Dyspnea: Dyspnea Victor Politi, M.D., FACP Medical Director, St. Anthony’s School of Allied Health Professions, Physician Assistant Program Slide 3: Dyspnea, the sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases. Slide 4: Dyspnea - common complaint/symptom “shortness of breath” or “breathlessness” Defined as abnormal/uncomfortable breathing Multiple etiologies - 2/3 of cases - cardiac or pulmonary etiology Slide 5: There is no one specific cause of dyspnea and no single specific treatment Treatment varies according to patient’s condition chief complaint history exam laboratory & study results Differential Diagnosis : Differential Diagnosis Composed of four general categories Cardiac Pulmonary Mixed cardiac or pulmonary non-cardiac or non-pulmonary Pulmonary Etiology: Pulmonary Etiology COPD Asthma Restrictive Lung Disorders Hereditary Lung Disorders Pneumonia Pneumothorax Cardiac Etiology: Cardiac Etiology CHF CAD MI (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Pericarditis Arrhythmias Mixed Cardiac/Pulmonary Etiology: Mixed Cardiac/Pulmonary Etiology COPD with pulmonary HTN and/or cor pulmonale Deconditioning Chronic pulmonary emboli Pleural effusion Noncardiac or Nonpulmonary Etiology: Noncardiac or Nonpulmonary Etiology Metabolic conditions (e.g. acidosis) Pain Trauma Neuromuscular disorders Functional (anxiety,panic disorders, hyperventilation) Chemical exposure Easily Performed Diagnostic Tests: Easily Performed Diagnostic Tests Chest radiographs Electrocardiograph Screening spirometry Slide 12: In cases where test results inconclusive complete PFTs ABGs EKG Standard exercise treadmill testing/ or complete cardiopulmonary exercise testing Consultation with pulmonologist/cardiologist may be useful ABGs: Commonly used to evaluate acute dyspnea can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing ABGs PULSE OX: Rapid, widely available, noninvasive means of assessment in most clinical situations- insensitive (may be normal in acute dyspnea) The % of Oxygen saturation does not always correspond to PaO 2 The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels PULSE OX ASTHMA: ASTHMA What is Asthma: What is Asthma A Chronic disease of the airways that may cause: Wheezing Breathlessness Chest tightness Nighttime or early morning coughing Slide 19: The bronchospasm characteristic of the acute asthmatic attack is typically reversible. It improves spontaneously or within minutes to hours of treatment Slide 20: Asthma can exist by itself or coexist with chronic bronchitis, emphysema, or bronchiectasis Symptoms/Chief Complaint: Symptoms/Chief Complaint Progressive dyspnea Cough Chest tightness Wheezing/coughing Slide 22: The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction Focus of Therapy: Focus of Therapy Pharmacologic manipulation of airway smooth muscle Do not overlook physiologic impairment caused by mucous production and mucosal edema Bronchospasm can be reversed in minutes Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - may lead to atelectasis, infectious bronchitis, pneumonitis Asthma Triggers: Asthma Triggers Immunologic reaction Viral respiratory/sinus infections change in temperature/humidity Drugs/Chemicals - aspirin, NSAIDS Exercise GE reflux Laughing/coughing Environmental factors - strong odors, pollutants, dust, fumes Patient Exam: Patient Exam Wheezing may be audible w/o stethoscope Use of accessory muscles of inspiration diaphragmatic fatigue Paradoxical respirations - reflect impending ventilatory failure Altered mental status - lethargy, exhaustion, agitation, confusion Patient Exam: Patient Exam Hypersonance to percussion decreased intensity of breath sounds prolongation of expiratory phase w or w/o wheezing Patient Exam: Patient Exam The intensity of the wheeze may not correlate with the severity of airflow obstruction “quiet chest” - very severe airflow obstruction Asthma Treatment: Asthma Treatment Nebulized B-adrenergic drugs Corticosteroids Nebulized anticholinergics Magnesium sulfate Oxygen Long acting beta-agonists Inhaled steroids Managing Asthma: : Managing Asthma: Indications of a severe attack: Breathless at rest hunched forward talking in words rather than sentences Agitated Peak flow rate less than 60% of normal Treatment Goals of Severe Asthma: Treatment Goals of Severe Asthma Improve airway function rapidly Avoid hypoxemia Prevent respiratory failure and death COPD: COPD COPD: COPD Hallmark symptom - Dyspnea Chronic productive cough Minor hemoptysis pink puffer blue bloater COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat. : COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat. COPD - Physical Findings: COPD - Physical Findings Tachypnea Accessory respiratory muscle use Pursed lip exhalation Weight loss due to poor dietary intake and excessive caloric expenditure for work of breathing Dominant Clinical Forms of COPD: Dominant Clinical Forms of COPD Pulmonary emphysema Chronic bronchitis Most patients exhibit a mixture of symptoms and signs COPD - Advanced Dx: COPD - Advanced Dx secondary polycythemia cyanosis tremor somnolence and confusion due to hypercarbia Secondary pulmonary HTN w or w/o cor pulmonale COPD Treatment Strategy: COPD Treatment Strategy Elimination of extrinsic irritants bronchodilator & glucocorticoid therapy Antibiotics Mobilization of secretions “respiratory vaccines” Oxygen therapy - if oxygen saturation <90% at rest on room air Spirometry: Spirometry PNEUMONIA: PNEUMONIA Slide 42: 6th leading cause of death in the US Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases Common types of respiratory infections: Common types of respiratory infections Tracheobronchitis Pneumonia Effusions Empyema Abscess Cavitary lesions post-obstructive Common Respiratory Viruses: Common Respiratory Viruses Influenza A & B Parainfluenza 1& 3 Respiratory Syncytial Virus Adenovirus Cytomegalovirus Herpes Simplex & Zoster/varicella Hanta Virus Infection Respiratory Syncytial Virus: Respiratory Syncytial Virus Rapid diagnosis of Respiratory Syncytial Virus Infection by immunofluorescence of respiratory secretions Classic Pneumonia Symptoms: Classic Pneumonia Symptoms Dyspnea, chills high fever, cough/sputum pleuritic chest pain Viral Pneumonia - symptoms: Viral Pneumonia - symptoms Chest Pain Fever Dyspnea Prodrome - malaise, upper respiratory symptoms, and other GI symptoms Viral pneumonia - Clinical Findings: Viral pneumonia - Clinical Findings Minimal/variable Chest exam - may reveal wheezing Fine rales if heard can signify interstitial involvement Chest x-ray - patchy densities or interstitial involvement Viral pneumonia Management /Prophylaxis: Viral pneumonia Management /Prophylaxis Supportive treatment - decrease severity of symptoms bed rest analgesics expectorants Patients w/ airway obstruction - treat w/bronchodilators secondary bacterial infection - antibiotics Atypical Pneumonia: Atypical Pneumonia Accounts for 25% of community acquired pneumonias Mycoplasma/chlamyda/legionella can case extrapulmonary manifestations - meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia typically bilateral infiltrates on chest x-ray primarily effects younger persons Atypical Pneumonia Treatment: Atypical Pneumonia Treatment Antibiotics Macrolides fluroquinolones doxycycline Bacterial pneumonia: Bacterial pneumonia 3.3 million cases yearly in US responsible for 10% of hospital admissions unilateral infiltrate on x-ray high mortality in elderly population most common cause pneumococcal followed by haemophilus influenza Slide 54: Pneumococcus pneumonia accounts for up to 90% of all bacterial pneumonias Patients with a chronic Dx are at an increased risk of contracting pneumonia Bacterial pneumonia presentation: Bacterial pneumonia presentation acute shaking - chills tachypnea tachycardia malaise anorexia myalgias flank or back pain vomiting Lab Tests: Lab Tests WBC Chest X-ray Pulse Ox ABGs Sputum exam Blood cultures pleural fluid exam Pneumothorax: Pneumothorax Causes of Spontaneous Pneumothorax: Causes of Spontaneous Pneumothorax Pleural blebs Bullae Emphysema Interstitial lung disease Alpha 1 antitrypsin deficiency Traumatic and Iatrogenic Causes: Traumatic and Iatrogenic Causes Penetrating wounds Line placements Lung biopsies Mechanical ventilation Two most common symptoms: Two most common symptoms Dyspnea Chest pain Physical Examination: Physical Examination Decreased breath sounds hyperresonance to percussion decreased tactile fremitus In patients with emphysema - clinical findings may be subtle Chest X-ray to Confirm Dx: Chest X-ray to Confirm Dx 500ml of air required to visualize pneumothorax on x-ray Characterized by - hyperlucency and lack of lung markings at the periphery of the lung and appearance of fine line that represents the retraction of the visceral from the parietal pleura Treatment Options: Treatment Options Observation - if pneumothorax involves < 15-20% of hemithorax and patient relatively asymptomatic Tube thoracostomy Simple Aspiration Pulmonary Embolism: Pulmonary Embolism PE History: PE History PE is so common and deadly that the dx should be considered in any patient who presents with chest symptoms that cannot be proven to have another cause PE Risk Markers: PE Risk Markers Hypercoagulable states Prior hx of DVT or PE Recent surgery or pregnancy Prolonged immobolization Underlying malignancy smoking birth control pills trauma Classic triad of signs/symptoms: Classic triad of signs/symptoms These symptoms are not sensitive or specific and occur in fewer than 20% of patients diagnosed with PE Hemoptysis Dyspnea Chest Pain PE Physical Exam: PE Physical Exam Massive PE causes hypotension due to acute cor pulmonale Physical findings in early submassive PE may be completely normal Initially, abnomal findings are absent in most patients with PE Massive PE - Signs/Symptoms: Massive PE - Signs/Symptoms Tachypnea -96% Rales - 58% Accentuated second heart sound - 53% Tachycardia - 44% Fever - 43% S 3 or S 4 gallop - 34% signs/symptoms suggestive of thrombophlebitis - 32% Lower extremity edema - 24% Cardiac murmur - 23% Cyanosis - 19% Massive PE Diagnostic Studies: Massive PE Diagnostic Studies VQ scan Pulmonary angiography CT Echocardiography (TEE) Pulmonary artery catheterization Diagnostic algorithm D-dimer blood gases increased A-a gradient A-a gradient: A-a gradient A-a gradient = predicted pO 2 – observed PO 2 PAO 2 = (FIO 2 X 713) – (PaCO 2 /0.8) at sealevel PAO 2 = 150-(PaCO 2 /0.8) at sealevel on room air Normal range 10-15mm > 30 years of age Normal range 8mm < 30 years of age Increased A-aDO 2 =diffusion defect Right to left shunt V/Q mismatch Examples: Examples A doubel overdose brings two 30 yr old patients to the ED. Both have ingested substantial amounts of barbiturates and diazepam. Blood gases drawn on room air revealed these values: patient 1- pH =7.18, PCO 2 = 70mmHg, PO 2 =50mmHg, HCO 3 =24mEq/L; patient2- pH =7.31, PCO 2 =50mmHg, PO 2 =50mmHg, HCO 3 =25mEq/L Comment: Comment The A-a gradient calculation for patient 1 is as follows: A-a DO 2 = PAO 2 – PaO 2 PAO 2 = 150 – (1.25x PCO 2 ) PAO 2 = 150 – (1.25x 70) PAO 2 = 62 A-a =62 – 50 A-a = 12 Comment: Comment The calculation reveals a normal gradient, indicating that the etiology for hypoxemia and hypoventilation is extrinsic to the lung itself. Comment: Comment The A-a gradient calculation for patient 2 is as follows: PAO 2 = 150 – (1.25 x PCO 2 ) PAO 2 = 150 – (1.25 x 50) PAO 2 = 150 – 63 PAO 2 = 87 Therefore, A-a = 87 – 50 =37 (an abnormally increased gradient) Comment: Comment We can be reasonably confident that patient 1 suffered hypoventilation due to the effect of the ingested drugs on the brain stem. Temporary mechanical ventilation restored this patient’s gas exchange. Comment: Comment Patient 2, on the other hand, had an increased A-a gradient, indicating a lung problem in addition to any central cause for hypoventilation. The chest x-ray film revealed that this patient’s overdose was complicated by aspiration pneumonitis and that the patient required treatment with antibiotics in addition to mechanical ventilation. Treatment Strategies: Treatment Strategies Fluid administration anticoagulation Vena caval interruption Thrombolytics oxygen pulse ox CHF: CHF Left sided Failure: Left sided Failure Blood/fluid back-up into the lungs - result in SOB Fatigue Cough (especially at night) PND orthopnea Right sided Failure: Right sided Failure Build-up of fluid in the veins - Edema of feet, legs and ankles may effect liver/portal circulation and 3rd spacing into soft tissue/ascites/pleural effusion Causes of CHF: Causes of CHF Variety of cardiac diseases Most common cause of CHF - CAD other causes - valvular heart dx, HTN,cardiomyopathies, myocarditis, renal dx,fluid overload,liver dx w/loss of protein and osmotic forces,high altitude and many others Physical Findings: Physical Findings Peripheral edema JVD tachycardia tachypnea, using accessory muscles of respiration Skin - diaphoretic/cold/gray/cyanotic Wheezing/rales on ausculation Apical impulse displaced laterally ascites hepatosplenomegaly Diagnostic Work-Up: Diagnostic Work-Up History Physical exam EKG Echo Chest x-ray BNP ABG/pulse ox Treatment: Treatment Diuretics Digitalis Peripheral vasodilators/NTG Positive inotropic agents ACE inhibitors Beta blockers Oxygen MS04 BNP Questions ?: Questions ?