P ulmonary dyspnea

Pulmonary dyspnea

DR.Hatice TürkerSureyyapasa Chest Diseases and Thoracic Surgery

education and Research Hospital , Istanbul,

TTD 15.ANNUAL CONGRESS /ANTALYA 13-04-2012

APPROACH TO THE DIAGNOSIS OF DYSPNEA

I have no disclosure

PLAN

Pulmonary DyspneaDefinitionMechanismsCauses of dyspneaAssesmentDifferential diagnosisTherapy

Dyspnea-increased effort of breathing

‘’Dyspnea’’

Dys: difficult, painfulPneumea:breath

DEFINITION OF DYSPNEA

Patients perceptions:Unsatisfied inspiration

Chest tightness

Sensation of feeling breathless

Cannot get enough air

Hunger for air

Incomplete exhalation

Clinical : A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.


Am Respir Crit Care Med.Vol 159,1999Am Respir Crit Care Med. Vol 185,2012

Physiological: The stimulation of pulmonary and extrapulmonary afferent receptors and the transmission of afferent information to the serebral kortex,where the sensation is perceived as uncomfortable or unpleasant


SUBSTANTIAL EVIDENCE

Dyspnea per se can only be perceived by the person experiencing it. Adequate assesment of dyspnea depends on self-report.

1-Distinct mechanisms and afferent pathways are reliably associated with different sensory qualities (notably work/effort, tightness, and air hunger/unsatisfied inspiration) 2-Distinct sensations most often do not occur in isolation 3-Dyspnea sensations also vary in their unpleasantness and in their emotional and behavioral significance.

Am Respir Crit Care Med. Vol 185,2012

CYCLIC EFFECTS OF DYSPNEA

DYSPNEA

IMMOBILITY

LACK OF FITNESS

SOCIAL ISOLATION

DEPRESSION

Dyspnea

Exercise tolerance

Quality of life

MECHANISM OF DYSPNEA

Comprehensive respiratory medicine,1999

Sensory stimuliAirway receptors, parenchimal receptors, solunum kasları

kemoreceptorseffort

emotions

MECHANISM OF DYSPNEA

muscle stretchmuscle length

I DON’T BREATHN.VagusN.Phrenic N.Intercostal Respiratory system

motor stimuli

Prof. Dr.Gül Öngen’in izniyle

Work/effort

Hunger for air

Tightness

Arise through cortical motor command

Stimulation of airway receptors

Imbalance when ventilation increases

QUALITIES OF DYSPNEA


Increased ventilatory demand

Impaired mechanical response

Increased physiologic dead spacePulmonary embolismPulmonary artery compressionemphysema

Airway obstructionChronic bronchitistumor

MetabolicExerciseAltered CO2 Metabolic asidosis

Decreased chest wall compliancePost-thoracotomyObesity

NeurohumeralörohumoralPainAnxietyDepression

Decreased parenchymal elasticityPulmonary fibrosisCongestion

Inspiratory muscle weaknessNeuromuscular diseaseCachexia due to cancerMyopathyElectrolyte imbalance

CAUSES OF DYSPNEA

ASSESMENT OF DYSPNEA

• History• Work/effort• Acute dyspnea• Chronic dyspnea• Associated symptoms• Positional dyspnea

CHARACTERISTICS OF HISTORY

Persistance among the day and year and variability

Causes triggering or augmenting dyspnea

What are the associated symptoms?

What is the relationship with position?

AnamnesisWork/effortAcute dyspneaChronic dyspneaAssociated symptomsPositional dyspnea

Persistance among the day and year and variabilityIntermittent

Persistent

Nocturnal

Seasonal

Occupational ( work,home ...etc.)


Intermittent dyspneaReversibl causes

Acute bronchoconstriction

Congestive heart failure

Acute pulmonary embolism

Pleural effusion

Persistent dyspneaIrreversibl causes COPD

Interstitial

Chronic pulmonary embolism

PAH

Diaphragmatic dysfunction

Chest wall disorders


Nocturnal dyspneaAsthma

Congestive heart failure

Gastroesophageal reflux

Sleep-apnea syndrome

Nasal obstructions



Modified Borg scale(MBS)Visual analog scale(VAS)Modified Medical Research Council(MMRC)Oxygen cost diagram (OCD)Baseline dyspnea index (BDİ)Değişen dispne indeksi (DDİ)

DYSPNEA/EFFORTAnamnesisWork/effortAcute dyspneaChronic dyspneaAssociated symptomsPositional dyspnea

Domain Definition Examples

Sensory-perceptual experience

Measurement of what breathing feels like to the patient

Single item ratings of intensity (Borg scale,VAS)

Affective distress Measurs of how distressing breathing feels

Single-item ratings of severity,multi-item scales of emotional responses such as anxiety

Symptom impact or burden

Measures of how dyspnea affects functional ability,quality of life,health status

Undimensionel rating of disability(MRC), multidimensionel ratings of functional ability and quality of life

DOMAINS OF DYSPNEA MEASUREMENT

Borg, 1982Verbal expression of degree of dyspnea in a nonlinear and numerical

way,It’s easier to apply with exercise,It’s appropiate for comparison of persons or groups.

MODIFIED BORG SCALE

0 Nothing at all

0.5 Very very slight (but noticeable)

1 Very slight

2 Slight

3 Moderate

4 Somewhat severe

5 Severe

6

7 Very severe

8

9 Very very severe

10 Maximal

Score Symptoms

MODIFIED BORG SCALE

VISUAL ANALOG SCALE

0 cm 10 cm

What can you do today?Everything

How severe is your dyspnea today?

Very difficult

How severe is your dyspnea while dressing today?Very severe

No dyspnea

None

Nothing

Description of Breathlessness Grade ScoreI only get breathless with strenous exercise

0 None

I get short of breath when hurrying on level ground or walking up a slight hill

1 Slight

On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace.

2 Moderate

I stop for breath after walking about100 yards or after a few minutes on level ground

3 Severe

I am too breathless to leave the house or I am breathless when dressing.

4 Very severe

Modified Medical Research Council scale (MMRC)

It’s a vertical visual analog scale with 13 items designed for assessment of oxygen need during sleep and walking uphill.

OXYGEN COST DIAGRAM

Standing

Slow walking on the level

Bed-making

Slow walking uphill

Sitting

Sleeping

Washing yourself

Brisk walking on the level

Brisk walking uphill

Medium walking

0

medium walking uphill

OXYGEN COST DIAGRAM

BASALINE DYSPNEA INDEX

It’s a versatile scale

Functional disability (daytime activities and work performance)

Intensity and difficulty of the physical activity

Grade of effort

Total BDI score: 0-12Low scores show that dyspnea is severe

Mahler DA, Chest 1984;85:751-58

ACUTE VE CHRONİC DYSPNEA

Acute: dyspnea that develops over hours or days.

Chronic: dyspnea that develops over weeks,months or years.


Acute• Pulmonary edema• Asthma• Chest wall travma• Spontan pneumotorax• Pulmonary embolism• Pneumonia• Pleural effusion• Pulmonary hemoraji

Chronic• COPD• Left ventricular failure• Interstitial fibrosis• Asthma• Pleural effusion• Pulmonary embolism• Pulmonary vascular disease

CAUSES OF PULMONARY DYSPNEA


DIFFERENTIAL DIAGNOSIS OF DYSPNEA RAPID ONSET CAUSES

Acute Dyspnea

Over 1-2 hrAsthma (previous history)

Left ventricular failure

Over hours/days

Pneumonia Acute bronchitis

Hyperventilation Asidosis

Renal failureDiabetic ketoacidosis

Poisoning SalicylateMethyl alcoholEthylene glycol

Hyperventilation syndrome

immediate Pneumothorax Pulmonary embolismForeign body

ACUTE DYSPNEA-ASSOCIATED SYMPTOMS

+ Chest pain

•Acute pulmonary embolism•Myocardial infarction•Aortic dissection•Pericardial effusion•Tamponade

+ Pleuritic chest pain

•Pulmonary embolism•Effusion •Lobar collapse•Pneumonia

Dyspnea

Stridor •Tracheal tumor•Foreign body


Dyspnea

bulbar symptoms•Motor neuron disease•Myasthenia gravis +

Sputum • ++++Bronchiectasis• ++ Chronic bronchitis• Asthma(yellow-green)

hemoptysis • pulmonary embolism• tumor• COPD(acute exacerbation•Pulmonary edema•vasculitis

ACUTE DYSPNEA-ASSOCIATED SYMPTOMS

CHRONIC DYSPNEA-ASSOCIATED SYMPTOMS

Dyspnea (months-years) with chronic pulmonary disease

Wheeze No wheeze

±sputum smoking

sputum+++

Occupational history

±crackles±clubbing

±pleurisy±hemoptysisAtopic?

Asthma COPD Bronchiectasis

Pneuömo-cniosis ILD

Pulmonary embolism


POSITIONAL DYSPNEA

Paroxysmal nocturnal: severes shortness of breath and coughing that generally occur at night

Orthopnea: shortness of breath which occurs when lying flat

Trepopnea: sensed while lying on one side but not on the other

Platypnea: shortness of breath worsens when sitting or standing up

Dyspnea due to exercise


APPROACH TO THE DIAGNOSIS OF DYSPNEA

Pulmonary function tests•Pulmonary volumes and flow rate•Diffision capacity•Arterial blood gases•Exercise tests/ 6DYT•Provocation tests

Imaging methods•Conventional radiography/ /CT/ HRCT•Ventilation/perfussion syntigraphy•Diaphragm scopic examining•Neuroimaging

Laryngoscoping examining

PolysomnographyPsychological investigation

TREATMENT OF DYSPNEA

SAT PaO2 (<%90-92)

Heart failure,pulmonary edema

Pneumothorax

Pulmonary embolism

Asthma attacs

COPD exacerbations

Foreign body aspiration

Pneumonia

ARDS

Hemothorax

Oxygen

Diuretics

Chest tube

Anticoagulan or thrombolytic theraphy

Short acting bronchodilators

Bronchodilators,antibiotics,sist. steroids

Bronchoscopy

antibiotics

IMV

Pleural drenage

DIAGNOSIS TREATMENT

TREATMENT OF DYSPNEA


Oxygen TreatmentHelioxPharmacologic treatmentPulmonary rehabilitationNonpharmacological approaches

OXYGEN TREATMENT

HELIOX TREATMENT

Opioids have been the most widely used.

Short-term administration reduces breatlessness.

Long-term efficacy is limited and conflicting.

Associated with frequent side effects (constipation)

Respiratory depression is uncommon with the doses used to treat dyspnea, even in elderly patients

PHARMACOLOGICAL TREATMENT

Nebulized furosemide has been investigated as a novel pharmacologic approach.

The mechanism of the effect is uncertain.

Decreased breatlessness induced in normal volanteers.

Currently insufficient data to support its use in the treatment of dyspnea.



AnxiolyticsAntidepressantsFhenothiazinesIndomethacinInhaled topical anestheticsNitrous oxideSodium bicarbonate

INEFFECTIVE

Can Respir J 2011;18:69-78Cochrane Databasa Syst Rev 2010;Thorax 2008;63:872-875

PULMONARY REHABILITATION

Integral component of the management of patients with chronic lung disease.

Decreases dyspnea during exercise

Improved exercise tolerance

Inspiratory muscle training (IMT) reduces of dyspnea intensity and dynamic hyperinflation

NONPHARMACOLOGICAL APPROACHES

Cold airChest wall vibrationNoninvasive ventilation

ALTERNATIVE MEDICINE

AcupunctureYoga

Mimosa bloossom

Spring flower

Daisy

Narcissus flower

Hycinth

THANK-YOU FOR YOUR ATTENTION

P ulmonary dyspnea

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