APPROACH TO A CASE OF DYSPNEA

by Prof. Arvind Mishra M.D. Dept. of Medicine

DEFINITION

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity (By American Thoracic Society)

CAUSES OF DYSPNEA

1)Respiratory causes

2)Cardiovascular causes

3)Dyspnea with normal cardiorespiratory function

RESPIRATORY CAUSES1. Diseases of the airway2. Diseases of the pleura and lung parenchyma3. Diseases of the chest wall

1)Diseases of the airway e.g. Asthma and COPD Characterised by expiratory airflow obstruction

Hyperinflation of lung and chest wall

Increased resistive and elastic load on the ventilatory muscles and increased work of breathing

Hypoxia

2)Diseases of the pleura and lung parenchyma

• Pleural effusion• Infective diseases of parenchyma - Pneumonia -Pneumonia occuring over existing parenchymal

infective diseases-Bronchiectasis,lung abscess• Interstitial lung disease – caused by -occupational exposures - autoimmune disorders

3)Diseases of the chest wall

a)Diseases that stiffens the chest wall -kyphoscoliosis

b)Diseases that weakens the chest wall -myasthenia gravis and guillain - barre

syndrome

CARDIOVASCULAR CAUSES

• Diseases of left heart• Diseases of pulmonary vasculature• Diseases of pericardium

Diseases of left heart e.g. Coronary heart diseases Valvular heart diseases Dilated cardiomyopathy

Greater end diastolic volume and incresed LV end diastolic and pulmonary capillary pressure

Interstitial edema and stimulation of pulmonary receptors leading to dyspnea

Diseases of pulmonary vasculature• Pulmonary thromboembolic diseases

• Primary pulmonary hypertension

• Pulmonary vasculitis

Increased pulmonary artery pressure and stimulation of pulmonary receptors leading to dyspnea

Diseases of pericardium

• Constrictive pericarditis• Cardiac tamponade

Dyspnea caused by -incresased pulmonary vascular pressure -decreased cardiac output stimulation of metaboreceptors and

chemoreceptors

Dyspnea with normal cardiorespiratory function

ANEMIA- stimulation of metaboreceptors

OBESITY-impaired ventilatory pump function and high cardiac output

EVALUATION OF A PATIENT WITH DYSPNEA

A)History

B)Physical examination

C)Investigations

HISTORY1)Effect of position a)Orthopnea-CHF, Obesity, asthma triggered

by oesophageal reflux b)Platypnea-left atrial myxoma2)Timing Nocturnal- CHF , Asthma3)Duration a)Acute- Myocardial ischemia Pulmonary embolism

b)Chronic- a)COPD

b)Interstitial lung disease

c)Chronic thromboembolic disease

4)RISK FACTORS – related to

a)Occupational lung disease

b)Coronary artery disease

PHYSICAL EXAMINATIONA)General appearance - Evidence of increased work of breathing a)supraclavicular retractions b)use of accessory muscles c)tripod position

Increased airway resistance or stiff lungs and chest wall

-Vital signs a)RR b)pulsus paradoxus: COPD , Asthma-General examination a)anemia b)cyanosis-central/peripheral c)clubbing-cyanotic heart disease Bronchiectasis lung abscess Empyema thoracis Interstitial pulmonary fibrosis etc. d)pedal edema-cor pulmonale e)Joint swelling or deformity-Collagen Vascular Ds

CHEST EXAMINATIONa)Symmetry of movementsb)Percussion: dullness-pleural effusion hyperresonance-emphysema tympanitic-pneumothoraxc)Auscultation: Rales/ rhonchi/ diminished breath sounds/prolonged

expiratory phase

Disorders of airway/ interstitial edema/fibrosis

CVS EXAMINATIONA)Elevated right heart pressure -raised JVP -edema -ascitis -tender hepatomegalyB)Left ventricular dysfunction -Gallop rhythm(S3 and S4 gallop)

C)Valvular disese -murmurs

INVESTIGATIONS POINTING NEUROLOGICAL, MUSCULAR AND SKELETAL DISORDERS

• Neurological disease-NCV testing• Muscular disease- Creatine phosphokinase

enzyme estimation(CPK)• Skeletal deformities-X-ray of affected area of

spine(AP/Lateral view)

ABDOMINAL EXAMINATION

A)Paradoxical movement of abdomen-

diaphragmatic weakness

B)Tender hepatomegaly-Right heart failure

C) Tense Ascitis- Chonic liver disese ,Chonic heart

failure

If diagnosis not evident yet? What next….

CXR-assess for cardiac size , evidence of CHF-Assess for hyperinflation-Assess for pneumonia, ILD and Pleural effusion

Chest X raya)Prominent pulmonary vasculature in upper zone: pulmonary venous hypertensionb)Enlarged central pulmonary arteries: pulmonary artery hypertensionc)Enlarged cardiac silhouette-Dilated

cardiomyopathy, valvular disease d)Pleural effusion- CHF ,TB, Pneumonia, Pulmonary

embolismCT –Chest: for further evaluation (in ILD ,Pulmonary embolism)

CARDIOPULMONARY EXERCISE TEST-To distinguish cardiovascular from respiratory

dyspnea-If at peak exercise: a) patient achieves predicted maximum ventilation,

increase in dead space/hypoxemia or develops bronchospasm- Respiratory system is involved

b)HR is>85% of predicted maximum, BP becomes excessive high/decrease during exercise, O2 pulse falls(O2 consumption/HR,an indicator of stroke volume) ischemic changes on ECG- Cardiovascular system is involved

TREATMENT-

A)correct the underlying problem B)If A) is not possible, try to lessen the severity

of symptoms -supplemental oxygen -pulmonary rehabilitation programs

MCQs

1)A 40 year old man ,chronic smoker and a known diabetic presented with sudden onset brethlessness since 1 day. O/E peripheral extremities are cool, B/L crepts in the chest and neck veins are engorgerd .MOST LIKELY DIAGNOSIS

a)Spontaneous pneumothoraxb)Pulmonary embolismc)Cardiac tamponaded)Myocardial infarction

2)A young patient presented with high grade fever ,left sided chest pain in the evening hours and developed marked breathlessness by next morning.X-ray chest revealed areas of parenchymal necrosis, air filled cystic spaces and pleural effusion on left. Possibility will be

a)Fried landers pneumoniab)Staphylococcal pneumoniac)Pneumonia by H.influenzaed)Nosocomial pneumoniae

3)A 40 year old women developed sudden sharp-shooting chest pain on the right side which followed immediately by marked breathlessness .Very rapidly patient developed shock,BP was not recordable.On general examination ,patient revealed cyanosis.Most likely etiology would be

a)Tension pneumothoraxb)Status asthmaticusc)Cardiac tamponaded)Cardiogenic shock

4)A 30 year old male came with H/O severe epigastric pain with radiation to back and recurrent vomitings for past 3 days and breathlessness for past one day. No H/O .jaundice or abdominal pain in past. O/E: BP- 104/68, RS-decreased BS in Left hemithorax, Abdomen –decreased bowel sounds. Biochemical investigation reveals hypocalcemia,hyperglycemia and hypertriglyceridemia. Most likely diagnosis

a)Acute pancreatitisb)Perforation peritonitisc)GERDd)Left side pneumonitis

5) A 28 year old man, a known diabetic came with h/o gastroenteritis 1 week back –cause could not be evaluated. Patient has developed symmetrical weakness of B/L lower limb followed by trunk and B/L upper limb without BBI for past 3 days. Since morning patient has developed breathlessness. Diagnosis

a)Lead poisoningb)Myasthenia Gravisc)Guillain Barre Syndromed)Diabetic neuropathy