CME- Breathlessness Rad
Transcript of CME- Breathlessness Rad
Radtthiga ChelvarajMBBS
Batch 11Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Causes of breathlessness
Non-cardiorespiratory1.Metabolic acidosis
2.Psychogenic
Source : Clinical examination, A systematic guide to physical diagnosis, Talley & O’ Connor
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Causes of dyspnoeaSystem Acute dyspnoea at restCardiovascular Acute pulmonary edema
Respiratory Acute severe asthmaAcute exacerbation of COPDPulmonary embolismTension pneumothorax
Others Metabolic acidosis
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Causes of dyspnoeaSystem Chronic exertional dyspnoea
Cardiovascular Chronic heart failureAngina
Respiratory COPDChronic asthmaBronchial carcinomaInterstitial lung disease
Others Severe anemia
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Important aspects -Dyspnoea
• Onset?• Severity? • Number of episodes?• *Association with cardiovascular symptoms ?• *Association with respiratory system?
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Associated symptoms
• Productive cough or acute chest illness (Hx of chronic cough with sputum, worse in the morning)
• Breathlessness• Wheezing
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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)
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Association with cardiovascular system
• Relieving factors ? • Orthopnoea? ( beds used to sleep)• Paroxysmal Nocturnal Dyspnoea?
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
COPD AND ASTHMA
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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*
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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)
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
History and signsConditions History SignsAcute severe asthma
Previous episodesAtopyAsthma medication
-Tachycardia-Pulsus paradoxus-Cyanosis-Reduced peak flow-Rhonchi
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
History and signs
Conditions History SignsAcute exacerbation of COPD
Previous episodes, *admissionsSmoking
-Cyanosis-Raised JVP--LL Edema( Cor pulmonale)-Respiratory distress signs
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Systemic manifestations
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Investigations• Chest X-ray signs ofhyperinflation• flattening of the
diaphragm• increased
retrosternal air space
• long, narrow heart
shadow.• hypovascularity of
lung parenchyma
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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 .
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Conditions History Signs
Left ventricular failure
Chest painOrthopnoeaPNDPink, frothy sputum
-Raised JVP--Central cyanosis-Bibasal crackles -S3-Cardiomegaly-Cold extremities-LL edema
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Conditions History Signs
Metabolic acidosis Evidence of Diabetes/ renal diseases
-Acetone breath-Hyperventilation- Kussmaul’s breathing -Dehydration
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Investigations
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
-
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Acute exacerbations of COPD
• Characterised by:• Increases in symptoms• Deterioration of lung function• Development of respiratory failure
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Discharge
• Once patient is stable
• Short term nebuliser
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Acute exacerbation of asthma
• Characterised by:• Increased symptoms• Deterioration in PEFMay be precipitated by infections(viral)
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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)
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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)
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Indications for endotracheal intubation
• deterioration of arterial blood gas despite optimal therapy :
• PaO₂ < 60 mmHg• Pa CO₂> 45 mmHg• pH low
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Discharge
• Counselling on medications
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Left ventricular failure
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11
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