on doing less than ordinary activity.

GRADE 4 –Dyspnoea at rest.

NYHA SCALE

I. Not troubled by breathlessness with

strenuous exercise.

II. Shortness of breath when hurrying or walking up a slight hill.

III. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace.

IV. Stops for breath after walking about 100m or after a few min. or level ground.

V. Too breathless to leave the house or breathless when dressing or undressing.

MRC CLASSIFICATION

0. Not troubled by breathlessness with strenuous exercise.

1. Shortness of breath when hurrying or walking up a slight hill.

2. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace.

3. Stops for breath after walking about 100m or after a few min. or level ground.

4. Too breathless to leave the house or breathless when dressing or undressing.

MMRC SCALE

PPT/RELIEVING FACTORS

Precipitating factors :

+ exercise

+ exposure – cigarette ,allergens

+ occupational exposure

+ obesity

+ severe weight loss

+ medication Relieving factors :

- rest

- medication

ASSOCIATED SYMPTOMS

-FEVER

-CHEST PAIN

-Central chest pain

-Pleuritic chest pain

-Pericardial pain

-WHEEZE

Chronic sputum production

Change in the pitch of voice

Palpitations and syncope

Haemoptysis

Dysphagia or odynophagia

Vomiting and diarrhoea

Heart burn

Muscle weakness or myalgias

Visual disturbances & headache

Bone pain

PAST MEDICAL HISTORY SURGICAL HISTORY DRUG HISTORY OCCUPATIONAL HISTORY SMOKING HISTORY

PHYSICAL EXAMINATION

EXAMINE NOSE LOOK FOR CYANOSIS PALLOR ICTERUS CLUBBING EDEMA CERVICAL LYMPHADENOPATHY

RAISED JVP PERIPHERAL PULSES AND BRUITS GOITRE

Hypotension, tachycardia, and tachypnea : acute pulmonary edema , ARDS

Hypertension in a dyspnoeic patients:

hypertension-related diastolic heart failure with pulmonary oedema, hyperthyroidism, or phaeochromocytoma

Pulsus paradoxus - asthma, COPD, cardiac tamponade.

BLOOD PRESSURE

Cardiovascular examination Elevated neck veins, extra heart sound (S3 gallop

rhythm), and fluid retention - congestive heart failure. Elevated neck veins, pulsus paradoxus, a pericardial

knock, pericardial rub, and the Kussmaul's sign - Constrictive pericarditis and effussion

An irregular or fast heart beat - a tachyarrhythmia or atrial fibrillation.

A loud S2 -PAH A systolic heart murmur- acute valvular insufficiency,

mechanical valve malfunction.

Respiratory examination

Pursed lip breathing - COPD.

A barrel chest - emphysema and cystic fibrosis.

Stridor -upper airway obstruction

Hoarseness - in laryngitis, laryngeal tumours, vocal cord paralysis.

The trachea may deviate away from the lesion-tension pneumothorax or a large pleural effusion.

Unilateral dullness to percussion - pleural effusion, atelectasis, foreign body aspiration, pleural tumours, or pneumonia.

Hyper-resonance - pneumothorax or severe emphysema.

Subcutaneous emphysema - pneumomediastinum

Neurological examination

Cranial nerve palsies associated with dyspnoea -botulism.

Ptosis -myasthenia gravis, myotonic dystrophy, or botulism.

Pneumothorax

Sudden-onset dyspnoea associated with unilateral chest pain may indicate acute pneumothorax.

On examination, breath sounds are unilaterally absent, and percussion of the ipsilateral chest may reveal tympany.

The trachea may also be deviated away from the lesion.

Acute asthma

Acute-onset dyspnoea associated with wheezing and cough, especially in a person with prior history of asthma

Asthma is diagnosed based on the history and demonstration of airflow obstruction reversibility.

RESPIRATORY CAUSES

Anaphylaxis Exposed to a medication, food product, or insect bite.

Sudden-onset dyspnoea is accompanied by cutaneous manifestations , voice changes, a choking sensation, tongue and facial oedema, wheezing, tachycardia, and hypotension.

Nausea, vomiting, and diarrhoea

Pulmonary contusion History of trauma

may present with dyspnoea, circulatory collapse, and shock.

Acute pulmonary embolism

Sudden dyspnoea and chest pain, associated with tachycardia, tachypnoea, hypotension, hypoxaemia, hemoptysis and calf tenderness.

Foreign body aspiration

History of epilepsy, syncope, altered mental status (e.g., intoxication, hypoglycaemia), or choking and coughing after ingesting food (particularly nuts) may suggest foreign body aspiration.

Cyanosis and stridor followed by hypotension and circulatory collapse .

Upper airway obstruction

Significant dyspnoea, inspiratory stridor, and occasionally expiratory wheezing, exacerbated by exercise.

Acute myocardial infarction Presents with central chest pain radiating to the

shoulders and neck frequently accompanied by dyspnoea.

► O/E patient may be clammy and hypotensive.

S3 or S4 gallop rhythm

pulmonary rales.

characteristic ECG changes,

elevated cardiac enzymes

CARDIAC CAUSES

Acute valvular insufficiency Acute dyspnoea,

systolic murmur and signs of acute cardiovascular collapse with hypotension, tachycardia, and pulmonary rales.

An echocardiogram is typically required to establish the diagnosis.

Aortic dissection Dyspnoea

severe chest pain that may radiate to the back.

hypotension and absent peripheral pulses.

Emergency echocardiogram or a CT chest is used for diagnosis.

Congestive heart failure Presents with dyspnoea worsened by exertion,

orthopnoea and paroxysmal nocturnal dyspnoea, elevated neck veins, peripheral fluid retention, an S3 gallop rhythm, and pulmonary congestion (fine bibasal rales) .

The CXR shows characteristic signs of pulmonary venous congestion with cardiomegaly.

Echocardiography.

B-type natriuretic peptide >100 pg/ml

Complete heart block Dyspnoea with weakness, light-headedness, or syncope.

ECG

Pericardial tamponade Dyspnoea accompanied by neck vein and facial

engorgement, shock, peripheral cyanosis, and tachycardia.

An enlarged cardiac silhouette on CXR and a low-voltage ECG, echocardiography.

INVESTIGATIONS

CBP – Anemia , polycythemia ( ch.Hypoxemia),

BIOCHEMICAL – - Occult renal disease - acid – base derangement - collagen vascular disease - thyroid diseaseBNP – Secreted by ventricles in response to

inc. ventr . pressure . - LVF ,COR PULMONALE CXR – SPIROMETRY – (airway & parenchymal

diseases)

ECG - CAD, pulm HTN, arrhythymiasPFT – - lung volume & flow rate - DLco - Arterial blood gases - Cardiopulmonary exercise testing - bronchial challenge - maximal insp. Pressure Imaging techniques - VP scan - CT (HRCT/contrast) CT angiogram - Gallium scan - Diaphragmatic fluoroscopy BRONCHOSCOPY

CARDIAC EVALUATION –

-ECHO

-Thallium scan

-Holter monitoring(occult ischemia /arrythmia)

-Cardiac monitoring

-Cardiac catherisation (with exercise)

CARDIOPULMONARY EXERCISE TESTING

ESOPHAGEAL EXAMINATION / pHmonitoring

ENT examination

Sleep studies

Psychological assessment

Treat the underlying cause

Pneumothorax - closed tube thoracostomy

Foreign body removal

Asthma – bronchodilators,steroids

Anaphylaxis – adrenaline & avoidance of

precipitating agent

TREATMENT

TREATMENT STRATEGIES

REDUCE VENTILATORY DEMAND DECREASE SENSE OF EFFORT IMPROVE RESP.MUSLE FUNCTION PULMONARY REHABILITATION

REDUCE VENTILATORY DEMAND

-Treat airway disease

-Supplemental oxygen

-Opiates & sedatives.

-Exercise training.

-Cognitive behavioural therapy

DECREASE SENSE OF EFFORT & IMPROVE RESP. MUSCLE FUNCTION

-Energy conservation (walk slowly)

-Breathing strategies ( pursed lip breath)

-Position ( leaning forwards)

-Correct obesity / malnutrition

-Inspiratory Muscle exercise

-Resp . Muscle rest(nasal /transtracheal O2)

-Medication (theophylline)

PULMONARY REHABILITATION

PATIENT EDUCATION EXERCISE TRAINING OPTIMIZE BODY COMPOSITION PSYCHOSOCIAL SUPPORT PHYSIOLOGIC ASSESSMENT