Approach to acute breathlessness Flashcards
Causes of breathlessness categories
Respiratory airways Parenchymal Pulmonary circulation Chest wall and pleura Cardiovascular Anemia Non cardiorespiratory
Airways disease causes
COPD Asthma Bronchitis Bronchiectasis CF Laryngeal/pharyngeal/bronchial Ca
Parenchymal disease
ILD Infections ARDS Pneumothorax Pneumoconiosis
Pulmonary ciruclation
Pulmonary embolism
Chronic thromboembolic pulmonary HTN
AV malformation
Chest wall and pleura
Effusion Tumor Fractured ribs AS Kyphoscolosis NM disorders
Cardiac causes
LVF
MVD
Cardiomyopathy
Pericardial effusion or constrictive pericarditis
Non cardio-respiratory
Psychogenic Acidosis Hypothalmic Thyroid Ascites Stoke Normal ageing, deconditioning GORD
Questions to ask breathless
How long? Exercise? PND/Orthopnea? Heart or lung? Fever? Smoker? Tightness in chest? Wheezy at night Difficulty getting breath Painful? Come on suddenly
Conditions causing life threatening acute breathlessness
PE MI CCF Pneumothorax Anaphylaxis Pulmonary edema Tamponade Acute asthma
Subacute definitiona and causes of breathlessness
Acute asthma Acute COPD Pulmonary edema Infections Metabolic acidosis
Chronic definition and causes
CCF COPD ILD Valvular Anemia Fibrosis Pulmonary vascular/hypertensive disease
Associated symptoms to enquire about
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
Define orthopnea, platypnea, trepopnea
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
What might dyspnea in pregnant patient indicate
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
Other past history important
Prgenancy Obesity Rheumatological disorders Autoimmune Malignancies Penumonia GORD TB Heart failure Radiation
ETT/ventilation
Physical examination- general findings to look for
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
Other components of examination for dyspnea
CV exam
- +JVP in CHF, COPD, constrictive pericarditis, pneumothorax
- S3
- edema
Respiratory examination
Neurological examination->MG, myotonic dystrophy, botulism
What findings when pericardial effusion and pericardial constriction
Elevated neck veins, pulsus paradoxus, pericardial knock, pericardial rub, Kussmauls
Investigations to order
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
ABG purpose, findings
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)
Hypoxemia mechanism categories
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)
FBC findings
Leukocytosis
- Infection
- Sepsis
- Autoimmune
Eosinophilia
- parasite
- vasculitides
- asthma
- cocaine
Anemia- as primary reason
Lymphocytopenia
- Viral
- Chemotherapy
Electrolyte findings
Hyponatremia
- CCF
- CKD
- Liver failure
- Hypothyroid
LFT findings
Bilirubin +
- Liver
- CCF
- Leptospirosis
Transaminases
- Liver failure-MI
- Atypical pneumonia
Kidney function findings
Renal insufficiency->metabolic acidosis causing dyspnea
BNP
Associated with CCF
Also
- Sepsis
- CAD
- PE
- COPD w/ cor pulmonale
- Renal failure
- Liver cirrhosis
- Hyperthyroid
What does pulmonary function involve
Spirometry
Measuring lung volumes
Evaluating DLCO
Two defects on PFTs
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
