Dyspnea

Question 1

What is dyspnea?

Answer 1

SUBJECTIVE complaint, abnormally increased awareness of breathing OR sensation of difficulty of breathing

2nd most common reason for ER visits in US

Question 2

When taking a history, what is the FIRST question you need to ask for a pt w/ a CC of dyspnea?

Answer 2

HOW LONG HAS THIS BEEN GOING ON FOR???????

acute vs. chronic dyspnea is VERY IMPORTANT!

Question 3

How does a slow progression of dyspnea differ from a rapid progression?

Answer 3

• Slow progression = likely to lead to a chronic etiology
• Rapid = likely to lead to an acute etiology and/or likely to coincide w/ alarm symptoms that may need immediate intervention

Question 4

What are 10 possible associated symptoms?

Answer 4

1. Chest pain
2. Hemoptysis
3. Fever
4. Cough (productive vs. nonproductive)
5. Wheezing
6. Constitutional : fever, night sweats, weight loss, fatigue
7. Itching/hives
8. Edema
9. Weight Loss
10. Feeling of impending doom

Question 5

What could chest pain indicate?

Answer 5

1. Myocardial infarction…..(ask about radiation, description of pain)
2. Pneumothorax
3. Pulmonary embolism (can be unilateral or bilateral pleuritic pain too)
4. Cardiac tamponade (central chest heaviness)
5. Pericarditis (pleuritic pain radiating to the back w/ positional improvement)
6. Pleuritic vs. cardiac

Question 6

What could a FEVER indicate?

Answer 6

80% of pts. w/ pneumonia have fever

20% of pts. w/ PE have fever

Question 7

What could a NON PRODUCTIVE cough indicate?

Answer 7

Asthma
Pulmonary embolism
GERD

Question 8

What could a PRODUCTIVE cough indicate?

Answer 8

Acute Pneumonia
Flash pulmonary edema
COPD (chronic bronchitis)

Question 9

What could WHEEZING indicate?

Answer 9

Asthma
COPD
Anaphylaxis

Question 10

What could ITCHING/HIVES indicate?

Answer 10

Anaphylaxis

Question 11

What could UNILATERAL EDEMA OF EXTREMITIES indicate?

Answer 11

DVT w/ PE

Question 12

What could BILATERAL EDEMA OF EXTREMITIES indicate?

Answer 12

1. Cardiomyopathy - more likely to have bilateral edema (DVT…unilateral)
2. Pericardial disease
3. Pulmonary Hypertension

Question 13

What could WEIGHT LOSS indicate?

Answer 13

Cancer

Question 14

What could a FEELING OF IMPENDING DOOM indicate?

Answer 14

Anxiety

Question 15

MODIFIERS……Worse when LYING FLAT???

Answer 15

YES – ORTHOPNEA –> CHF

Question 16

MODIFIERS…. Pain better when lay on one side or the other?

Answer 16

Trepopnea … occurs w/ unilateral effusions

Question 17

What are 11 risk factors/associated diseases for dyspnea?

Answer 17

1. Hx CHF
2. Hx MI
3. Hx CAD
4. Meds –> especially new meds that were started around the time of onset
5. Smoking history … hx of COPD, CAD, Lung CA
6. Occupation …. was there occupational exposure?
7. Prolonged immobilization
8. Hx of CA
9. OCP/ Estrogen Use
10. Surgery
11. Recent Travel

Question 18

What are the 5 Risk Factors for DVT/PE?

Answer 18

1. Prolonged Immobilization
2. Hx of CA
3. OCP/ Estrogen Use
4. Surgery
5. Recent travel

Question 19

What are the 6 Alarm Symptoms for Dyspnea?

Answer 19

1. Chest pain (pleuritic vs. Cardiac)
2. Lip swelling, hives AND wheezing
3. Pink frothy sputum
4. Fever w/ sputum production
5. Fever w/ worsening sore throat and hoarse voice
6. Awakens from a sleep

Question 20

What does ALARM SYMPTOM CHEST PAIN indicate?

Answer 20

1. Pleuritic –> sharp, unilateral chest pain that increases with respiration….

serious causes = Pulmonary embolism, PTX, pneumonia

2. Cardiac –> MI

Question 21

What does ALARM SYMPTOM “LIP SWELLING, HIVES AND WHEEZING” indicate?

Answer 21

Anaphylaxis, angioedema

Question 22

What does ALARM SYMPTOM “PINK FROTHY SPUTUM” indicate?

Answer 22

Flash Pulmonary Edema

Question 23

What does ALARM SYMPTOM FEVER W/ SPUTUM PRODUCTION indicate?

Answer 23

Pneumonia vs. bronchitis…

Pneumonia = bacterial

Most of Bronchitis = VIRAL…AKA NO ANTIBIOTICS!!

Question 24

What does ALARM SYMPTOM “FEVER W/ WORSENING SORE THROAT AND HOARSE VOICE” indicate?

Answer 24

Epiglottis

Question 25

Why does dyspnea occur?

Answer 25

The purpose of breathing is to meet the metabolic demands of the body…

Question 26

What are the FOUR major physiologic reasons dyspnea results from?

Answer 26

1. Any condition that increases the work of breathing … CANT GET THE AIR IN!
2. POOR oxygen uptake
3. Any condition that increases respiratory drive
4. Exacerbation of primary psychological conditions

Question 27

1. Any condition that increases the work of breathing… CAN GET THE AIR IN!

Answer 27

1. Airway obstruction
   Changing in lung compliance
   Respiratory muscle weakness

THINK OF ANATOMY…

a) Upper airway –> epiglottis, foreign body
b) Bronchi –> asthma, acute bronchitis
c) Alveoli –> Emphysema, Interstitial lung disease
d) External compression –> PTX
e) Thoracic wall –> scoliosis

Question 28

2. Poor oxygen uptake

Answer 28

LUNG CIRCULATION PROBLEM

a) Pulmonary Embolism
b) Left sided Heart Failure
c) Pulmonary Hypertension

HEMOGLOBIN DISORDER

a) Anemia
b) Carbon monoxide poisoning

Question 29

3. Any condition that increases respiratory drive

Answer 29

Hypoxia, metabolic acidosis

REMEMBER…. metabolic acidosis is a surplus of positive cations (hydrogen)… the way the body compensates for a metabolic acidosis is to increase the respiration rate… WHY? in the respiratory system, CO2 is an ACID… to decrease CO2, you need to increase the respiratory rate… which results in DYSPNEA

Question 30

4. Exacerbation of primary psychological conditions

Answer 30

Anxiety

BE CAREFUL!!!!!!!! MANY PATIENTS who have organic causes for their dyspnea will appear to be anxious.

Question 31

What can manifest as ANXIETY?

Answer 31

HYPOXIA!!!!

Question 32

Whats the FIRST THING TO DO when categorizing dyspnea?

Answer 32

Determine if its ACUTE OR CHRONIC!

Will help us determine what type of questions will be most important.

Question 33

What is the duration of acute dyspnea?

Question 34

What are the FOUR physical signs of ACUTE dyspnea?

Answer 34

1. Can only say 2-3 words w/o stopping to take a breath
2. Nasal flaring
3. Cyanosis
4. ACCESSORY MUSCLE USE: chest wall retractions, abdominal muscle use, neck muscle use (particularly the sternocleidomastoid and scalene muscles)

Question 35

What are the CAUSES of ACUTE dyspnea? (8)

Answer 35

PPOPPA-MM

1. Pulmonary Embolism
2. Pulmonary Edema
   a) Pulmonary (less common than cardiogenic): high altitude, gas inhalation
   b) Cardiogenic : CHF
3. Obstructed Airway
   a) Foreign body
   b) Epiglottis
4. Pneumothorax (spontaneous)
5. Pneumonia/Bronchitis
6. Asthma or COPD
7. MI/tamponade
8. Medications

Question 36

What is the duration of chronic dyspnea?

Answer 36

> 1 Month

Question 37

What will the majority of people w/ chronic dyspnea of unclear etiology end up having? (5)

Answer 37

COPD
Asthma
Interstitial Lung Disease
Myocardial Dysfunction
Obesity/Deconditioning

Question 38

What are the CARDIOVASCULAR causes of CHRONIC DYSPNEA? (4)

Answer 38

Muscle : cardiomyopathies

Vessels : Ischemia

Valves : Regurgitation, stenosis, or infection

Pericardium : Effusion, inflammation

Question 39

What are the PULMONARY causes of CHRONIC DYSPNEA? (6)

Answer 39

Bronchi : Mass, Foreign Body

Bronchioles : Asthma, chronic bronchitis

Interstitial Lung Disease

Alveoli : Emphysema, Chronic Pneumonia

Pleura : Effusions

Lung Cancer

Question 40

What are the “OTHER” causes of CHRONIC DYSPNEA? (5)

Answer 40

Anemia

Chest wall abnormalities : Scoliosis, Pectus Excavatum (sternum and chest wall appear to be sunken in)

Deconditioning

Acidosis

Neurmomuscular Disease
(either an issue w/ ACTUAL MUSCLES DOING THE WORK of breathing… OR issue w/ the CONTROL of respirations in the CNS)