Approach to acute breathlessness

Question 1

Causes of breathlessness categories

Answer 1

Respiratory airways
Parenchymal
Pulmonary circulation
Chest wall and pleura
Cardiovascular
Anemia
Non cardiorespiratory

Question 2

Airways disease causes

Answer 2

COPD
Asthma
Bronchitis
Bronchiectasis
CF
Laryngeal/pharyngeal/bronchial Ca

Question 3

Parenchymal disease

Answer 3

ILD
Infections
ARDS
Pneumothorax
Pneumoconiosis

Question 4

Pulmonary ciruclation

Answer 4

Pulmonary embolism
Chronic thromboembolic pulmonary HTN
AV malformation

Question 5

Chest wall and pleura

Answer 5

Effusion
Tumor
Fractured ribs
AS
Kyphoscolosis
NM disorders

Question 6

Cardiac causes

Answer 6

LVF
MVD
Cardiomyopathy
Pericardial effusion or constrictive pericarditis

Question 7

Non cardio-respiratory

Answer 7

Psychogenic
Acidosis
Hypothalmic
Thyroid
Ascites
Stoke
Normal ageing, deconditioning
GORD

Question 8

Questions to ask breathless

Answer 8

How long?
Exercise?
PND/Orthopnea?
Heart or lung?
Fever?
Smoker?
Tightness in chest?
Wheezy at night
Difficulty getting breath
Painful?
Come on suddenly

Question 9

Conditions causing life threatening acute breathlessness

Answer 9

PE
MI
CCF
Pneumothorax
Anaphylaxis
Pulmonary edema
Tamponade
Acute asthma

Question 10

Subacute definitiona and causes of breathlessness

Answer 10

Acute asthma
Acute COPD
Pulmonary edema
Infections
Metabolic acidosis

Question 11

Chronic definition and causes

Answer 11

CCF
COPD
ILD
Valvular
Anemia
Fibrosis
Pulmonary vascular/hypertensive disease

Question 12

Associated symptoms to enquire about

Answer 12

Fever- infection
Central chest pain- MI, PE, pulmonary embolism, pleurisy
Palpitations-paroxysmal tachyA, PE, valvular, HA, anxiety
Syncope
Wheezing
Change in voice-pneumomediastinum, GORD, AA, lung cancer
Hemoptysis- bronchitis, bronchiectasis, malignancy, vasculitis, infection, PE
Dysphagia- laryngitis, epiglotitis
Muscle weakness, myalgia
Bone pain
Anxiety

Question 13

Define orthopnea, platypnea, trepopnea

Answer 13

Orthop- dysP while supine, improves in upright
Platyp- dysP on assuming upright->typical in patent foramen ovale, abominal muscle deficiency or hepatopulmonary syndrome
TrepoP- infrequent, breathlessness in left lateral position, associated with CHF

Question 14

What might dyspnea in pregnant patient indicate

Answer 14

An undiagnosed medical condition-> VHD, pulmonary HTN, alpha 1 protease deficiency, PE, pneumothoraz, AV malformation

If in recent labour- may indicate PE, sepsis/shock, amniotic fluid/trophoblastic embolism

Question 15

Other past history important

Answer 15

Prgenancy
Obesity
Rheumatological disorders
Autoimmune
Malignancies
Penumonia
GORD
TB
Heart failure
Radiation

ETT/ventilation

Question 16

Physical examination- general findings to look for

Answer 16

MSE changes
Sighing
Cyanosis- COPD, PE, airway obstruction, drug toxicity, Congenital heart disease, valves, tamponade
Jaundice- liver failure, lepto
Goitre
Kyphoscoliosis
Clubbing
\+Abdominal girth- CHF, cirrhosis, effusions, constrictive pericarditis
Urticarial rash- anaphylaxis

Question 17

Other components of examination for dyspnea

Answer 17

CV exam

• +JVP in CHF, COPD, constrictive pericarditis, pneumothorax
• S3
• edema

Respiratory examination
Neurological examination->MG, myotonic dystrophy, botulism

Question 18

What findings when pericardial effusion and pericardial constriction

Answer 18

Elevated neck veins, pulsus paradoxus, pericardial knock, pericardial rub, Kussmauls

Question 19

Investigations to order

Answer 19

Pulse oximetry- evaluation of hypoxemia
ABG
FBC
Sputum culture
CXR
ECG
Troponins
PEFR
UEC
LFTs
Kidney function
BNP
Echo
Pulmonary function tests
Spirometry

Highr resolution CT scan
V/Q

Question 20

ABG purpose, findings

Answer 20

Hypercapnia

• COPD
• Stroke
• Airway obstruction
• Obesity hypoventilation

Hypocapnia

• Anxiety
• PE

Hypoxemia
shunting (acute respiratory distress syndrome, pneumonia, pulmonary oedema, cyanotic valvular disease),
V/Q mismatching (COPD, asthma, pulmonary embolism), diffusion impairment (interstitial lung disease), or hypoventilation (COPD exacerbation, neuromuscular disease, stroke, upper airway obstruction, or obesity-hypoventilation syndrome)

Question 21

Hypoxemia mechanism categories

Answer 21

shunting (acute respiratory distress syndrome, pneumonia, pulmonary oedema, cyanotic valvular disease), V/Q mismatching (COPD, asthma, pulmonary embolism), diffusion impairment (interstitial lung disease), or hypoventilation (COPD exacerbation, neuromuscular disease, stroke, upper airway obstruction, or obesity-hypoventilation syndrome)

Question 22

FBC findings

Answer 22

Leukocytosis

• Infection
• Sepsis
• Autoimmune

Eosinophilia

• parasite
• vasculitides
• asthma
• cocaine

Anemia- as primary reason

Lymphocytopenia

• Viral
• Chemotherapy

Question 23

Electrolyte findings

Answer 23

Hyponatremia

• CCF
• CKD
• Liver failure
• Hypothyroid

Question 24

LFT findings

Answer 24

Bilirubin +

• Liver
• CCF
• Leptospirosis

Transaminases

• Liver failure-MI
• Atypical pneumonia

Question 25

Kidney function findings

Answer 25

Renal insufficiency->metabolic acidosis causing dyspnea

Question 26

BNP

Answer 26

Associated with CCF

Also

• Sepsis
• CAD
• PE
• COPD w/ cor pulmonale
• Renal failure
• Liver cirrhosis
• Hyperthyroid

Question 27

What does pulmonary function involve

Answer 27

Spirometry
Measuring lung volumes
Evaluating DLCO

Question 28

Two defects on PFTs

Answer 28

obstructive deficit (low FEV1/FVC ratio, increased residual volume, increased total lung capacity), seen in asthma, bronchitis, and emphysema, and a restrictive deficit (symmetrical reduction of FEV1 and FVC, high FEV1/FVC ratio, low total lung capacity), seen in interstitial lung disease