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Description : Check out this medical presentation on Diastolic Heart Failure, which is titled "Diagnosis of Dyspnea", to know about dyspnea, an unpleasant, subjective sensation of abnormal respiration.

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DyspneaDyspnea 1 Dyspnea Diagnosis of Dyspnea Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency Medicine University Hospitals Case Medical Center
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DyspneaDyspnea 2 Dyspnea – from Latin ‘dyspnoea’ Dyspnea (also SOB, air hunger) subjective symptom of breathlessness. normal in heavy exertion pathological if it occurs in unexpected situations.
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DyspneaDyspnea 3 April, 99 2 Definition Dyspnea: unpleasant, subjective sensation of abnormal respiration. Labored breathing - physical presentation of respiratory distress/ dyspnea Many causes
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DyspneaDyspnea 4 Descriptors of Dyspnea Dyspnea on Exertion (DoE) Dyspnea after Eating (PPD) Nocturnal Dyspnea Paroxysmal nocturnal dyspnea Dyspnea in Pregnancy (hormonal, mechanical)
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DyspneaDyspnea 5 What is respiratory distress? Vague term meaning “not breathing well”. A constellation of signs including: using accessory muscles of respiration tachypnea Gasping Panting restlessness Sometimes, also confusion (hypoxemia) Somnolence (hypercarbia)
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DyspneaDyspnea 6 Respiratory Definitions Eupnea - normal breathing Bradypnea - decreased breathing rate Tachypnea – breathing very fast. Pt not always aware of it. Apnea – not breathing at all Hyperpnea - faster and/or deeper breathing Hyperventilation - rapid breathing with hypocarbia
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DyspneaDyspnea 7 April, 99 Goals of this presentation Discuss dyspnea & its differential diagnosis Discuss pathophysiology Discuss diagnostic tests for dyspnea
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DyspneaDyspnea 8 My Philosophy of teaching: Me: make it as simple as you can. No simpler. You: Interact, ask questions. You will stay awake ;). No question is dumb, and the answer will be just in front of you.
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DyspneaDyspnea 9 Principles of Emergency Medicine “Air goes in and out.” “Blood goes round and round.” “All bleeding stops eventually.” “All else is details.” But…the devil is in the details.
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DyspneaDyspnea 10 What is NOT Dyspnea? Not the O2 saturation of Hemoglobin Not the total amount of O2 attached to Hemoglobin Not the amount of O2 in solution in the blood (the PaO2) Not the respiratory rate, (not all tachypnea is dyspnea) But: a subjective sensation of air hunger.
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DyspneaDyspnea 11 Case 1 47 y/o man c/o dyspnea. SOB, worse on exertion Also admits to mild left sided CP, maybe respirophasic. Onset 5-7 days ago. Getting slightly worse What else do you want to know? What’s your current differential? Admit or Discharge?
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DyspneaDyspnea 12 Case 1 – additional history PMHx: none. No asthma SHx: Tobacco Smoker. Social drinker. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works at a desk. ROS: needs to see a dentist. No palpitations. No edema. No PND, nor orthopnea. Otherwise negative. What else do you want to know?
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DyspneaDyspnea 13 Case 1 V/S: T=36.9; P=85; RR=20; BP 128/79 HEENT: nl CHEST: WD, nl excursion, lungs hard to hear, but no rales, ronchi, wheezes. Cor: RRR w/o RMG. Abd: soft & NT, well muscled. Extr/MS/Neuro/Skin: all wnl. How will you approach this?
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DyspneaDyspnea 14 Approach to the patient with shortness of breath, or respiratory distress: the emergency approach.
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DyspneaDyspnea 15 1: Degree of urgency Is the patient going to live long enough to give you a history? If not, intervene. If yes, try to make a diagnosis.
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DyspneaDyspnea 16 2. Assess patient. Is the patient actively trying to breath?  look for mechanical obstruction. Correct it. Is patient hypoxic? If yes,  increase FiO2 Is the patient not able to breathe adequately? If no,  supplement respiratory efforts.
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DyspneaDyspnea 17 3. Locate the problem Causes of air hunger: mechanical, metabolic, cerebral, Psychological
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DyspneaDyspnea 18 4. Correct it Topic for another lecture After the (correct) diagnosis is made, treatment is (relatively) simple
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DyspneaDyspnea 19 Suspicion You don’t have to know all the diagnoses, but you do have to evaluate threat to life Know when & how to intervene. Understand your tools. Understand your available interventions. Know when to get help
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DyspneaDyspnea 20 Ask (yourself) questions. Can the chest wall support breathing? Are there barriers preventing the air getting through the airway to the blood? Are there metabolic reasons to increase respiratory rate? Is enough blood, of good quality, going round and round?  if not, assist circulation
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DyspneaDyspnea 21 What is the purpose of respiration: Gas exchange To assist in balancing blood (body) pH Lesser extent: temperature regulation / cooling the body Cellular respiration vs Organism respiration
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DyspneaDyspnea 22 Abnormal atmosphere CO: even small amounts of CO can bind with hemoglobin in place of O2 and prevent O2 binding (competitive inhibition) 300 times more tightly than O2 Methemoglobinemia occasionally causes dyspnea; usually just tachypnea Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow.
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DyspneaDyspnea 23 Other substances can injure the airways directly Noxious / toxic gases – work in many different ways and levels. Allergens – immune system modulated Particulates – “smothering” Irritants – cause bronchospasm
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DyspneaDyspnea 24 Mechanical Airway Obstruction External: gagging, strangulation, smothering Internal: food bolus, other mechanical airway obstructions: peanuts, beads, Internal growths: tumors, infections, abscesses Encroachment on the airway Internal substances: pus, blood, mucus, transudates
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DyspneaDyspnea 25 Muscular / Chest Wall system Diaphragm Chest wall muscles Accessory muscles such as supraclaviculars, neck muscles. Myesthenia, paralysis other muscular causes Increased muscle tension.
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DyspneaDyspnea 26 Air to blood interface: Mechanical filling of alveoli Lack of surfactant: alveoli collapse with exhalation Abnormalities (thickening) of alveolar membranes, Interstitium (tissues between the alveolus and the capillary endothelium) Capillary endothelium Blood: enough of it, flowing well enough
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DyspneaDyspnea 27 Causes of dyspnea Psychogenic Hypoxic Metabolic Pulmonary Cardiogenic Hematologic Any others?
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DyspneaDyspnea 28 April, 99 Tools to evaluate dyspnea Suspicion / Clinical knowledge. “If you don’t think of it, you will never find it.” History PE including Vital Signs, pulse ox, PEF Formal Studies
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DyspneaDyspnea 29 What other tools? PEF ABG Other blood tests CXR EKG CT UltraSound
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DyspneaDyspnea 30 Additional items of history Cough Vomiting Temporal relationship  What does that mean? Circadian variations
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DyspneaDyspnea 31 Cough What good is a cough? What bad is a cough? Central & peripheral triggers Air travels in excess of 150 kilometers per second during a cough can denude respiratory epithelium exposed basement membranes stimulate future antigenic response
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DyspneaDyspnea 32 Aphorism Coughing till you vomit is bronchospasm till proven otherwise. Consider cardiac. Vomiting AND THEN coughing -> think aspiration
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DyspneaDyspnea 33 Vital Signs What are the VS? Normal vs Stable How do they change over time? What does this tell you?
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DyspneaDyspnea 34 Vital Signs The meaning of each value depends on its context. A slowing respiratory rate in a bad asthmatic may mean he is about to die. A slowing respiratory rate in an anxious bystander may mean he is getting better.
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DyspneaDyspnea 35 Vital Signs: Respiratory rate: Do it yourself! Temp. Don’t trust the Triage Temps. HR, BP. What do they tell you about the RR?
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DyspneaDyspnea 36 Pulse Ox What is a dangerous level? Why? When is the pulse ox normal and the patient about to die? Why? When is the pulse ox bad and the patient is fine? Why?
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DyspneaDyspnea 37 VS - Combinations: High RR, HR, BP Discussion Low RR, HR, BP Discussion High RR, HR, low BP Discussion
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DyspneaDyspnea 38 Focused exam Accessory muscles Facial expression, color. Chest wall, lungs, heart, abd & extr. (Discussion)
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DyspneaDyspnea 39 Physical Exam Observation Auscultation – with and without a stethoscope. Where? Palpation – what & where & why? Scratch test The REST of the exam – habitus, edema, muscle wasting, lots more.
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DyspneaDyspnea 40 April, 99 Scratch Test Place stethoscope on mediastinum, gently scratch the anterior chest wall alternate sides, equidistant from the stethoscope. One side may not transmit sounds as well as the other. What would the scratch test tell you?
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DyspneaDyspnea 41 Pathophysiology chemoreceptors, mechanoreceptors, lung receptors 3 components that contribute to dyspnea: afferent signals, efferent signals, and central information processing. brain compares the afferent and efferent signals, and a "mismatch" results in the sensation of dyspnea.
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DyspneaDyspnea 42 Afferent neurons chemoreceptors carotid bodies, Various brain organs, juxtacapillary (J) receptors, chest wall and its musclesMuscle spindles sense stretch Lung parenchymal tissues,
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DyspneaDyspnea 43 Efferent signals motor neurons of respiratory muscles. Diaphragm, intercostal, abdominal muscles, accessory muscles.
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DyspneaDyspnea 44 Central Processing Objective data Subjective data Psychiatric is a diagnosis of exclusion
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DyspneaDyspnea 45 April, 99 MRC Breathlessness Scale Grade 0 1 2 3 4 Degree of dyspnea no dyspnea except with strenuous exercise Only when walking up incline or hurryingl Slow on level, or stops after 15 minutes stops few minutes of walking on the level minimal activity such as getting dressed, too dyspneic to leave the house The Modified Borg Scale
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DyspneaDyspnea 46 Causes of dyspnea 4 general categories: cardiac, pulmonary, mixed cardiac or pulmonary, Non-cardiac, non-pulmonary
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DyspneaDyspnea 47 Common specific disease entities Asthma Pneumonia Pleural effusion Pneumothorax Interstitial Lung disease COPD Psychogenic Pericardial effusion Cardiac ischemia CHF Dysrhythmia Mechanical obstruction Anemia
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DyspneaDyspnea 48 Blood tests ABG Vidas d-Dimer BNP Basic Metabolic Panel Cardiac Enzymes What else, and why?
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DyspneaDyspnea 49 April, 99 Chest radiography (CXR) Insufficient by itself Do your own read: the radiologist may not know what you are looking for and may overlook the most important clue. Look for pneumothorax, aortic dissection, pneumonia, pleural effusions, sub-segmental atelectasis, pulmonary infiltrates or an elevated hemi-diaphragm
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DyspneaDyspnea 50 CXR 1
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DyspneaDyspnea 51 CXR 2
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DyspneaDyspnea 52 CXR 3
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DyspneaDyspnea 53 April, 99 ECG Lots of clues as to cause of dyspnea Look for pericarditis (S1Q3T3, right axis deviation), myocardial infarction, ST segment elevation new onset atrial fibrillation or right heart strain
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DyspneaDyspnea 54 EKGs (TB Inserted)
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DyspneaDyspnea 55 April, 99 Arterial Blood Gases (ABG) Must be interpreted in context. “Complete” ABG includes lactate VBG sometimes very useful. When? Why?
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DyspneaDyspnea 56 ABG and Acid base balance. (This could easily be a few hours’ lecture.) 3 important components pH, CO2 and O2 pH changes because of both metabolic and respiratory causes. Each tries to compensate for abnormalities in the other.
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DyspneaDyspnea 57 pH pH should be 7.4. If lower  acidotic. If higher  basic.
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DyspneaDyspnea 58 PaCO2 should be 40, +/- If lower, breathing too much. If higher, not breathing enough. CO2 / HCO3 is the end product of oxidative metabolism
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DyspneaDyspnea 59 PaO2 O2 % (Pulse Ox) = saturation. Should be 85 -100. If lower  hypoxic. If higher than 100  getting more than 21% or over-breathing seriously. PaO2 is a measure of oxygen carriage. Oxygen carrying capacity is a function of amount of carrier, and carrier saturation.
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DyspneaDyspnea 60 Respiratory Acidosis and Alkalosis Low pH = acidosis Lo pH, high CO2  respiratory acidosis Lo ph, low CO2  metabolic alkalosis High pH = alkalosis Hi pH, low CO2  respiratory alkalosis Hi pH, high CO2  metabolic alkalosis
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DyspneaDyspnea 61 April, 99 Ventilation / Perfusion Scanning (V/Q Scan) combined with clinical suspicion sensitivity is 85 - 90% positive predictive value depends on clinical suspicion More radiation than a CT-PE study.
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DyspneaDyspnea 62 April, 99 CT Scan of the Chest 2 kinds: rapid helical without contrast. Usual speed, with contrast. CT more rapid, safer, detects other potential causes of dyspnea with better accuracy than VQ helical CT scanning – no contrast needed Regular PE protocol requires normal Cr or GFR. Why? Always consider Metformin. Why?
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DyspneaDyspnea 63 April, 99 Ultrasonography & Echocardiography Next lecture TEE = transesophagyl echocardiogram (TEE) is > 90% sensitive for large clots, very specific. This, we can’t do yet. TTE = TransThoracic echocardiogram: aortic dissection, cardiac tamponade, acute valvular lesion. This, we can do.
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DyspneaDyspnea 64 Specific entities: Asthma Pneumonia Acute Pulmonary Edema Pulmonary Embolism Emphysema Pneumo / hemothorax Carbon Monoxide (CO) Cyanide poisoning
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DyspneaDyspnea 65 Asthma: Reversible bronchoconstrictuion Air blocked between the large airways to the alveoli. Alveoli may collapse. Treatment: open the airways, prevent stacking (time enough for exhalation). Keep O2 high enough to keep patient’s brain alive. Consider steroids, permissive hypercarbia.
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DyspneaDyspnea 66 Pulmonary edema: Basic problem: Heart stretches so far it can’t contract well. (Falls off Frank Starling Curve) Cardiac oxygen demand exceeds availability. Air can’t cross the air-blood interface. Fluid seeps from the blood into the alveoli. Surfactant gets diluted. Caused by cardiac and vascular derangements. Vicious cycle.
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DyspneaDyspnea 67 Pulmonary edema: Symptoms: Sudden onset; respiratory distress, Rales, ronchi. Foamy sputum. Sometimes blood tinged. Blood pressure high (vasoconstriction) usually 240/120. If onset between 4 pm and 8 pm, likely to be associated with acute MI.
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DyspneaDyspnea 68 Pulmonary edema Treatment: increase airway pressure, to force fluids back into the vascular system, (BVM with patient effort, CPAP or intubation) increase FiO2, dilate blood vessels and reduce systemic blood pressure (which reduces the work of the heart and reduces oxygen demand). Get excess fluid off via kidneys (if working), via bleeding (bloodletting) or sequester fluid (tourniquets).
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DyspneaDyspnea 69 Diabetic KetoAcidosis DKA Tachypnea often without Air hunger metabolic derangement: blood is too acid. Respiratory system tries to compensate, gets overwhelmed.
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DyspneaDyspnea 70 Pneumo / hemo thorax. Stuff gets between the inside of the chest wall and the lung. Air can’t get in well, and blood can’t go round and round well enough. Treatment: mechanically remove the stuff that keeps the lung collapsed. Needle, needle with flutter valve, or chest tube. Intubation or BVM may make things worse, if there is a flap.
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DyspneaDyspnea 71 Pneumonia Infection in the lower airway. Consolidation (fluid in alveoli) often only one part of a lung. Generally SICK. Upper, middle and lower airways clogged by mucus, often tenacious. Fever increases metabolic demand for O2. Treatment: Antibiotics if bacterial (Abx) thin the mucus mechanical ventilation if needed.
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DyspneaDyspnea 72 Pulmonary Embolism A blood clot in the pulmonary circulation (often from the systemic venous circulation) blocks. Blood can’t go round and round, so there is lack of oxygen in the circulating blood. Diagnosis: hypoxemia, tachycardia, tachypnea, sometimes chest pain. Treatment: anticoagulation and o2 supplementation. CO2 usually normal. Why is CO2 normal?
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DyspneaDyspnea 73 Emphysema Not enough lung tissue. That is, a paucity of the blood/air interface. Optimize all functioning tissue. Treatment: new lungs.
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DyspneaDyspnea 74 CO poisoning: competitive inhibition of O2 binding at hemoglobin site. Treatment: overwhelm the CO with 100% O2. If not good enough, use hyperbaric O2.
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DyspneaDyspnea 75 Cyanide poisoning: Mechanism: inhibition of O2 utilization at the cellular level. There can be plenty of O2 in the air, and in the blood, but the cells can’t use it. Treatment: inactivate the cyanide using “BAL” British Anti-Lewisite. Time is of the essence
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DyspneaDyspnea 76 Summary: Dyspnea is a subjective Think systematically Multiple causes / multiple tools to diagnose the problem “When you can’t breathe, not much else matters.”
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DyspneaDyspnea 77 REFERENCES Saracino A (October 2007). "Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?". Emerg Med Australas 19 (5): 394–404. Stenton C (2008). "The MRC breathless scale.". Occup Med 58 (3): 226–7. doi:10.1093/occmed/kqm162. PMID 18441368. Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990. Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed. Baltimore: Williams & Wilkins, 1986. Tobin MJ. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med 1990;150:1604-13. Silvestri GA, Mahler DA. Evaluation of dyspnea in the elderly patient. Clin Chest Med 1993;14:393-404. Cockcroft A, Adams L, Guz A. Assessment of breathlessness. Q J Med 1989;72:669-76. Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med 1993;8:383-92. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997. Fauci AS, ed. Harrison's Principles of internal medicine. 14th ed. New York: McGraw-Hill, 1997. Enright PL, Hyatt RE, eds. Office spirometry: a practical guide to the selection and use of spirometers. Philadelphia: Lea & Febiger, 1987:253. Baum GL, Wolinsky E, eds. Textbook of pulmonary diseases. 4th ed. Boston: Little, Brown, 1989: 1595-2102. Rubenstein E, Federman DD, eds. Respiratory medicine. In: Scientific American medicine. New York: Scientific American, 1995.