10. Shortness of Breath

Question 1

How can you classify the causes of SOB by timing?

Answer 1

Sudden: Bronchospasm, anaphylaxis, PE, Pneumothorax, foreign body
Days: pneumonia, HF + pleural effusion
Weeks: COPD, Lung cancer, pulmonary fibrosis

Question 2

What are 5 risk factors to ask about in someone with SOB?

Answer 2

Smoking
Pets
Occupation e.g. exposure to asbestos 
Drugs: hypersensitivity pneumonitis
PMH: AI conditions e.g. RA + SLE can cause interstitial lung disease + pleural effusions

Question 3

What 5 associated symptoms should you ask someone with SOB about?

Answer 3

Chest pain
Cough
Muscle weakness/ fatigue
Tender limbs 
FLAWS
Blood loss

Question 4

What is COPD?

Answer 4

Bracket term covering chronic bronchitis + emphysema

Question 5

List 3 causes COPD

Answer 5

Smoking: >20 pack years
Occupational exposure to lung irritants
Alpha 1 antitrypsin deficiency

Question 6

What are 5 signs of COPD?

Answer 6

Hyperexpanded chest
Breathing through pursed lips
Reduced air entry/ chest expansion
Prolonged expiratory phase
Hyper-resonant percussion

Question 7

What are 5 key features in the HPC for asthma?

Answer 7

Wheeze
Chest tightness +/ cough
Worse at night/ mornings/ during exercise
Hx or FHx of other atopies
Symptoms worse with NSAIDs, aspirin, beta blockers

Question 8

What 3 signs might you see on examination in someone with interstitial lung disease?

Answer 8

Clubbing
Reduced chest expansion
Late inspiratory fine crackles

Question 9

What are 6 key features in the HPC for heart failure?

Answer 9

SOB OE
Orthopnea
Paroxysmal nocturnal dyspnoea
Swollen ankles
Sleeping with multiples pillows
Pink frothy sputum

Question 10

What are 5 symptoms of congestive heart failure and the reasoning behind them?

Answer 10

SOB: not pumping enough blood. Back pressure forces fluid from the pulmonary vasculature into the alveoli.

Orthopnoea: lying down increases venous return to the heart while it is already struggling to pump. Increases congestion in pulmonary vaculature, forcing fluid into the lungs.

Displaced apex beat due to dilation of the heart.

Crackles in lungs due to build up of blood in pulmonary vessels, forcing fluid into alveoli + causing collapse

Peripheral oedema due to back pressure in the venous system and salt + water retention due to activation of RAAS by a low cardiac output.

Question 11

What are the 4 broad causes of SOB?

Answer 11

Insufficient O2 getting into the lungs
Insufficient O2 getting into the blood
Insufficient O2 getting around the body
Increased respiratory drive

Question 12

List 4 causes of insufficient O2 getting into the lungs

Answer 12

Obstructed airways: COPD
Decreased lung volume: Pneumothorax
Decreased volume of functioning lung: Cystic disease
Inability to inflate lungs: Obesity

Question 13

List 3 causes of insufficient O2 getting into the blood

Answer 13

Damage to alveolar membrane: Emphysema
Fluid between alveolar wall + capillary: oedema (HF)
Disrupted blood supply: PE

Question 14

List 3 causes of insufficient O2 getting around the body

Answer 14

Reduced CO: Aortic stenosis
Anaemia
Shock

Question 15

List 2 causes of increased respiratory drive

Answer 15

Hysterical hyperventilation

Acidaemia: DKA

Question 16

What is suggested by pleuritic chest pain? What about non pleuritic?

Answer 16

P: Pneumonia, PE, Pneumothorax
NP: CVS pathology

Question 17

What 6 characteristics about a cough must be established?

Answer 17

Productive?
Colour of sputum?
Blood?
When does cough occur?
Sound?
Persistent/ episodic?

Question 18

What may be the cause of SOB if associated with muscle weakness?

Answer 18

Neuromuscular disease e.g. GBS, MG, MND

Question 19

What cause of SOB is associated with tender limbs?

Answer 19

PE caused by DVT

Question 20

Why may blood loss contribute to SOB?

Answer 20

SOB can be caused by anaemia

Question 21

What history may make you suspect interstitial lung disease as cause of SOB?

Answer 21

Exposure to asbestos, silica or coal

Exposure to drugs e.g. methotrexate, Amiodarone

Question 22

List 5 risk factors suggesting a cause for heart failure

Answer 22

IHD (smoking, DM, hypercholesterolaemia)
Other atherosclerotic disease (Stroke, TIA)
HTN
Valvular disease
Cardiomyopathy

Question 23

List 4 signs of heart failure on examination

Answer 23

Raised JVP, hepatomegaly, peripheral oedema
Displaced apex beat
Crackles in both lung bases
3rd + 4th heart sounds

Question 24

What bloods would you request in a patient SOB? What are you looking for in each?

Answer 24

FBC: anaemia
Cholesterol, glucose, HbA1c: IHD 
TFTs: Hyperthyroidism
U+E's: electrolyte baseline before diuretic usage
BNP: HF

Question 25

What is Atelectasis?

Answer 25

Alveoli become deflated or possibly filled with alveolar fluid.
Leads to complete or partial collapse of entire lung/ lobe).

Question 26

What is type 1 respiratory failure caused by? List 3 diseases that cause this

Answer 26

Disease affecting amount of O2 able to get into pulmonary blood
Due to problems with gas exchange at the pulmonary membrane or ventilation of the lungs
COPD, Pneumonia, Pulmonary fibrosis

Question 27

What is type 2 respiratory failure caused by? List 3 diseases that cause this

Answer 27

Ventilatory failure resulting in alveolar hypoventilation
Air not being shifted in + out of the lungs adequately
Decreased expiratory drive e.g. Opiates
Impaired lung movements e.g. COPD