dyspenia ddx. mainpptx
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Transcript of dyspenia ddx. mainpptx
05/02/2023 Lailmaah habibi
الرحیم الرحمن الله بسم
Dyspnea defination Clinical : A subjective experience of
breathing discomfort that consists of (qualitatively) distinct sensations that vary in intensity.
Physiological: The stimulation of pulmonary and extra pulmonary afferent receptors and the transmission of afferent information to the cerebral cortex, where the sensation is perceived as uncomfortable or unpleasant
Physiology of Breathing
Pulmonary volumes
• the volume of air inspired or expired with each normal breath (about 500 ml).
The tidal volume
• the extra volume of air that can be inspired over and above the tidal volume with full force (about 3000 ml).
The inspiratory reserve volume
• the maximum extra volume of air that can be expired by forceful expiration after end of tidal expiration (about 1100 ml).
The expiratory reserve volume
• the volume of air remaining in the lungs after the most forceful expiration (about 1200 ml).
The residual volume
Pulmonary capacities
• The amount of air a person can breathe in (about 3500 ml).
The inspiratory capacity
• The amount of air remains in the lungs after normal expiration (about 2300 ml).
The functional residual 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 vital capacity
• The maximum volume to which the lungs can be expanded with the greatest possible effort (about 5800 ml).
The total lung capacity
" Dyspnea , a symptom , can be perceived only by the person experiencing it and must be distinguished from the signs of increased work 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
Mechanism of dyspnea
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.
A given disease state may lead to dyspnea by one or more mechanisms, some of which may be operative under some circumstances (e.g. exercise) but not others (e.g. , a change in position).
An increase in breathing occurs normally during exercise and a high altitudes
Motor Efferents Disorders of the ventilatory pump-most commonly , increased airway resistance or stiffness (decreased compliance) of the respiratory system-are associated with increased work of breathing or the sense of an increased effort to breathe
Sensory Afferents Chemoreceptors Mechanoreceptors Metaboreceptors
Dyspnea likely results from the complex interaction between:
chemoreceptor stimulation (Afferent)
mechanical breathing abnormalities (Efferent) perception of those
two by the CNS
Contribution of Emotional or Affective Factors to Dyspnea
Acute anxiety or fear may increase the severity of dyspnea either by altering the inter pretation of sensory data
ASSESSING DYSPNEAQuality of Sensation ;
Sensory Intensity
modified Borg scale or visual analogue scale can be utilized to measure dyspnea
at rest immediately following exercise or on recall of a reproducible physical
task such as climbing the stairs at home.
An alternative approach is to gain a sense of the patient's dis ability by inquiring about what activities are possible
non respiratory factors, such as leg arthritis or weakness
The following terms may be used in the assessment of the dyspneic patient: Tachypnea Hyperpnea Hyperventilation Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Platypnea
THE PNEA’S
DYSPNEA ACUTE – (PULMONARY EMBOLISM, PNEUMOTHORAX,
PULMONARY EDEMA) <30 days
CHRONIC – (COPD, CHF) >30 days
• TACHYPNEA – RR>20 BR/MIN ( PNEUMONIA)
• BRADYPNEA - RR< 8 BR/MIN (DRUGS, AGONAL
Stages of Cardiac dyspnea -EXERTIONAL DYSPNEA- due to exercise- ORTHOPNEA – lying flat and disappears
setting up (CHF, pregnancy, resp.muscle weakness)
-PND – acute SOB almost always accompanied by coughing and wheezing. usually occurs when a person is already sleep in a reclining position
(HF -early night , ASTHMA-late night ) -RESTING DYSPNEA-
Four general category causes
Cardiac Pulmonary
Mixed cardiac or pulmonary
non-cardiac non-pulmonary
COPD AsthmaRestrictiv
e Lung Disorders
Pulmonary Etiology
Hereditary Lung
DisordersPneumoni
aPneumo-thorax
Congestive Heart Failure
(CHF)
Coronary Artery
Disease (CAD)
Recent or past history
of Myocardial Infarction
(MI)
Cardiomyopathy
Cardiac Etiology
Valvular dysfuncti
on
Left ventricular hypertrop
hy
Pericarditis
Arrhythmias
COPD with pulmonary HTN and/or
cor pulmonale
Deconditioning
Chronic pulmonary
emboliPleural effusion
Mixed Cardiac/Pulmonary Etiology
Metabolic conditions
(e.g. acidosis)Pain Trauma
Noncardiac or Nonpulmonary Etiology
Neuromuscular disorders
Functional (anxiety, panic,
hyperventilation)Chemical exposure
Causes of dyspnea as assessed by Spirometry Echocardiography, &
EKG in 129 SubjectsOnly 69% of patients were diagnosed by these 3 tests
* Heart Disease defined as AF, LV systolicdysfunction or valve disease
Lung Disease defined as FEV1% < 70%
Obesity defined as BMI > 30 kg/m2
Pedersen et al., Int J Clin Pract, 2007, 61, 9, 1481–1491
DIFFERENTIAL DIAGNOSIS Respiratory system dyspnea Disease of the airways Disease of the chest wall Disease of the lung parenchyma
Disease of airways Asthma COPD Acute bronchitis ( bronchial constriction )
Disease of chest wall Kyphoscoliosis Weaken ventilatory muscle ( MG , GBS) Large pleural effusion Pneumo and heamothorax Traumatic chest injury
Disease of lung parenchyma
Infections Occupational exposure Autoimmune disorder
Cardiovascular system dyspnea
Diseases of the heart Disease of the mycardium (CAD) Non ischemic cardiomyopathies LV diastolic dysfunction Myocarditis Dysrhythmia Left atrial myxoma
Disease of the pericardium
Pericarditis (constrictive ) Cardiac tamponade
Disease of pulmonary vasculature
Pulmonary thromboembolism disease Primary pulmonary disease ( PPH ,
pulmonary vasculitis)
Dyspnea vs. normal cardiovascular and respiratory
Obesity Cardiovascular deconditioning Sensitivity to unpleasantness of hypercapnea impaired oxygen delivery (anemia, methe-
moglobinemia, cyanide ingestion, carbon monoxide)
Metabolic acidosis Panic disorder Neuromuscular disorder Toxin inhale and drugs
Speed of onset helps diagnosis;
Acute Foreign body Pneumothorax Acute asthma Pulmonary embolus Acute pulmonary edema
Subacute Asthma Parenchymal disease - eg. alveolitis,
effusions, pneumonia
Chronic COPD and chronic parenchymal diseases Non-respiratory causes – eg. Cardiac
failure, anemia
Steps to reach to diagnosis
History of present illness
Review of systems Past medical history
Physical examination Interpretation of findings
Testing Diagnosis
Chief compliantPatients perceptions: Unsatisfied inspiration Chest tightness Sensation of feeling breathless Cannot get enough air Hunger for air Incomplete exhalationAssociated underlying disease compliants
History of present illness
It should cover the following:
• Duration• Onset (e.g., Abrupt, insidious)• Positional changes• Provoking or aggravating factors (eg, allergen
exposure, cold, exertion, supine position). • Severity by assessing the activity level
required to cause dyspnea
Past medical history Past medical history should cover
disorders known to cause dyspnea, including asthma, COPD, and heart disease.
You should look for risk factors for the different etiologies (next slide).
Occupational exposures (eg, gases, smoke, asbestos) should be investigated
Review of systems
In this step, you should look for symptoms of possible causes.
For example:
chest pain or
pressure suggests
pulmonary embolism
[PE], myocardial ischemia,
or pneumonia
dependent edema,
orthopnea, and
paroxysmal
nocturnal dyspnea suggests
heart failure
fever, chills, cough,
and sputum
production
suggests pneumoni
a
Risk factors for the different etiologies
•Smoking historyFor cancer, COPD, and
heart disease
•Family history, hypertension, and high cholesterol levels
For coronary artery
disease
•Recent immobilization , trauma or surgery, recent long-distance travel, prior or family history of clotting, pregnancy, oral contraceptive use, calf pain, leg swelling, and known deep venous thrombosisFor PE
Physical examination Vital signs: fever, tachycardia, and
tachypnea. Temperature PR RR PO2 sat
Breathlessness : emergency presentations
Wheezing? Asthma COPD Heart Failure Anaphylaxis
Stridor? (Upper airway obstruction) Foreign body or tumor Acute epiglottitis Anaphylaxis Trauma, eg laryngeal fracture
Crepitations? Heart failure Pneumonia Bronchiectasis Fibrosis
Chest clear? Pulmonary embolism Hyperventilation Metabolic acidosis, eg diabetic ketoacidosis
(DKA) Anemia Drugs, eg: salicylates Shock (may cause air hunger) Pneumocystis pneumonia Central causes
Others Pneumothorax – pain, increased resonance Pleural effusion – 'stony dullness'
Hyperventilation Syndrome
Response to stress, anxiety Patient exhales CO2 faster than
metabolism produces it Blood vessels in brain constrict Anxiety, dizziness, lightheadedness Seizures, unconsciousness
Hyperventilation Syndrome
Chest pains, dyspnea Numbness, tingling of fingers, toes,
area around mouth, nose Carpopedal spasms of hands, feet
Foreign Body Obstruction Suspect in any child with
Sudden onset of dyspnea Decreased LOC
Suspect in any adult who develops dyspnea or loses consciousness while eating
Pulmonary Embolism Associated with:
Prolonged bed rest or immobilization Casts or orthopedic traction Pelvic or lower extremity surgery Phlebitis Use of BCPs
Pulmonary Embolism Signs/Symptoms
Dyspnea Chest pain Tachycardia Tachypnea Hemoptysis
Sudden Dyspnea + No Readily Identifiable Cause = Pulmonary Embolism
The probable Differential diagnosis of dyspnea with acute onset
Pulmonary embolism
Abrupt onset of sharp chest pain, tachypnea,
and tachycardia
Often risk factors for pulmonary embolism• cancer, • immobilization• DVT• pregnancy,• use of oral
contraceptives• recent surgery or
trauma
CT angiography V/Q scanning
pulmonary arteriography
The probable Differential diagnosis of dyspnea with acute onset
Anxiety disorder causing hyperventilation
Situational dyspnea often
accompanied by psychomotor agitation and
paresthesias in the fingers or
around the mouth
Normal examination
findings and pulse oximetry
measurements
Diagnosis of exclusion
Diagnosis Features
Acute asthma Wheeze with reduced peak flow rate
Previous similar episodes responding to bronchodilator therapy
Diurnal and seasonal variation in symptoms
Symptoms provoked by allergen exposure or exercise
Sleep disturbance by breathlessness and wheeze
Pulmonary oedema Cardiac disease
Abnormal ECG
Bilateral interstitial or alveolar shadowing on chest x-ray
Pneumonia Fever
Productive cough
Pleuritic chest painFocal shadowing on chest X-ray
Exacerbation of chronic obstructive pulmonary disease
Increase in sputum volume, tenacity or purulencePrevious chronic bronchitis: sputum production daily for 3 months of the year, for 2 or more consecutive yearsWheeze with reduced peak flow rate
Pulmonary embolism
Pleuritic or non-pleuritic chest pain
Haemoptysis
Risk factors for venous thromboembolism present (signs of DVT commonly absent)
PneumothoraxSudden breathlessness in young otherwise fit adult
Breathlessness following invasive procedure e.g subclavian vein puncture
Pleuritic chest pain
Visceral pleural line on chest x-ray, with absent lung markings between this line and the chest wall
Cardiac tamponade Raised JVP
Pulsus paradoxus > 20mmHgEnlarged cardiac silhouette on chest X-rayKnown carcinoma of bronchus or breast
Laryngeal obstruction
History of smoke inhalation or the ingestion of corrosives
Palatal or tongue oedemaAnaphylaxis
Tracheobronchial obstruction
Stridor (inspiratory noise) or mnophonic wheeze (expiratory 'squeak')
Known carcinoma of the bronchus
History of inhaled foreign body
PaCo2>5 kPa in the absence of chronic obstructive pulmonary disease
Wheeze unresponsive to bronchodilators
Large pleural effusion
Distinguished from pulmonary consolidation on the chest x-ray by:
Shadowing higher laterally than medially
Shadowing does not conform to that of a lobe or segment
No air bronchogram
Trachea and mediastinum pushed to opposite side
Arterial blood gases and pH in breathlessness with a normal chest X-ray
Disorder PaO2 PaCO2 PHa
Acute asthma Normal/low Low High
Acute exacerbation of COPD Usually low
May be high
Normal or low
Pulmonary embolismNormal/low (without pre-existing cardiopulmonary disease) Low High
Pre-radiological pneumonia Low Low High
Sepsis syndrome Normal/low Low Low
Metabolic acidosis Normal Low Low
Hyperventilation without organic disease High/normal Low High
Diagnostic studies Causes of dyspnea that can be managed
without chest radiography are few: ingestions causing lactic acidosis, anemia, methemoglobinemia, and carbon monoxide poisoning.
Chest radiographs
Electrocardiograph
Screening spirometry
Diagnosis
Testing
Pulse oxime
try
CXR ECG ABG
Extra Testing If no clear diagnosis obtained from chest
x-ray and ECG and patient is at moderate or high risk of having PE, he should undergo CT angiography ventilation/perfusion scanning.
• Patients who are at low risk may have d-dimer testing (a normal d-dimer level
effectively rules out PE in a low-risk patient).
Ancillary studies list
Chest x-ray (CXR) ECG Cardiac
biomarkers
Brain natriuretic
peptideD-
Dimer ABGCarbon dioxide
monitoring
Chest CT and VQ scan
Peak flow and pulmonary
function tests (PFTs)
Negative inspiratory
force
BNP or NT pro BNP Bronchopulmonary provocation test Chest HR CT Carboxyhemoglobin and methemoglobin
level
Basic Workup of Exertional Dyspnea
Lung Disease Airways disease Interstitial Lung DiseaseNeuromuscular Disease Vocal Cord Dysfunction
PFTsChest Imaging (CXR, CT)Methacholine Challenge Testing
Heart DiseaseMyocardial Disease (Systolic, Diastolic)Valvular Heart DiseaseCoronary Artery Disease
EKGEchocardiographyBNP
Pulmonary Vascular Disease (Pulmonary Hypertension, PE) Echocardiography, CTPA,
V/QMetabolic Disease Anemia Thyroid Disease
CBC, TFTs
Deconditioning, Anxiety Exclusion
treatment The treatment of urgent or emergent
causes of dyspnea should aim to relieve the underlying cause.
Pending diagnosis, immediately provided supplemental oxygen
Opioid therapy, anxiolytics, and corticosteroids can provide substantial relief independent of the severity of hypoxemia
Pulmonary rehabilitation, moderate to severe COPD or interstitial pulmonary fibrosis
Experimental interventions-e.g. , cold air on the face , chest wall vibration , and inhaled furosemide-aimed at modulating the afferent information from receptors throughout the respiratory system are being studied. Morphine has been shown to reduce dyspnea out of proportion to the change in ventilation in laboratory models.
Resources CURRENT Medical Diagnosis and
Treatment 2015 Harrison's Principles of Internal Medicine,
19E 2-VOLUME SET (2015) [PDF] [UnitedVRG]
Rosen Emergency Medicine -2014 . Guyton and Hall Textbook of Medical
Physiology Merck Manual of Diagnosis & Therapy http://en.wikipedia.org/wiki/Dyspnea#Treatment
THANK YOU