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Respi > Approach to dypsnea > Flashcards

Approach to dypsnea Flashcards

1
Q

What are the ddx for SOB + Chest pain?

A
  • AMI
  • Acute coronary syndrome
  • Pneumothorax
  • Pulmonary embolism: Hypoxemia (decreasing SPO2) with clear lungs + tachycardia and dyspnoea is indicative of PE
  • Pleural Effusion
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2
Q

What are the ddx for SOB + Stridor?

A
  • Anaphylaxis
  • Epiglottitis
  • Retropharyngeal Abscess
  • Foreign Body
  • Croup (in children)
  • Extrinsic compression (malignancy)
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3
Q

What are the ddx for SOB + fluid overload?

A
  • 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
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4
Q

What are the ddx for SOB + infective picture?

A
  • Pneumonia
  • TB
  • Bronchiectasis
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5
Q

What are the ddx for SOB + Wheeze?

A
  • COPD: Tracheal tug, Smoker, Hyperinflation
  • Asthma: Atopic symptoms w episodic symptoms; occurs when exposed to cold air / animal dander
  • Bronchiectasis: Expiratory Rhonchi
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6
Q

What are the ddx for SOB + non specific increase effort in breathing?

A
  • Pleural Effusion: Stony dull
  • Chest signs present: Hyper-resonance
  • PE
  • DKA: +/- Kussmaul breathing
  • Anemia
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7
Q

What are the ddx for SOB + weakness (neuro cause)?

A
  • Guillian Barre

- Myasthenia Gravis

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8
Q

What are the respiratory causes of acute dyspnea?

A

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)
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9
Q

What are the cardiovascular causes of acute dyspnea?

A

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

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10
Q

What are the non cardiovascular, non respiratory causes of acute dyspnea?

A

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

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11
Q

What are the respiratory causes of chronic dyspnea?

A
  • Asthma
  • COPD
  • Pleural effusion
  • Cancer
  • Interstitial lung disease
  • Chronic pulmonary thromboembolism
  • Bronchiectasis
  • Cystic fibrosis
  • Pulmonary hypertension
  • Pulmonary vasculitis
  • TB
  • Laryngeal/tracheal stenosis
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12
Q

What are the cardiovascular causes of chronic dyspnea?

A
  • 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
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13
Q

What are the non cardiovascular, non respiratory causes of chronic dyspnea?

A
  • Severe anemia
  • Obesity / Kyphoscoliosis
  • Pregnancy (progesterone, etc)
  • Physical deconditioning
  • Diaphragmatic paralysis
  • Neuromuscular (Myasthenia Gravis, Gullian-Barré)
  • Cirrhosis (hepatopulmonary syndrome)
  • Tense ascites
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14
Q

What are the clinical features suggestive of TB as a cause of dypsnea?

A
  • Constitutional sx: LOW, fever, night sweats
  • Travel, contact hx
  • Immunocompromised
  • Upper lobe consolidation (reactivation)
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15
Q

What are the clinical features suggestive of bronchiectasis as a cause of dypsnea?

A

Bronchiectasis - Copious purulent sputum (typically green)

  • Haemoptysis
  • Clubbing, coarse inspiratory crepitation, rhonchi
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16
Q

What are the clinical features suggestive of pneumonia as a cause of dypsnea?

A
  • A/W fever, SOB, sputum production
  • Bronchial breath sounds, dullness to percussion, coarse crepitation, increased vocal resonance
  • Consolidation on CXR
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17
Q

What are the clinical features suggestive of malignancy as a cause of dypsnea?

A
  • Dyspnea
  • Constitutional sx
  • Diminished breath sounds, focal wheezing (obstruction)
  • Family hx
  • Smoking
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18
Q

What are the clinical features suggestive of COPD as a cause of dypsnea?

A
  • 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
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19
Q

What are the clinical features suggestive of asthma as a cause of dypsnea?

A
  • 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
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20
Q

What are the clinical features suggestive of ILD as a cause of dypsnea?

A
  • 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
21
Q

What are the clinical features suggestive of pleural effusion as a cause of dypsnea?

A
  • Pleuritic chest pain (presents w SOB + chest pain)

- Stony dullness, decreased breath sounds

22
Q

What are the clinical features suggestive of pulmonary embolism as a cause of dypsnea?

A
  • 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

23
Q

What are the clinical features suggestive of pneumothorax as a cause of dypsnea?

A
  • Pleuritic chest pain (presents w SOB + chest pain)
  • Decreased breath sounds, hyper-resonance
  • decreased vocal resonance
24
Q

What are the clinical features suggestive of congestive cardiac failure as a cause of dypsnea?

A
  • 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
25
Q

What are the clinical features suggestive of acute coronary syndrome as a cause of dypsnea?

A
  • Diffuse, crushing central pain (angina) with radiation to arm, neck, jaw
  • Diaphoresis, N&V
  • Risk factors: age >60, previous hx, vascular
26
Q

What are the clinical features suggestive of pericarditis/ cardiac tamponade as a cause of dypsnea?

A
  • ECG changes
  • Pericardial Friction Rub
  • ↑JVP, Tachycardia, HypoTN
  • Look at Approach to ECG
27
Q

What are the clinical features suggestive of anemia as a cause of dypsnea?

A

Anaemia - A/W pallor, chest pain, giddiness, palpitations, fatigue, bleeding

28
Q

What is the MRC breathlessness scale?

A
  • 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
29
Q

What questions would you ask to defined the the breathlessness?

A

Define the Symptom

  • Short of air?
  • Having to breathe slower but deeper (obstructive) or faster but shallow (restrictive)
  • Chest tightness/chest pain?
  • Restricted breathing?
30
Q

What aggravating/ relieving factors would you ask in a patient who is breathless?

A
  • 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?
31
Q

What questions would you ask in a patient who is breathless about severity/ effort tolerance?

A
  • How many bus stops? Climbing stairs?

- Ask about current and baseline effort tolerance

32
Q

What etiologies can sudden dypsnea point to?

A

pulmonary emboli, pneumothorax, foreign body, AMI

33
Q

What etiologies can dypsnea that occurs over a few hours point to?

A

asthma, pulmonary edema

34
Q

What etiologies can dypsnea that occurs over days to weeks point to?

A

pleural effusion, infection, growth of tumor

35
Q

What etiologies can dypsnea that occurs over years point to?

A

COPD, pulmonary fibrosis, non-respiratory causes (eg. Anemia)

36
Q

What are the associated symptoms to ask in someone who is breathless?

A

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
37
Q

What are the relevant PMH to ask in patients who are breathless?

A

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
38
Q

What are the relevant drug hx to ask in patients who are breathless?

A
  • Drug allergy
  • Current medications
  • NSAIDS, beta blocker, aspirin? – asthma
  • Methotrexate, amiodarone? – pulmonary fibrosis
39
Q

What are the relevant fam hx to ask in patients who are breathless?

A
  • Ischemic heart disease
  • Lung Cancer
  • Atopic diseases
  • Emphysema (alpha antitrypsin deficiency)
  • Thromboembolic disease
  • Connective tissue diseases
40
Q

What are the relevant social hx to ask in patients who are breathless?

A

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
41
Q

What are the red flags of breathlessness?

A
  • Tachypnea
  • Tachycardia
  • Tracheal deviation
  • Stridor (on inspiration; indicative of upper airway obstruction)
  • Cyanosis
  • Hypoxia
  • Hypotension
  • Confusion
  • Use of accessory muscles
42
Q

What is dypsnea?

A

Dyspnea is the subjective complaint of shortness of breath.

43
Q

What is orthopnea?

A

Orthopnea refers to dyspnea in recumbency that is at least partially relieved by assuming an upright position

44
Q

What is paroxysmal nocturnal dyspnea ?

A

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.

45
Q

What would you look out for on GENERAL Inspection in a breathless patient?

A
  • 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
46
Q

What are the vital signs to look out for in a breathless patient?

A

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
47
Q

What is the cardio examination to perform in a breathless patient?

A

Cardiac heave – pulmonary hypertension

Apex beat – displaced?

Lower limb calf swelling or tenderness

Auscultation

  • Rubs (pericardial vs pleural)
  • Murmurs
  • Gallops
48
Q

What is the respi examination to perform in a breathless patient?

A

Expansion

Vocal resonance

Percussion

  • Ipsilateral dullness
  • Contralateral hyperresonance

Auscultation

  • Bronchial breathing
  • Crepitation
  • Wheeze
  • SC emphysema
  • Stridor
  • Rhonchi
49
Q

What are the investigations to be performed in a breathless patients?

A

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

Respi (13 decks)

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