Approach to dypsnea Flashcards
What are the ddx for SOB + Chest pain?
- AMI
- Acute coronary syndrome
- Pneumothorax
- Pulmonary embolism: Hypoxemia (decreasing SPO2) with clear lungs + tachycardia and dyspnoea is indicative of PE
- Pleural Effusion
What are the ddx for SOB + Stridor?
- Anaphylaxis
- Epiglottitis
- Retropharyngeal Abscess
- Foreign Body
- Croup (in children)
- Extrinsic compression (malignancy)
What are the ddx for SOB + fluid overload?
- AMI: ECG + Cardiac Enzymes
- Acute Valvular Dysfunction
- Arrhythmia: ECG
- Acute Nephritic Syndrome
- Renal Failure
- Decompensated CCF
- Cor Pulmonale
- Pericardial Effusion / Cardiac Tamponade: ECG, Pericardial Rub
- Decompensated Cirrhosis
What are the ddx for SOB + infective picture?
- Pneumonia
- TB
- Bronchiectasis
What are the ddx for SOB + Wheeze?
- COPD: Tracheal tug, Smoker, Hyperinflation
- Asthma: Atopic symptoms w episodic symptoms; occurs when exposed to cold air / animal dander
- Bronchiectasis: Expiratory Rhonchi
What are the ddx for SOB + non specific increase effort in breathing?
- Pleural Effusion: Stony dull
- Chest signs present: Hyper-resonance
- PE
- DKA: +/- Kussmaul breathing
- Anemia
What are the ddx for SOB + weakness (neuro cause)?
- Guillian Barre
- Myasthenia Gravis
What are the respiratory causes of acute dyspnea?
Upper Airway Obstruction (stridor)
- Foreign body (Aspiration)
- Anaphylaxis
- Epiglottitis
- Extrinsic compression (malignancy)
- Retropharyngeal abscess
- Croup (in children)
Lower Airway Disease
- Acute bronchitis
- Acute exacerbation of asthma
- Acute exacerbation of COPD
- Acute exacerbation of bronchiectasis
Parenchymal Disease
- Pneumonia
- Lobar collapse
- Acute respiratory distress syndrome
Other Respiratory
- Pneumothorax
- Haemothorax
- Pleural effusion
- Pulmonary embolism
- Chest wall injury (flail chest, rib fracture)
What are the cardiovascular causes of acute dyspnea?
Acute pulmonary edema, can be caused by:
• Mitral valve regurgitation
• AMI
• Arrhythmia
Acute coronary syndrome / AMI
Cardiac tamponade (aka pericardial dx)
Arrhythmia
Anemia
Acute valvular heart disease
Acute decompensated Heart Failure
What are the non cardiovascular, non respiratory causes of acute dyspnea?
Metabolic acidosis disorders
- Anemia
- Acidosis – DKA, lactic acidosis
- Toxins
Neurologic
- Intracranial lesions
- High spinal lesions
- Neuromuscular diseases
Poisoning (e.g. organophosphate, CO)
Psychogenic (Anxiety)
Neck Trauma
What are the respiratory causes of chronic dyspnea?
- Asthma
- COPD
- Pleural effusion
- Cancer
- Interstitial lung disease
- Chronic pulmonary thromboembolism
- Bronchiectasis
- Cystic fibrosis
- Pulmonary hypertension
- Pulmonary vasculitis
- TB
- Laryngeal/tracheal stenosis
What are the cardiovascular causes of chronic dyspnea?
- Heart failure
- Coronary artery disease / Ischemic heart disease
- Valvular heart disease (commonly aortic stenosis) – since anemia is a major cause of dyspnoea
- Paroxysmal arrhythmia
- Constrictive pericarditis
- Pericardial effusion
- Cyanotic congenital heart disease
What are the non cardiovascular, non respiratory causes of chronic dyspnea?
- Severe anemia
- Obesity / Kyphoscoliosis
- Pregnancy (progesterone, etc)
- Physical deconditioning
- Diaphragmatic paralysis
- Neuromuscular (Myasthenia Gravis, Gullian-Barré)
- Cirrhosis (hepatopulmonary syndrome)
- Tense ascites
What are the clinical features suggestive of TB as a cause of dypsnea?
- Constitutional sx: LOW, fever, night sweats
- Travel, contact hx
- Immunocompromised
- Upper lobe consolidation (reactivation)
What are the clinical features suggestive of bronchiectasis as a cause of dypsnea?
Bronchiectasis - Copious purulent sputum (typically green)
- Haemoptysis
- Clubbing, coarse inspiratory crepitation, rhonchi
What are the clinical features suggestive of pneumonia as a cause of dypsnea?
- A/W fever, SOB, sputum production
- Bronchial breath sounds, dullness to percussion, coarse crepitation, increased vocal resonance
- Consolidation on CXR
What are the clinical features suggestive of malignancy as a cause of dypsnea?
- Dyspnea
- Constitutional sx
- Diminished breath sounds, focal wheezing (obstruction)
- Family hx
- Smoking
What are the clinical features suggestive of COPD as a cause of dypsnea?
- Chronic cough + sputum (clear or white) production on most days over a 3-month period for more than 2 years
- Long smoking hx
- Haemoptysis
- Rhonchi + coarse crepitations
- hyper- resonance on percussion
- Hyperinflation of lungs
- Bilateral decreased chest expansion
What are the clinical features suggestive of asthma as a cause of dypsnea?
- A/W dyspnea, wheezing, chest tightness
- Diurnal variation
- Triggers: seasonal, URTI, cold, dry air, dust, mold, fumes, beta blocker
- Ask about severity, treatment compliance, exposures
- Atopic history, family history
- Reversible airway obstruction on spirometry
Spirometry is used to measure airflow obstruction
What are the clinical features suggestive of ILD as a cause of dypsnea?
- Dry cough a/w Exertional Dyspnea
- Fine end inspiratory crepitation, clubbing
Etiology:
- Occupation history
- Autoimmune sx: joint pain (RA), red eyes, alopecia, rash (SLE), Sarcoidosis, UC – ILD can be a cause of rheumatoid lung disease
- Drugs
- Idiopathic
- Hypersensitivity
What are the clinical features suggestive of pleural effusion as a cause of dypsnea?
- Pleuritic chest pain (presents w SOB + chest pain)
- Stony dullness, decreased breath sounds
What are the clinical features suggestive of pulmonary embolism as a cause of dypsnea?
- Central, pleuritic pain (presents w SOB + chest pain)
- Malignancy, recent surgery, immobility, DVT
- Syncope, signs of shock
- ECG changes (sinus tachycardia most common)
- Tachycardia
- Decreased effort tolerance
- Haemoptysis (due to pulmonary infarct)
- Hypoxemia (decreasing SPO2) with clear lungs + tachycardia and dyspnea is indicative of PE
- Patients with PE will try to breath faster (increased ventilation) to compensate for VQ mismatch
Hence PaCO2 will decrease, whereas PaO2 depends on severity of PE
What are the clinical features suggestive of pneumothorax as a cause of dypsnea?
- Pleuritic chest pain (presents w SOB + chest pain)
- Decreased breath sounds, hyper-resonance
- decreased vocal resonance
What are the clinical features suggestive of congestive cardiac failure as a cause of dypsnea?
- Orthopnoea (SOB when lying flat), PND (Paroxysmal nocturnal dyspnoea)
• PND = severe SOB + cough at night, awakens pt - Pedal edema
- Crepitations
- ↑JVP
- If acute –> pulmonary edema –> feel like drowning + pink frothy haemoptysis
- Family history of heart disease
What are the clinical features suggestive of acute coronary syndrome as a cause of dypsnea?
- Diffuse, crushing central pain (angina) with radiation to arm, neck, jaw
- Diaphoresis, N&V
- Risk factors: age >60, previous hx, vascular
What are the clinical features suggestive of pericarditis/ cardiac tamponade as a cause of dypsnea?
- ECG changes
- Pericardial Friction Rub
- ↑JVP, Tachycardia, HypoTN
- Look at Approach to ECG
What are the clinical features suggestive of anemia as a cause of dypsnea?
Anaemia - A/W pallor, chest pain, giddiness, palpitations, fatigue, bleeding
What is the MRC breathlessness scale?
- 1: Not troubled by breathlessness except on strenuous exercise
- 2: SOB when hurrying on the level and walking up a slight hill
- 3: Walks slower than most people on the level, stops after mile or so, or stops after 15 minutes walking at own pace
- 4: Stops for breath after walking about 100 yards or after a few minutes on level ground
- 5: Too breathless to leave house, or breathless when undressing
What questions would you ask to defined the the breathlessness?
Define the Symptom
- Short of air?
- Having to breathe slower but deeper (obstructive) or faster but shallow (restrictive)
- Chest tightness/chest pain?
- Restricted breathing?
What aggravating/ relieving factors would you ask in a patient who is breathless?
- Exertion/rest?
- Temperature, exercise, smoke? – asthma
- Anxiety/stress
- Lying flat (Orthopnea) - “how many pillows do you use at night?”
- Sleep (PND) - “do you ever wake up at night having to catch your breath?”
- Bronchodilators?
What questions would you ask in a patient who is breathless about severity/ effort tolerance?
- How many bus stops? Climbing stairs?
- Ask about current and baseline effort tolerance
What etiologies can sudden dypsnea point to?
pulmonary emboli, pneumothorax, foreign body, AMI
What etiologies can dypsnea that occurs over a few hours point to?
asthma, pulmonary edema
What etiologies can dypsnea that occurs over days to weeks point to?
pleural effusion, infection, growth of tumor
What etiologies can dypsnea that occurs over years point to?
COPD, pulmonary fibrosis, non-respiratory causes (eg. Anemia)
What are the associated symptoms to ask in someone who is breathless?
Respiratory
- Pleuritic chest pain
- Cough
- Sputum – ask color, amount
- Haemoptysis
- Wheeze
- Fever
- URTI symptoms
- Night sweats, LOW, LOA
- Nasal congestion
Cardiac
- Central chest pain/ angina
- Palpitations
- Ankle edema
- Other vascular disease
Others
- Anemia: pallor, chest pain, giddiness, palpitations, fatigue, bleeding
- Neuromuscular: numbness and weakness
- Raynaud’s Phenomenon
What are the relevant PMH to ask in patients who are breathless?
Asthma
COPD
ILD
Infectious contacts: TB
Cancer
Coronary artery disease / Ischemic heart disease
Hypertension, Hyperlipidemia, DM
Previous hospitalizations/surgery
Childhood illness
- Whooping cough, measles, recurrent chest infections – bronchiectasis
- Asthma
Immunosuppression tro opportunistic lung infections
Thromboembolic risk factors
- Immobility
- Recent surgery
- Oral contraceptives
What are the relevant drug hx to ask in patients who are breathless?
- Drug allergy
- Current medications
- NSAIDS, beta blocker, aspirin? – asthma
- Methotrexate, amiodarone? – pulmonary fibrosis
What are the relevant fam hx to ask in patients who are breathless?
- Ischemic heart disease
- Lung Cancer
- Atopic diseases
- Emphysema (alpha antitrypsin deficiency)
- Thromboembolic disease
- Connective tissue diseases
What are the relevant social hx to ask in patients who are breathless?
Smoking/alcohol
Occupational and home environment
- Asbestos – lung fibrosis, pleural cancer, lung cancer
- Dust, damp accommodation, occupational exposures (eg. Flour) – asthma
Animals/birds – allergens for asthma, allergic alveolitis
Travel history
Infectious contacts: TB
Effect of breathlessness on patient’s life
- ADL
- Support network
- Ability to take treatment
What are the red flags of breathlessness?
- Tachypnea
- Tachycardia
- Tracheal deviation
- Stridor (on inspiration; indicative of upper airway obstruction)
- Cyanosis
- Hypoxia
- Hypotension
- Confusion
- Use of accessory muscles
What is dypsnea?
Dyspnea is the subjective complaint of shortness of breath.
What is orthopnea?
Orthopnea refers to dyspnea in recumbency that is at least partially relieved by assuming an upright position
What is paroxysmal nocturnal dyspnea ?
Paroxysmal nocturnal dyspnea is the term applied to attacks of severe breathlessness that generally occur at night and usually awaken the patient from sleep.
Relief from or termination of the attack is frequently obtained when the patient sits up.
What would you look out for on GENERAL Inspection in a breathless patient?
- Cyanotic, pallor, clubbing
- Indrawing, intercostal retraction
- Mental status: Alert, agitated, comatose
- Audible stridor vs Wheeze
- Sputum: purulent, bloody, frothy
- Skin rash: hives, vasculitic rash
- Oral or neck swellings
- Indrawing, stridor, pursed lip breathing
- Speaking in short sentences or incomplete
- Jugular venous pressure
What are the vital signs to look out for in a breathless patient?
Respiratory rate and pattern
- Rate < 10
- Rate > 24
- Kussmaul breathing
Pulse rate, rhythm
- Rate > 110, < 40
- Rhythm – irregularly irregular
BP
- <90/ <50
- > 180/ >120
Temp
- Fever suggests infection
- But lack of fever does not rule out infection
- < 35 or hypothermia (not a good sign)
SpO2
- <90% with supplemental O2
- Low O2 sats not indicative of PCO2 values
- Low readings falsely low due to decreased perfusion
What is the cardio examination to perform in a breathless patient?
Cardiac heave – pulmonary hypertension
Apex beat – displaced?
Lower limb calf swelling or tenderness
Auscultation
- Rubs (pericardial vs pleural)
- Murmurs
- Gallops
What is the respi examination to perform in a breathless patient?
Expansion
Vocal resonance
Percussion
- Ipsilateral dullness
- Contralateral hyperresonance
Auscultation
- Bronchial breathing
- Crepitation
- Wheeze
- SC emphysema
- Stridor
- Rhonchi
What are the investigations to be performed in a breathless patients?
Blood Tests
- FBC: anemia, leukocytosis
- Renal panel
- Cardiac enzymes: Troponin I, CKMB
- Liver function test (if hepatic congestion)
- Arterial blood gases
- Electrolytes: Cr, HCO3, Anion gap, Lactate
ECG
- Ischemic changes
- Pulmonary embolism (SI QIII TIII)
- Atrial fibrillation or other arrhythmias
Chest X-ray
- Pulmonary edema
- Pleural effusion
- Consolidation
- Emphysema
- Pneumothorax
Spirometry (Lung function test)
- Obstructive lung disease (restricts air flow): Asthma, COPD, Bronchiectasis
- Restrictive lung disease (restricts lung expansion): Pulmonary Fibrosis, ILD, Sarcoidosis etc
Other more specific tests:
- Echocardiography – LVF, valve disorders
- V/Q scan or CT PA – PE, bronchiectasis
- CT thorax– pulmonary fibrosis, cancer
- CT pulmonary angiogram
