cme- breathlessness rad
TRANSCRIPT
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Radtthiga ChelvarajMBBS
Batch 11Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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Dyspnoea• Definition: abnormal awareness of breathing
occuring at an inappropriately low level of physical exertion or at rest.
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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Causes of breathlessness
Respiratory1.Airway diseases2.Parenchymal disease3.Pulmonary circulation4.Chest wall and pleura
Source : Clinical examination, A systematic guide to physical diagnosis, Talley & O’ Connor
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Causes of breathlessness Cardiovascular
1.Left ventricular failure
2.Mitral valve disease
3.Cardiomyopathy4.Pericardial
effusion
Source : Clinical examination, A systematic guide to physical diagnosis, Tally & O’ Connor
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Causes of breathlessness
Non-cardiorespiratory1.Metabolic acidosis
2.Psychogenic
Source : Clinical examination, A systematic guide to physical diagnosis, Talley & O’ Connor
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Causes of dyspnoeaSystem Acute dyspnoea at restCardiovascular Acute pulmonary edema
Respiratory Acute severe asthmaAcute exacerbation of COPDPulmonary embolismTension pneumothorax
Others Metabolic acidosis
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Causes of dyspnoeaSystem Chronic exertional dyspnoea
Cardiovascular Chronic heart failureAngina
Respiratory COPDChronic asthmaBronchial carcinomaInterstitial lung disease
Others Severe anemia
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Important aspects -Dyspnoea
• Onset?• Severity? • Number of episodes?• *Association with cardiovascular symptoms ?• *Association with respiratory system?
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Association with respiratory system?
• Are there good days or bad days?• Diurnal variation?• Aggravating factors?• Relieving factors?• American College of Physician (ACP) guideline for dx
and mx of COPD guideline:– history of >40 pack-years of smoking best single
predictor of airflow obstruction
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Associated symptoms
• Productive cough or acute chest illness (Hx of chronic cough with sputum, worse in the morning)
• Breathlessness• Wheezing
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Association with cardiovascular system
• Onset:?–Physical exertion or at rest?– Triggering factors? ( MI)• Distance walked before breathlessness
occur?• Chest pain? (site, radiation)• Aggravating factors? (exercise, exertional,
stress anxiety)
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Association with cardiovascular system
• Relieving factors ? • Orthopnoea? ( beds used to sleep)• Paroxysmal Nocturnal Dyspnoea?
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COPD AND ASTHMA
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Definition
• preventable & treatable respiratory disorder
• smoking• progressive, partially
reversible airflow obstruction
• lung hyperinflation + extrapx (systemic) manifestations
• comorbid conditions
• chronic airway inflammation
• Increased airway hyperresponsiveness
• sx of wheeze, cough,chest tightness and dyspnoea.
• Reversible with treatment.
COPD ASTHMA
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COPD vs Asthma• Onset? : Gradual• Severity? : Progressively getting worse (exertional dyspnoea dyspnoea at rest and
Overnight.• Number of episodes? : With disease progression,
intervals become shorter• SMOKING• Association with cardiovascular symptoms ? : nil*
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COPD vs Asthma
• Onset• Atopy : triggering factors?• Diurnal variations?• Good days and bad days? ( Days per week off
work or school)• Family history?• Reversibility of symptoms?• Other atopic disease? ( eczema, allergy)
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History and signsConditions History SignsAcute severe asthma
Previous episodesAtopyAsthma medication
-Tachycardia-Pulsus paradoxus-Cyanosis-Reduced peak flow-Rhonchi
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History and signs
Conditions History SignsAcute exacerbation of COPD
Previous episodes, *admissionsSmoking
-Cyanosis-Raised JVP--LL Edema( Cor pulmonale)-Respiratory distress signs
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Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
-Barrel chest-Pursed lip breathing-Tripod position-Cardiac apex not palpable-Reduced breath sound -Prolonged expiration-rhonchi
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Systemic manifestations
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Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
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Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
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Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
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Spirometry
• Objective demonstration of airflow obstruction.
Bronchodilator Reversibility Testing:• required to establish lung function at that
point of time. • significant if the change in FEV1 = 200 mL and
12% above the pre-bronchodilator .• If there is a marked response to
bronchodilators asthma .
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Classification of COPD Severity Based on Spirometric Impairment
Severity Classification by postbronchodilatorspirometricvalues
Mild FEV1/FVC < 0.70FEV1 > 80% predicted
Moderate FEV1/FVC < 0.7050% ≤ FEV1 < 80% predicted
Severe <FEV1/FVC < 0.7030% ≤ FEV1 < 50% predicted
Very severe FEV1/FVC < 0.70FEV1 < 30% predicted orFEV1 < 50% predicted pluschronic respiratory failure
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Conditions History Signs
Left ventricular failure
Chest painOrthopnoeaPNDPink, frothy sputum
-Raised JVP--Central cyanosis-Bibasal crackles -S3-Cardiomegaly-Cold extremities-LL edema
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Conditions History Signs
Metabolic acidosis Evidence of Diabetes/ renal diseases
-Acetone breath-Hyperventilation- Kussmaul’s breathing -Dehydration
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Investigations
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Conditions Chest radiography
Arterial blood gas analysis
ECG
Left ventricular failure
CardiomegalyAbsence of air bronchogramKerley B linePleural effusion
-Low Pa O₂- Low PaCO₂
-Sinus tachycardia-Signs of Myocardial Infarction-Arrhythmia
Acute severe asthma
Hyperinflated chest
-Low Pa O₂- Low PaCO₂
-Sinus tachycardia* Bradycardia with severe hypoxemia
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Conditions Chest radiography
Arterial blood gas analysis
ECG
Acute exacerbation of COPD
Hyperinflation Emphysema-Low Pa O₂-Low PaCO₂Bronchitis-Low Pa O₂-High PaCO₂- high bicarbonate
-Nil or signs of right ventricular strain
Metabolic acidosis
Normal -Normal Pa O₂-Low PaCO₂- low pH
-
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Acute exacerbations of COPD
• Characterised by:• Increases in symptoms• Deterioration of lung function• Development of respiratory failure
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Management
1. Oxygen therapy: ( 24- 28%)2. Bronchodilators: short acting β₂ agonist +
anticholinergic3. Corticosteroids: Prednisolone4. Antibiotic therapy: aminopenicillin, macrolide5. If above measures fail, do non-invasive
ventilation6. Other measures
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Discharge
• Once patient is stable
• Short term nebuliser
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Acute exacerbation of asthma
• Characterised by:• Increased symptoms• Deterioration in PEFMay be precipitated by infections(viral)
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Mild – moderate exacerbations
• ‘rescue’ oral corticosteroid (prednisolone 30-60mg daily)
• Indications for rescue course:• Worsening symptoms and PEF• Fall of PEF < 60%• Worsening sleep disturbance• Persistence morning sx• Diminished response to inhaled bronchodilator
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Acute severe asthma
• Initial assessment : PR, RR, BP and SaO2• PEF 35-50%• Respiratory rate > 25 /min• Heart rate >110b/min• Inability to complete sentences in 1 breath
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Treatment
• 1. Oxygen ( high concentration ), maintain O₂ saturation >90mmhg
• 2. Bronchodilators :• β₂ agonist – salbutamol via metered dose
inhaler + ipratropium bromide• 3. Corticosteroids: Prednisolone ( 30-60mg,
oral) or IV hydrocortisone(200 mg)
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Subsequent management
• If patient deteriorates IV Mg • Monitoring of treatment:• Record PEF every 15 min-30 min then, 4-6
hourly• Pulse oximetry ( SaO2>90mmHg)
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Indications for endotracheal intubation
• deterioration of arterial blood gas despite optimal therapy :
• PaO₂ < 60 mmHg• Pa CO₂> 45 mmHg• pH low
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Discharge
• Counselling on medications
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Left ventricular failure
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Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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