dyspnea chang shim, md pulmonary division jacobi medical center

Dyspnea

Chang Shim, MD

Pulmonary Division

Jacobi Medical Center

Dyspnea

Definition: Unpleasant or uncomfortable respiratory sensations

A subjective experience of breathing discomfort. The experience derives from interactions among multiple physiological, psychological, social and environmental factors.

Dyspnea

Common complaint among the general population.

6%-27% of different gender and age strata (37-70 yrs) in the Framingham Study

2.7% of the emergency room visits

Most common: asthma, myocardial dysfunction, COPD, interstitial lung disease

American Thoracic Society Shortness of Breath Scale

Grade Degree Description0 none No trouble walking up a slight hill1 mild SOB hurrying on the level or

walking up a slight hill

2 moderate Walks slower than the peers; has to stop for SOB walking at own pace

3 severe Stops for breath after walking about 100 yards or after a few minutes

4 very severe Too breathless to leave the house or breathless on dressing or undressing

Dyspnea: Direct Measurement

Visual Analog ScaleNot breathless---------------------------------------------Extremely breathless

Modified Borg Scale0 none0.5 very, very slight1 very slight2 slight 3 Moderate4 somewhat severe5 Severe7 very severe9 very, very severe10 maximal

Physiologic Categories of Diseases Causing Dyspnea-1

Mechanical interference with ventilationObstruction of airflow

Asthma, emphysemaEndobronchial tumorTracheal stenosis

Stiff lungsInterstitial fibrosisLV failureLymphangitic carcinoma

Resistance to expansion of the chest wall or diaphragmObesityPleural thickeningKyphoscoliosisAbdominal mass, ascites, pregnancy

Physiologic Categories -2

Weakness of the respiratory pumpAbsolute

Prior polioNeuromuscular disease- Guillain-Barre syndrome Myasthenia gravis, muscular dystrophy, SLE,

Hyperthyroidism, hypothyroidism, multiorgan dysfRelative

Pleural effusionPneumothoraxHyperinflation (emphysema)

Physiologic Categories -3

Increased respiratory drive

Hypoxia

Metabolic acidosis

Stimulation of intrapulmonary receptors-infiltrative lung disease, pulmonary hypertension, pulmonary edema

Physiologic Categories-4

Wasted ventilation

Capillary destruction: emphysema, interstitial lung disease

Large vessel obstruction: pulmonary embolism, pulmonary vasculitis

Psychological dysfunction

Anxiety-panic state, depression, litigation

Mechanisms of Dyspnea

Originates with the activation of sensory systems involved with respiration.

Relayed to the higher brain centers for processing of respiratory-related signals and cognitive and behavioral influences shape the ultimate sensation.

Evaluation of the Patient with Dyspnea

History and physical examination: characteristics of symptoms, quality, intensity, duration, distress.

Specific activities associated with dyspnea

Quantify intensity of dyspnea

Effect on life quality

Cardiovascular vs pulmonary dyspnea, or both

Special Studies-1

Pulmonary function studies

Lung volumes and flow rates

Diffusing capacity (DLCO)

Arterial blood gases

Cardiopulmonary exercise testing

Bronchial challenge

Maximal inspiratory pressure

Special Studies-2

Imaging studies

Ventilation-perfusion lung scan

Chest CT, HRCT (high resolution CT)

Gallium scanning

Diaphragmatic fluoroscopy

Special Studies-3

Cardiac evaluationEchocardiogram-for ventricular size and function, regional wall motion abnormalitiesDobutamine stress echocardiography-regional

wall motion abnormalities.Thallium perfusion scan Holter monitorCardiac catheterization/coronary angiographyPlasma BNP or N-terminal pro-BNP

most HF patients >400 pg/ml; normals 10 pg

Special Studies-4

Sleep studies

Esophageal pH monitor

ENT examination

Psychological assessment

Treatment of DyspneaAltered Central Perception

Cognitive-behavioral strategiesPerception of dyspnea results in part from the effects of cognitive, emotional, and behavioral factors on the conscious awareness of the demand to breathe and the affective response to the symptom.

Education about the disease processTeaching of the coping skills, for example,

relaxation, distraction, reassurance

Asthma

• Reverse airflow obstruction– Bronchodilators, anti-inflammatory agents

• Relieve chest tightness– Same as above

• Control cough– Same, + cough meds & local anesthetics

• Relieve anxiety– Anxiolytics: usually contraindicated – Rare exceptions: benzodiazepines, opiates

Reduce Resistive Load

Reverse bronchoconstriction.

Decrease airway inflammation and edema

Pharmacological therapy

Inhaled beta2-agonists, short and long-act

Inhaled anticholinergics

Theophylline probably related to deceased operational lung volumes.

COPD

• Reverse airflow obstruction: anti-cholinergics (short and long acting), corticosteroids, long acting beta agonists, theophylline

• Reverse hyperinflation/air trapping– Inhalation meds, Expiratory maneuvers, LVRD

• Exercise rehabilitation

COPD

• LVRS (lung volume reduction surgery):NETT

• Oxygen

• NIPPV for acute exacerbation

• Reduce ventilatory requirements: metabolism, V/Q, exercise rehab.

• Central drive: depressants: benzodiazepines, opiates

Treatment of Dyspnea

Reduce ventilatory demandIncreased VE or VE/MVC (maximal ventilatory capacity) correlates with exertional dyspnea.Reduce CO2 output, VD/VT (physiologic dead space), arterial hypoxemia, metabolic acidosis.

Hyperventilation itself causes dyspnea.

Reducing Metabolic Load

Exercise trainingImproves aerobic capacityReduces rate of rise of lactate levels with exerciseDecreases exertional dyspneaImproves exercise toleranceReduces VE per work rate primarily by decreasing breathing frequency.VCO2 and VO2 reduced at a given work rate=improved efficiency.

Reducing Metabolic Load

Supplemental oxygen during exercise

Patients with chronic lung disease have reductions in blood lactate and VE

Decreasing Central Drive

Inhaled pharmacologic therapyLidocaine may alter afferent information from the pulmonary receptors: AsthmaLow dose opiates via nebulizers ?

Fans: mechanoreceptors on the face or decrease in temperature of facial skin

Improve efficiency of CO2 eliminationVD/VT is increased. Slow deep breath

Altered breathing pattern: slow deep breathing, diaphragmatic breathing, pursed lip breathing


Oxygen Therapy

Depress hypoxic drive from the peripheral chemoreceptors in the carotid body.

Oxygen may blunt pulmonary artery pressure rise with exercise.

Oxygen may improve ventilatory muscle function.

Airflow over the face or nasal mucosa may ameliorate dyspnea.


Oxygen TherapyAs an adjunct to exercise training program.Prevents skeletal muscle deconditioning by

increasing ADL.Criteria: PO2 =<55 mmHg or 56-59 mmHg with

polycythemia or cor pulmonale.Flow rate should be adjusted to correct

hypoxemia.Delivery by nasal canula, face mask, transtracheal

catheter


Pharmacologic therapyOpiates

Respiratory depressants reduce the central processing of neural signals. Reduce VE & VO2 at rest and exercise.Endogenous opioids modulate dyspnea in acute bronchoconstriction.Opiates may alleviate dyspnea by blunting perception.

Side effects: hypercapnea, altered mental status, constipation, nausea, vomiting, drowsinessInhaled opiates are not effective.


AnxiolyticsMay relieve dyspnea by depressing hypoxic or

hypercapnic ventilatory responses.May alter emotional responses to dyspnea.

Benzodiazepines failed to demonstrate consistent improvement in dyspnea.

Poorly tolerated.May benefit individuals with respiratory panic

attacks, but needs close monitoring.

Reducing Ventilatory Impedance

Reduce lung hyperinflationDynamic hyperinflation during exercise or hyperventilation—auto-PEEP or intrinsic PEEP is important contributor to dyspnea.

Surgical volume reductionUnilateral bullectomy, or lung volume reduction surgery (LVRS) benefits by reduction of operating lung volumes.

Dyspnea decreased by reduced dynamic hyperinflation, improved chest wall mechanics and increased lung recoil and increased airflow.

Lung Volume Reduction Surgeryin Emphysema

Lung Volume Reduction Surgery

Continuous positive airway pressure(CPAP)

Low levels of CPAP relieve dyspnea in

Acute bronchoconstriction in asthma, Patients weaning from mechanical ventilation,

During exercise in advanced COPD.

Benefits of CPAP are probably related to reduction in auto PEEP

Improving Inspiratory Muscle FunctionStrength and Endurance

Respiratory muscle weakness, fatigue and dyspneaDecreased body weight—decreased diaphragm

mass, decreased intercostal muscle fiber sizeWeight loss of >10% of ideal body weight

Improvement of respiratory muscle function with enteral or parenteral nutrition

Inspiratory muscle training?Positioning: leaning forward positionPartial ventilatory supportMinimizing the use of steroids

Obesity

• Apple shaped, in contrast to pear shaped, is more burdensome to diaphragmatic movement.

• Central respiratory drive: supernormal• Upper airway dimension: crowded, relaxed

muscle• Airway dimension is related to lung volume. • Upright position, unloading of the diaphragm• CPAP (continuous positive airway pressure)

prevents large airway collapse• Bariatric surgery

Paralysis, Chest wall abnormality

Reversible conditions, myasthenia, Guillain Barre: mechanical ventilation until recovery of neuro-muscular function

Correct chest wall abnormality if feasible: pleural effusion, pneumothorax, flail chest

NIPPV

Diagnosis of Diaphragmatic Paralysis

Unilateral: often asymptomatic

VC sitting and supine

Sniff test under fluoroscopy

Sonography

Sniff Test

Not the cocaine variety

Sniff is a potent, brief inspiratory maneuver everyone is familiar with.

Monitor diaphragmatic movement (fluoroscopic imaging) from the patient’s side during sniffing. The paralyzed diaphragm moves up paradoxically while the intact diaphragm descends sharply.

Dyspnea in Diaphragm Paralysis

Body position or posture

Exercise tolerance

Stretch receptors in the muscles and tendons

Activities: rest, sleep, exertion

Diaphragm Pacer

Hyperventilation Syndrome

• Anxiety-panic attacks• Shortness of breath, tingling in finger tips, circum-oral

numbness, dry mouth, globus hystericus, sense of doom.

• In association with asthma, COPD, vocal cord dysfunction: management problem (beta agonist).

• Important to dissociate asthma from hyperventilation: PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee.

• Pharmacologic: narcotics, benzodiazepines• Self-corrected once patient lapses into coma

Dyspnea

Assessment

Borg scale for severity

Sensation: inability to inhale deeply

inability to exhale properly

Hyperinflation or air trapping in obstructive lung disease

Position or posture, helpful, detrimental

Bending over vs tripod positions in adults

Dyspnea in Obesity

Position or posture

Activity

Walking, climbing stairs

Bending over

Supine position with choking sensation

Lateral decubitus with pendulous belly is better tolerated.

Dyspnea with CHF

Receptors for dyspnea in J receptors or airway or stretch receptors in left atrium

Small airways dysfunction from peri-bronchial edema.

Interstitial vs alveolar space edema

Oxygen desaturation


Pharmacologic therapyOpiates

Respiratory depressants reduce the central processing of neural signals. Reduce VE & VO2 at rest and exercise.Endogenous opioids modulate dyspnea in acute bronchoconstriction.Opiates may alleviate dyspnea by blunting perception.

Side effects: hypercapnea, altered mental status, constipation, nausea, vomiting, drowsinessInhaled opiates are not effective.


AnxiolyticsMay relieve dyspnea by depressing hypoxic or

hypercapnic ventilatory responses.May alter emotional responses to dyspnea.

Benzodiazepines failed to demonstrate consistent improvement in dyspnea.

Poorly tolerated.May benefit some individuals with respiratory panic

attacks, but need close monitoring.

Reducing Ventilatory Impedance

Reduce lung hyperinflationDynamic hyperinflation during exercise or hyperventilation—auto-PEEP or intrinsic PEEP is important contributor to dyspnea.

Surgical volume reductionUnilateral bullectomy, or lung volume reduction surgery (LVRS) benefits by reduction of operating lung volumes.

Dyspnea decreased by reduced dynamic hyperinflation, improved chest wall mechanics and increased lung recoil and increased airflow.

Continuous positive airway pressure(CPAP)

Low levels of CPAP relieve dyspnea in

Acute bronchoconstriction in asthma, Patients weaning from mechanical ventilation,

During exercise in advanced COPD.

Benefits of CPAP are probably related to reduction in auto PEEP

Obesity








NIPPV


• Anxiety-panic attack• Shortness of breath, tingling in finger tips, circumoral

numbess, dry mouth, globus hystericus, sense of doom.• In association with asthma, COPD, vocal cord

dysfunction: management problem (beta agonist).• Important to dissociate asthma from hyperventilation:

PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee.

• Pharmacologic: narcotics, benzodiazepines• Self-corrected once patient lapses into coma.

Dyspnea

Assessment







Dyspnea in Obesity

Position or psture

Activity


Bending over


Lateral decubitus with pendulous belly is better tolerated

Dyspnea with CHF

Receptors for dyspnea in J receptors or airway or stretch receptors in left atrium

Small airways dysfunction for peri-bronchial edema.

Interstitial vs alveolar space

Oxygen saturation

Obesity








NIPPV


• Anxiety-panic attacks• Shortness of breath, tingling in finger tips, circumoral

numbess, dry mouth, globus hystericus, sense of doom.• In association with asthma, COPD, vocal cord

dysfunction: management problem (beta agonist).• Important to dissociate asthma from hyperventilation:

PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee.

• Pharmacologic: narcotics, benzodiazepines• Self-corrected once patient lapses into coma.

Dyspnea

Assessment







Dyspnea in Obesity

Position or psture

Activity


Bending over


Lateral decubitus with pendulous bellybetter tolerated

Physiologic Categories of Diseases-3

Increased respiratory drive

Hypoxia

Metabolic acidosis

Stimulation of intrapulmonary receptors-infiltrative lung disease, pulmonary hypertension, pulmonary edema

Physiologic Categories-4

Wasted ventilation

Capillary destruction: emphysema, interstitial lung disease

Large vessel obstruction: pulmonary embolism, pulmonary vasculitis

Psychological dysfunction

Anxiety, depression, litigation

Dyspnea with CHF

Receptors for dyspnea in J receptors or airway or stretch receptors in LA



Oxygen saturation

Dyspnea with CHF

Receptors for dyspnea in J receptors or airway or stretch receptors in LA



Low pO2, low cardiac output, tissue acidosis, pulmonary interstitial pressure

Dyspnea and circumstances

Effect of Anxiety on respiratory sensation

Anxiety provoked from dyspnea

Interactions of anxiety and dyspnea

Asthma and panic attacks

Asthma and vocal cord dysfunction

dyspnea chang shim, md pulmonary division jacobi medical center

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