Chronic Dyspnoea

Question 1

What is the definition of dyspnoea?

Answer 1

Undue awareness of ones own breathing due to a change in either rate, depth or work of breathing (WOB)

Question 2

What changes can lead to dyspnoea?

Answer 2

Changes in 02,CO2 or pH
Lung perfusion
Ventilation
Diffusion related issues (Interstitial lung disease)
Pump failure (spine, diaphragm, muscles)

Exercise
Pregnancy

Question 3

What is an example of a disease which limits lung perfusion leading to dyspnoea?

Answer 3

Pulmonary Embolism

Question 4

What is a common ventilation issue which can lead to dyspnoea?

Answer 4

COPD

Question 5

What are some issues with muscles that can lead to dyspnoea?

Answer 5

Myasthenia gravis
Phrenic nerve palsy
Guillain barre syndrome

Question 6

What are some systemic causes of dyspnoea?

Answer 6

CKD
Heart failure (leading to pulmonary oedema

Question 7

What is orthopnoea?

Answer 7

Breathlessness on lying flat

Question 8

What are some causes of Orthopnoea?

What is a good question to ask to gauge the severity?

Answer 8

Congestive heart failure
Severe COPD

How many pillows do you use to sleep at night

Question 9

What is the term used to describe waking up in the night coughing due to fluid in lungs?

Answer 9

Paroxysmal nocturnal dyspnoea

Question 10

What can cause paroxysmal nocturnal dyspnoea?

Answer 10

Congestive heart failure

Question 11

What is platypnoea orthodeoxia syndrome?

Answer 11

When patient is comfortable lying down but becomes breathless with dropping 02 sats when they stand up

Question 12

What conditions does Platypnoea orthodeoxia syndrome suggest?

Answer 12

AV shunting (Pulmonary AV fistula)
Patent Foramen Ovale

Question 13

What is trepopnoea?

Answer 13

Laying on one side causes breathlessness

Question 14

What is trepopnoea suggestive of?

Answer 14

Unilateral. Lung disease
Compression related to big tumour
Pleural effusion
Aneurysm of aorta
Large hiatus hernia

Question 15

What is bendopnoea?

What can you ask a patient to gauge?

Answer 15

SOB on bending down

Ask if the can tie their shoe laces

Question 16

What are some causes of bendopnoea?

Answer 16

COPD
Congestive heart failure
Pleural effusion

Question 17

What is the definition of chronic breathlessness?

Answer 17

Develops over weeks to months

Question 18

What is the definition of acute breathlessness?

Answer 18

Develops over minutes to a few hours

Question 19

What is the definition of subacute breathlessness?

Answer 19

Develops over several hours to days

Question 20

List as many causes of chronic breathlessness as possible:

Answer 20

Obstructive - COPD, asthma, Bronchiectasis, cystic fibrosis, obstructive sleep apnoea
Restrictive - intersitial lung disease (pulmonary fibrosis, silicosis, asbestosis, pneumoconiosis, byssinosis)

Mesothelioma
TB
Lung cancer
Chronic. PE
Primary pulmonary hypertension
Congestive heart failure
Cardiac issues
Kyphoscoliosis
Renal failure
DKA
Anaemia.

Question 21

What is byssinosis?

Answer 21

Interstitial lung disease due to inhalation of cotton

Question 22

What is the most common cardiac issue in older people that causes chronic dyspnoea?

Answer 22

Aortic stenosis
Mitral stenosis

Question 23

Hx:

What is important to ask about the presenting complaint for chronic breathlessness?

Answer 23

Duration
Onset
Severity (functional impairment)
Factors worsening or alleviating

Question 24

Hx:

What it’s important to understand from a patients Social history with chronic breathlessness?

Answer 24

Smoking
Alcohol
Physical activity (exercise TOLERANCE)
Travel history (TB or other travel related infections)
Pets (Bird fanciers lung)
Occupation (asbestosis, pneumoconiosis, silicosis, byssinosis)

Question 25

Hx: What are some important associated features we would want to ask about which might aid a diagnosis for a cause for chronic breathlessness?

Answer 25

Chest pain Palpitations Syncope Weight loss Fever Sputum Cough Muscle weakness

Question 26

Hx: What are some drugs that can contribute to chronic dyspnoea?

Answer 26

Beta blockers Amiodarone (amiodarone immunities) Nitrofurantoin Methotrexate Bleomycin

Question 27

What is paradoxical breathing?

Answer 27

When the chest falls anal abdomen rises with inhalation

Question 28

What does paradoxical breathing suggest?

Answer 28

Diaphragmatic paralysis Severe muscle weakness (severe asthma exacerbation, COPD exacerbation, myasthenia gravis)

Question 29

What is the NICE criteria for a CXR to query a lung cancer?

Answer 29

Over 40yr or ever smoked with unexplainable symptoms: -cough -fatigue -SOB -chest pain -weight loss

Question 30

What values on spirometry would you expect to find for obstructive lung disease?

Answer 30

FEV1:FVC ratio < 0.7

Question 31

What values on spirometry would you expect to find for restrictive lung disease?

Answer 31

FEV1:FVC ratio > 0.8

Question 32

What is interstitial lung disease?

Answer 32

Conditions characterised by inflammation of alveolar epithelium and interstitium leading to fibrosis

Question 33

What are some causes of interstitial lung disease?

Answer 33

Idiopathic pulmonary r fibrosis Hypersensitivity pneumonic it’s Sarcoidosis Connective tissue disease related pulmonary fibrosis Drug induced Occupational (silicosis, asbestosis, pneomconiosis, byssinosis)

Question 34

What investigations would you do on someone with chronic breathlessness?

Answer 34

FBC U+Es LFTs ECG Thyroid function test CXR Abdo US. (Ascites? Liver. Cirrhosis?) Peak expiratory flow rate Spirometry

Question 35

What is an example of a measure/scale of breathlessness?

Answer 35

MRC scale of dyspnoea

Question 36

How is the MRC (medical research council scale for dyspnoea graded?

Answer 36

1-5

Question 37

What is grade 1 of the MRC scale of dyspnoea?

Answer 37

Not troubled by breathlessness expect on strenuous exercise

Question 38

What is grade 2 of the MRC scale of dyspnoea?

Answer 38

Short of breath when hurrying on the level or walking up a slight hill

Question 39

What is grade 3 of the MRC scale of dyspnoea?

Answer 39

Walks slower than most people on the level Stops after a mile or so or stops after 15miins walking at own pace

Question 40

What is grade 4 of the MRC scale of dyspnoea?

Answer 40

Stops for breath after walking about 100 yards or after a few minutes on level ground

Question 41

What is grade 5 of the MRC scale of dyspnoea?

Answer 41

Too breathless to leave the house or breathless while undressing

Question 42

What are some other scales that we can use to assess breathlessness?

Answer 42

CPET (cardiopulmonary exercise testing) 6 minute walking distance and shuttle walk