Approach to Dyspnoea Flashcards
What is dyspnoea and when does it arise?
Subjective sensation of breathing discomfort (experience varies widely)
Arises when there is a recognition by the subject of an inappropriate relationship between respiratory work and total body work (i.e. there is an imbalance in the drive to breath and the mechanical effort)
List 5 categories of clinical causes of dyspnoea
Respiratory
Cardiac
Chest wall restriction/muscle weakness
Metabolic/anaemia
Psychogenic (Dx of exclusion!)
Describe 3 possible mechanisms of dyspnoea, and provide examples of conditions which fit these mechanisms
Increased drive: exercise, metabolic acidosis, hypoxia, anxiety
Increased load (WOB; may be resistive or elastic): asthma, COPD
Decreased strength of respiratory muscles: NMD, cachexia
List 4 early Ix which would be appropriate in a patient presenting with dyspnoea, and 5 others you would consider depending on the clinical context
Initial: CXR, ECG, ABGs, basic bloods
Dependent on clinical context: lung function, CT, V/Q scan, exercise test, echo
What does wheeze suggest about the anatomical site of the problem?
Airways
What do crepitations/crackles suggest about the anatomical site of the problem?
Terminal lung units
What does stony dullness suggest about the anatomical site of the problem?
Pleural
Where is the “silent zone” in terms of localising pathology based on examination findings?
Pulmonary vessels (often no localising signs)
Mr Evans, previously well 23 year old male, presents with sudden onset SOB of a few hours duration, now quite severe; accompanied by L-sided chest pain which is moderate and pleuritic (onset at same time as SOB)
Smokes 10 cigarettes/day
DDx?
Pneumothorax
Arrhythmia
PE
Pneumonia
Asthma (less likely)
Anxiety
Mr Evans, previously well 23 year old male, presents with sudden onset SOB of a few hours duration, now quite severe; accompanied by L-sided chest pain which is moderate and pleuritic (onset at same time as SOB)
Smokes 10 cigarettes/day
O/E: looks unwell, quite distressed with increased WOB, RR 26, HR 125 SR, BP 80/60, afebrile, SaO2 93% RA, midline trachea, reduced chest expansion on L, hyperresonant percussion note on L, reduced air entry into L lung
Ix and expected findings?
CXR: collapse of L lung, air in the L thorax with increased volume of the thorax, mediastinal shift to R
Mr Evans, previously well 23 year old male, presents with sudden onset SOB of a few hours duration, now quite severe; accompanied by L-sided chest pain which is moderate and pleuritic (onset at same time as SOB)
Smokes 10 cigarettes/day
O/E: looks unwell, quite distressed with increased WOB, RR 26, HR 125 SR, BP 80/60, afebrile, SaO2 93% RA, midline trachea, reduced chest expansion on L, hyperresonant percussion note on L, reduced air entry into L lung
CXR: collapse of L lung, air in L thorax with increased volume of the thorax, mediastinal shift to R
Dx?
Mx?
Dx: tension pneumothorax
Mx: urgent chest tube (this may have been done without a CXR if patient was unwell enough)
Mr Harvey, 23 year old male, presents with progressive SOB over 2/7 which is now present at rest, on background of recent URTI; associated Sx include wheeze and dry cough
PHx: childhood asthma (age 3-12), allergic rhinitis
Most likely Dx?
Expected findings O/E?
Dx: acute asthma
O/E: likely to be widespread polyphonic wheeze, elevated RR, decreased SaO2, may be associated tachycardia
Mr Harvey, 23 year old male, presents with progressive SOB over 2/7 which is now present at rest, on background of recent URTI; associated Sx include wheeze and dry cough
PHx: childhood asthma (age 3-12), allergic rhinitis
O/E: RR 24, HR 110 SR, BP 110/70, SaO2 97% RA, widespread wheeze
Ix?
Mr Harvey, 23 year old male, presents with progressive SOB over 2/7 which is now present at rest, on background of recent URTI; associated Sx include wheeze and dry cough
PHx: childhood asthma (age 3-12), allergic rhinitis
O/E: RR 24, HR 110 SR, BP 110/70, SaO2 97% RA, widespread wheeze
CXR normal, peak flow 300/min
ABG: pH 7.5, CO2 30, O2 70, HCO3 23
Interpret the Ix results
Dx?
Mx?
Results: ABG shows respiratory alkalosis with widened A-a gradient, gas exchange is NOT normal despite normal saturation on the monitor
Dx: exacerbation of asthma
Mx: bronchodilators, corticosteroids, O2
List 4 other important Sx of respiratory disease
Cough (acute or chronic)
Haemoptysis
Chest pain
Daytime sleepiness
Mrs Walters, 68 year old female, presents with sudden onset SOB (present now for 1/24, quite severe)
Associated features: R-sided pleuritic chest pain, mild fever
PHx: R TKR 3/7 ago, persistent leg swelling since then, no previous cardiorespiratory disease or injury
Non-smoker
O/E: not too unwell but clear evidence of tachypnoea and some increased WOB, RR 24, temp 37.6, HR 110, BP 110/70, SaO2 93% RA, chest clear with normal percussion and normal breath sounds
Most likely Dx?
Ix?
Mx?
Dx: acute PE
Ix: CXR (would expect normal), ABG (may be evidence of respiratory alkalosis), CTPA (example finding attached)
Mx: anticoagulation
Mrs Harris, 68 year old woman, presents with progressive SOB over 6/12, worse over last 1/7
Associated features: chronic cough (usuallly with white sputum, now worse with change in sputum amount and colour), fever, some orthopnoea
Heavy smoker (35 pack-years)
DDx?
COPD with acute infective exacerbation (and consider possibility of underlying cancer)
CCF with acute exacerbation
Anxiety
Muscle weakness
Anaemia
Mrs Harris, 68 year old woman, presents with progressive SOB over 6/12, worse over last 1/7
Associated features: chronic cough (usuallly with white sputum, now worse with change in sputum amount and colour), fever, some orthopnoea
Heavy smoker (35 pack-years)
O/E: unwell, RR 26, temp 37.8, HR 90 SR, BP 140/80, SaO2 88% RA, evidence of increased WOB and use of accessory muscles, signs of hyperinflation, prolonged expiration with wheeze
List 3 signs of hyperinflation
Ix?
Signs of hyperinflation: barrel chest, reduced chest expansion, hyper-resonant percussion
Ix: CXR, ABG
Mrs Harris, 68 year old woman, presents with progressive SOB over 6/12, worse over last 1/7
Associated features: chronic cough (usuallly with white sputum, now worse with change in sputum amount and colour), fever, some orthopnoea
Heavy smoker (35 pack-years)
O/E: unwell, RR 26, temp 37.8, HR 90 SR, BP 140/80, SaO2 88% RA, evidence of increased WOB and use of accessory muscles, signs of hyperinflation, prolonged expiration with wheeze
ABG: pH 7.28, pCO2 60, HCO3 26
Interpret the ABG results
Mx?
Acute type II respiratory failure
Mx: bronchodilators, controlled O2, corticosteroids, Abx, NIV
Mr Treglia, 68 year old male, with progressive SOB over 6/12, worsening over last 1/7
Associated features: orthopnoea, PND, SOA (all present to minor degree over 6/12 but worse for last 1/7), palpitations in last 1/7
PHx: previous AMI 4 years ago, PPM, HTN, DM
Ex-smoker
DDx?
HF
Arrhythmia
ACS
COPD
Anaemia
Mr Treglia, 68 year old male, with progressive SOB over 6/12, worsening over last 1/7
Associated features: orthopnoea, PND, SOA (all present to minor degree over 6/12 but worse for last 1/7), palpitations in last 1/7
PHx: previous AMI 4 years ago, PPM, HTN, DM
Ex-smoker
O/E: unwell looking with increased WOB, RR 26, afebrile, HR 130 irregular, BP 100/70, SaO2 90% RA, JVP 5cm, SOA ++, displaced apex beat, 3rd HS present but no murmurs, normal chest expansion but stony dull percussion in bases (R>L) and bilateral inspiratory crepitations just above the dull areas
Ix?
ECG
ABG
CXR
Mr Treglia, 68 year old male, with progressive SOB over 6/12, worsening over last 1/7
Associated features: orthopnoea, PND, SOA (all present to minor degree over 6/12 but worse for last 1/7), palpitations in last 1/7
PHx: previous AMI 4 years ago, PPM, HTN, DM
Ex-smoker
O/E: unwell looking with increased WOB, RR 26, afebrile, HR 130 irregular, BP 100/70, SaO2 90% RA, JVP 5cm, SOA ++, displaced apex beat, 3rd HS present but no murmurs, normal chest expansion but stony dull percussion in bases (R>L) and bilateral inspiratory crepitations just above the dull areas
ECG shows rapid AF
ABG: pH 7.43, pCO2 36, pO2 60, HCO3 20
CXR attached
Intrepret the ECG and CXR findings to arrive at a Dx
ECG: rapid AF (rate 100-140)
CXR: PPM, ABCDE (alveolar opacity in bases, Kerley B lines i.e. interstitial oedema, cardiomegaly, dilated upper lobe vessels, bilateral pleural effusions)
Mr Treglia, 68 year old male, with progressive SOB over 6/12, worsening over last 1/7
Associated features: orthopnoea, PND, SOA (all present to minor degree over 6/12 but worse for last 1/7), palpitations in last 1/7
PHx: previous AMI 4 years ago, PPM, HTN, DM
Ex-smoker
O/E: unwell looking with increased WOB, RR 26, afebrile, HR 130 irregular, BP 100/70, SaO2 90% RA, JVP 5cm, SOA ++, displaced apex beat, 3rd HS present but no murmurs, normal chest expansion but stony dull percussion in bases (R>L) and bilateral inspiratory crepitations just above the dull areas
CXR shows evidence of HF
Likely Dx and Mx?
Dx: long standing HF with acute exacerbation due to new onset rapid AF
Mx: digoxin, B blocker, diuretic, ACEI, warfarin, O2
