Shortness of Breath during ExertionFatima AlAwadh

Summarize the case ( Signs & Symptoms & Findings).

Define Dyspnea. Demonstrate the Differential Diagnosis. Display the Anatomy of the Respiratory

Tract. Recognize the Volumes of the Lung. Clarify the Physiology of Breathing. Understand the Pathophysiology of Dyspnea. Mention the Diagnostic Investigations. Enumerate First Aids & Treatments.

Objectives

67-year-old man. Smoke two packs of cigarettes a day.

Stopped smoking six years ago.

Retired coffee salesman.

Married. No pets.

Drinks little alcohol. No other illnesses.

Case

Shortness of breath due

to effort.

Trouble breathing while sitting still.

Productive cough with green sputum.

Looks pale, feels as his temperature is raised.

No shivers, sore throat, vomiting, diarrhea, and not sick.

Case Signs & Symptoms

Thin with broad chest

Moderate SOB

Trachea is positioned in the midline

Thorax moves up &

down symmetrical

ly

Breathing rate is 32 per min

Reduced breath sound

across lung

Wheezing on

expiration

Case Findings on Physical Examination

Extended expiration

BP 132/78 mmHg

Heart rate 94 per min

Arterial oxygen

saturation 91%

Decreased FVC & FEV1

Increase TLC, FRC &

RV

Case Findings on Physical Examination

Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.

Dyspnea - common complaint “shortness of breath”.

Defined as uncomfortable breathing. Dyspnea on exertion is excessive or

abnormal shortness of breath on exertion.

Dyspnea

Four general categories:

Differential Diagnosis

Cardiac Pulmonary

Mixed cardiac

or pulmonar

y

non-cardiac

non-pulmonar

y

Pulmonary Etiology

COPD AsthmaRestrictive

Lung Disorders

Hereditary Lung

Disorders

Pneumonia

Pneumo-thorax

Congestive Heart Failure

(CHF)

Coronary Artery

Disease (CAD)

Recent or past history

of Myocardial Infarction (MI)

Cardiomyopathy

Cardiac Etiology

Valvular dysfunction

Left ventricular

hypertrophyPericarditis

Arrhythmias

COPD with pulmonary HTN and/or

cor pulmonale

Deconditioning

Chronic pulmonary emboli

Pleural effusion

Mixed Cardiac/Pulmonary Etiology

Metabolic conditions (e.g. acidosis) Pain Trauma

Noncardiac or Nonpulmonary Etiology

Neuromuscular disorders

Functional (anxiety, panic, hyperventilation)

Chemical exposure

Anatomy Respiratory Tract

Pulmonary Volumes & Capacities

The tidal volume

• the volume of air inspired or expired with each normal breath (about 500 ml).

The inspiratory reserve volume

• the extra volume of air that can be inspired over and above the tidal volume with full force (about 3000 ml).

The expiratory reserve volume

• the maximum extra volume of air that can be expired by forceful expiration after end of tidal expiration (about 1100 ml).

The residual volume

• the volume of air remaining in the lungs after the most forceful expiration (about 1200 ml).

Pulmonary Volumes

The inspiratory capacity

• The amount of air a person can breathe in (about 3500 ml).

The functional residual capacity

• The amount of air remains in the lungs after normal expiration (about 2300 ml).

The vital capacity

• The maximum amount of air that can be expelled after first filling the lungs to maximum and expiring to maximum (about 4600 ml).

The total lung capacity

• The maximum volume to which the lungs can be expanded with the greatest possible effort (about 5800 ml).

Pulmonary Capacities

Physiology of Breathing

The pathophysiology is poorly understood.

There are no specialized receptors for dyspnea.

Recent MRI studies have identified a few specific areas in the midbrain that may mediate perception of dyspnea.

Pathophysiology

Pathophysiology

Dyspnea likely results from the complex interaction between:

chemoreceptor stimulation

(Afferent)

mechanical breathing

abnormalities (Efferent)

perception of those two by

the CNS

Pathophysiology

Dyspnea results when a "mismatch" occurs in CNS

between afferent & efferent signaling.

As the brain receives afferent ventilation information, it is

able to compare it to the current level of respiration by

the efferent signals.If the level of respiration is inappropriate for the body's status then dyspnea might

occur.

Chest radiographs

Electrocardiograph

Screening spirometry

Diagnosis

Diagnosis

In cases where test results inconclusive

complete PFTs

ABGs

Standard exercise treadmill testing or complete cardiopulmonary exercise

testing

Consultation with pulmonologist/cardiologist may be

useful

call local emergency.

Check the airway, breathing, and

pulse.

If necessary, begin CPR.

Loosen any tight clothing.

Help the person use any

prescribed medication

monitor breathing and pulse.

open wounds (esp with air bubbles) in neck or chest must be closed

Bandage the sucking wound

with plastic wrap sealing it except for one corner.

First Aid

DO NOT Do NOT give the person food or drink. Do NOT move the person if there has been a

chest or airway injury, unless it is absolutely necessary.

Do NOT place a pillow under the person's head. This can close the airway.

Do NOT wait to see if the person's condition improves before getting medical help. Get help immediately.

First Aid

The primary treatment is directed at its underlying cause.

Examples if fluid is collecting in the lung, the

fluid may need to be drained to lessen the dyspnea.

Chemotherapy or radiation therapy may shrink a tumor to lessen the dyspnea.

If dyspnea is being caused by an infection, antibiotics may be needed.

Treatment

Bronchodilators open a patient's airways and decrease their dyspnea.

Steroidshelp reduce swelling in the lungs that may be causing the shortness of breath.

Anti-anxiety drugs can help break the cycle of panic that can lead to more breathing difficulties.

Pain medications can make breathing easier.

Pharmacological Treatment

http://www.joshcorwin.com/pa/PAC18%20-%20Emergency%20Medicine/Test%201/DYSPNEA.PPT

http://nursingcrib.com/case-study/asthma-case-study/ Guyton and Hall Textbook of Medical

Physiology http://

sciencscarter08-28.wikispaces.com/Respiratory+System+101

Merck Manual of Diagnosis & Therapy http://en.wikipedia.org/wiki/Dyspnea#Treatment http://www.umm.edu/ency/article/000007trt.htm http://

www.valleyhealthlink.com/Taxonomy/RelatedDocuments.aspx?id=0&sid=0&ContentTypeId=34&ContentID=21274-1

References

Thanks