Dr. Nighat Majeed Dr. Nighat Majeed Assistant professor medicineAssistant professor medicine

Medical unit 11 Medical unit 11 SHL/SIMS LahoreSHL/SIMS Lahore

INTRODUCTION

Dyspnea derived , from the word dyspnoos, (shortness of breath) is

perceived to be difficulty of breathing or painful breathing.

• Dyspnea on exertion indicates dyspnea that occurs or worsens during physical

activity.

ETIOLOGY

Acute dyspnoea• Cardiac causes(Cardiogenic pulmonary

edema).

• Acute attack of bronchial asthma.

• Pulmonary Embolism.

• Spontaneous pneumothorax.

• Pneumonia.

Acute dyspnoea

• Adult respiratory distress syndrome.

• Non cardiac pulmonary edema(noxius gas inhalation,high altitude pulmonary edema,neurogenic pulmonary edema).

Acute dyspnoea

• Massive pleural effusion.

• Foreign body aspiration.

• Acute hyperventilation syndrome(neuropsychiatric).

• Metabolic acidosis.

Chronic Dyspnoea

Disorders of the cardiovascular system

Pulmonary edema.Pericardium disorders.

Cardiac tamponade. Constrictive pericarditis.Pericardial effusion.

Malignant hypertension. Pulmonary embolism. Valvular heart disease.

Disorders of the cardiovascular system

Aortic dissection. Cardiomyopathy.Congenital heart disease. Heart failure. Ischemic heart disease.

Disorders of the lungs

Obstructive lung diseases • Chronic obstructive pulmonary disease. Chronic Bronchitis Emphysema• Bronchial asthma. • Cystic fibrosis. • Laryngeal edema due to allergies. • Hookworm disease.

Diseases of lung parenchyma and

pleura

Interstitial lung disease(Sarcoidosis, Pneumoconiosis, Rheumatoid lung, Scleroderma, Hisyiocytosis X, Lymphangiticcarcinomatosis, Idiopathic pulmonary fibrosis).

Fibrosing alveolitisPleural effusion/pleural fibrosis.Alveolar filling disease(alveolar proteinosis,

alveolar cell carcinoma, alveolar microlithiasis).

Diseases of lung parenchyma and pleura

• Infections.

• Atelectasis.

• Hypersensitivity pneumonitis.

• Lung cancer.

• Ankylosing spondylitis.• Broken ribs. • Kyphosis of the spine. • Obesity. • Pregnancy. • Pectus excavatum. • Scoliosis.

Restriction of the chest Wall

Immobilization of the diaphragm

• Lesion of the phrenic nerve.

• Polycystic liver disease.

• Tumor in the diaphragm.

Disorders of the blood and metabolism

Anemia. Hypothyroidism. Metabolic acidosis. Sepsis. Leukemia.

Disorders affecting breathing nerves and

musclesAmyotrophic lateral sclerosis Guillain-Barré syndrome Multiple sclerosis Myasthenia gravis Parsonage Turner syndrome Eaton-Lambert syndrome

Others

Psychological conditions.

Anxiety disorders and panic attacks.

Medications.

Heart or Lung?Chronic Dyspnoea

History(pulmonary disorders)Smoking in cardiopulmonary disease.Smoking in occupational lung diseases.Worsening dyspnoea in emphysema.Productive cough for at least three months of a

year for two consecutive year period.Wheezing in emphysema and bronchial

asthma.Repeated pulmonary infections in chronic

bronchitis.Cough,fever,pleuritic chest pain in pneumonia

History(pulmonary disorders) Haemoptysis in bronchogenic carcinoma,

pneumonia and tuberculosis. Diaphragmatic problems cause dyspnoea that

worsen on lying down.Past history of tuberculosis.Pulmonary vascular diseases cause slowly

progressive dyspnoea.Occupational history in occupational lung

disease.Recurrent pneumothorax in COPD, and

eosinophilic pneumonia.

History(pulmonary disorders)

Symptoms suggestive of history of connective tissue diseases, such as scleroderma, Rheumatoid arthritis, polymyositis, sarcoidosis, eosinophilic granuloma, pneumoconiosis.

Recurrent pneumothorax, diabetes insipidus in eosinophilic granuloma.

In lymphangitic carcinomatosis, symptoms caused by primary carcinoma.

• Large amount of sputum production in alveolar filling diseases.

History(pulmonary disorders)

Drug history in pulmonary fibrosis.

Pulmonary vascular diseases; presents with slowly progressive dyspnoea.

History (Non pulmonary diseases)

• Congestive heart failure Dyspnoea,orthopnea,paroxysmal nocturnal dyspnoea,nocturia,ankle edema.

• Psychogenic dyspnoea is the diagnosis of exclusion.• Upper airway disease patient with complaint of audible

wheezing.• Pulmonary embolism

History (Non pulmonary diseases)Non cardiogenic pulmonary edemaH/o hemorrhagic or septic shock.H/O acute pancreatitis.Multiple trauma.Near drowning.Pneumonia.High altitude pulmonary edema.

Hyperventilation SyndromeResponse to stress, anxiety.Patient exhales CO2 faster than metabolism

produces it.Blood vessels in brain constrict.Anxiety, dizziness, lightheadedness.Seizures, unconsciousness.Chest pains, dyspnea.Numbness, tingling of fingers, toes, area

around mouth, and nose. Carpopedal spasms of hands, feet.

Physical examination

Cardiac causes Pulmonary edemaLateral or downward displacement of apex

beat.Third heart sound.Gallop rhythm.MurmursFine crepitations at lung bases.Wheezes.Periphral edema,Hepatomegaly,distended neck

veins are the signs of right sided heart failure.

Non cardiogenic Pulmonary edema;Shock.Patechial haemorrages.Wheeze.Crepitations.

Examination(pulmonary disorders)

Emphysema Anteroposterior diameter of chest is

increased, hypertrophy of accessory muscles of respiration, hyperresonant percussion note, decreased breath sounds with prolonged expiration.

Examination(pulmonary disorders)

Chronic bronchitis• Diagnosed by the history, patient may have

the findings of airway obstruction.• Cyanotic, plethoric or have signs of

corpulmonale in severe disease.

Examination(pulmonary disorders)

Chronic Bronchial asthma• Wheezing.

• Signs of hyperinflation of lungs.

Examination(pulmonary disorders)

Restrictive lung disease• Interstitial lung disease; clubbing, dry

inspiratory bibasilar crepitations.• Signs of associated systemic diseases like

arthritis, skin rash, lymphadenopathy, splenomegaly.

• Evidence of primary carcinoma in lymphangitic carcinomatosis.

Examination(pulmonary disorders)

Thoracic abnormalities are evident on physical examination.

Pleural fibrosis; diminished expansion of chest wall, dull percussion note decreased fremitus and decreased breath sounds.

Rales in alveolar filling defects.Pulmonary hypertension; right ventricular

lift and loud P2.and periphral edema.

Examination(pulmonary disorders) Upper Airway( IDL)

• Foreign Body Obstruction• Pharyngeal Edema• Croup• Epiglottitis Suspect in any child with sudden onset of

dyspnea. Suspect in any adult who develops dyspnea

or loses consciousness while eating.

Examination (Non pulmonary diseases Anemia pallor. Upper airway disease Wheezing, stridor and a tracheostomy

scar. Obesity with excess adiposity.

Investigations

Chest X-rayPneumoniaLobar consolidation with air

bronchograms.Pleural effusions.Diffuse and non lobar consolidation in viral

and mycoplasma infection.

Chest X-ray Chronic Obstructive airway Disease• Emphysema;Bullous changes,evidence of

hyperinflation of lungs and attenuation of pulmonary vasculature.

• Chronic bronchitis;evidence of corpulmonle(RVH associated with pulmonary hypertension).

Chest X-ray Chronic bronchial asthma;

• Hyperinflation,diffuse fibrosis or chronic segmental fibrosis.

Chest X-rayRestrictive lung disease;• In interstitial lung disease,

linear ,fibronodular, or fibroreticular infiltrates.

• Lytic lesions of ribs or pneumothorax in histiocytosis X.

• Kerly’s lines,pleural effusions, and mediastinal lymphnodes in lymphangitic carcinomatosis.

• A lung mass may be demonstrable.

Chest X-rayHypomotility and dilatation of esophagus

owing to connective tissue disease may be manifested as mediastinal airfluid levels.

Silicosis is upper lobe disease with multiple interstitial nodules.

Cavitary shadows due to superimposed mycobacterial infection.

Asbestosis predominantly involve lower lobe in a linear pattern with pleural thickening or calcified plaques on pleura.

Chest X-ray• Kyphosis and scoliosis are obvious skeletal

deformities.• Air bronchograms in alveolar filling

diseases.• Pulmonary hypertension showed enlarged

pulmonary arteries with or with out air bronchograms.

Chest X-rayCongestive heart failure; upper lobe

diversions hilar congestion, kerley B lines.Anemia ;chest X-ray is normal,at times

cardiomegaly is there.Upper airway disease it is usually normal.Obese patients have usually normal chest

x-ray.

Laboratory dataComplete blood count.Urine analysis.Blood chemistries.Sputum examination.Electrocardiogram.Blood gases.Serum protein electrophoresis to look for

alpha-1 globulin level.Alpha-1 antrypsin levels.

Pulmonary function testsFEV-1.

FEV-1/FVC.

CT scan of the chest

Lung biopsy