Dyspnoea

Question 1

Definition of dyspnoea?

Answer 1

Subjective sensation of Shortness of breath. An abnormal, uncomfortable awareness of respiration.

Question 2

Name the Types of dyspnoea (6)

Answer 2

1. Acute dyspnoea
2. Chronic dyspnoea
3. Exertional dyspnoea
4. Orthopnoea
5. Paroxysmal nocturnal dyspnea

Question 3

Define: Orthopnoea

Answer 3

Dyspnoea when supine due
to redistribution of fluid in
lung. Patient may need to be
upright or propped on a
number of pillows to sleep

Question 4

Define: Paroxysmal nocturnal dyspnea

Answer 4

1. Severe dyspnoea waking patient from sleep.
   Due to:
   a) Transudation of fluid
   b) Reabsorption of oedema to interstitial tissues
   c) increase in work of breathing.

Question 5

Differentials for acute dyspnoea: Respiratory (8)

Answer 5

Asthma
Bronchitis
Pneumonia
Pneumothorax
Acute pulmonary oedema
Pulmonary embolism
ARDS
Allergen exposure
Foreign body obstruction

Question 6

Differentials for acute dyspnoea: Cardiac (2)

Answer 6

Cardiac tamponade
Shock

Question 7

Differentials for acute dyspnoea:
Other (5)

Answer 7

Psychogenic
Haemolysis
Rib fracture
CO poisoning
Metabolic acidosis

Question 8

Differentials for chronic dyspnoea
Respiratory (7):

Answer 8

Bronchiectasis
COPD
Chronic anaemia
Infiltrative tumour
Interstitial lung disease
Pleural effusion
Pulmonary hypertension

Question 9

Differentials for chronic dyspnoea:
Cardiac (3):

Answer 9

Heart failure
Pericardial effusion
Restrictive pericarditis

Question 10

Differentials for chronic dyspnoea:
Other (4)

Answer 10

Severe obesity
Ankylosing spondylitis
Kyphoscoliosis
Neuromuscular disease

Question 11

Dyspnoea:
Questions to ask on history

Answer 11

1. Onset?
   (Sudden or gradual, sporadic or in certain circumstances such as on exertion or exposure to an allergen or at rest)
2. Duration?
   (Acute or chronic)
3. Exercise tolerance?
   (Steps climbed/distance walked)
4. Effect on function?
   (NYHA classification scale)
5. Exacerbating and relieving factors?
   (Use of puffers, resting, change of setting)
6. Diurnal variation?
   (Asthma)
7. Worse when lying flat?
   (Orthopneoa)
8. How many pillows does the patient sleep with?
   (Orthopneoa)
9. Do you ever wake from sleep gasping for breath?
   (Paroxysmal nocturnal dyspnoea)
10. Associated symptoms?
    (Chest pain, swelling of ankles, panic or anxiety, cough)

Question 12

Examination findings:
Inspection

Answer 12

1. Respiratory rate:
   (brady <8bpm ; tachy >25bpm)
2. Cyanosis: (peripheral, central)
3. Use of accessory muscles of respiration
   (sternocleidomastoids, scalene)
4. Pursed lips breathing
   (COPD)
5. Increased AP diameter/barrel chest
   (COPD)
6. Elevated JVP (>5cm)
   (Heart failure)
7. Tracheal shift from midline
   (Pneumonthorax, pleural effusion)

Question 13

Examination findings:
Percussion

Answer 13

1. Dull note
   (Consolidation; pneumonia)
2. Stony dull note
   (Fluid; pleural effusion)
3. Hyperresonant note
   (Air trapping; COPD)

Question 14

Examinaiton findings:
Auscultation

Answer 14

1. Absent unilateral breath sounds
   (Pneumothorax)
2. Fine crackles
   (Interstitial LD)
3. Coarse crackles
   (Heart failure)
4. Inspiratory and expiratory crackles
   (Bronchiectasis)
   5.Wheeze
   (Asthma)
5. Stridor
   (Upper airway obstruction)
6. S3 gallop
   (Heart failure)
7. Fixed S2 split
   (Pulmonary hypertension)

Question 15

Investigations that should be considered/completed for a dyspnoeic patient

Answer 15

Bedside: ECG
Laboratories: ABG, FBC
Imaging: CXR, ECHO
Other tests: Pulm Function Tests

Question 16

What may be found on CXR with a dyspnoeic patient?

Answer 16

1. Pleural effusion
   (meniscus sign = curved upper margin)
2. Pneumothorax
   (loss of lung markings, pleural reflection)
3. Pneumonia
   (consolidation as indicated by opacification)
4. Emphysema
   (lungs extend beyond rib VI, low and flat hemidiaphragms)

Question 16

NYHA Functional Classification Scale
Class I

Answer 16

Class I (asymptomatic left ventricular dysfunction)

No limitations, ordinary physical activity does not cause undue fatigue, dyspnoea or palpitations

Question 17

NYHA Functional Classification Scale
Class II

Answer 17

Class II (mild CHF)

Slight limitation of physical activity, ordinary physical activity results in fatigue, dyspnoea, palpations or angina

Question 18

NYHA Functional Classification Scale
Class III

Answer 18

Class III (moderate CHF)

Marked limitation of physical activity, less than ordinary activity leads to symptoms

Question 19

NYHA Functional Classification Scale
Class IV

Answer 19

Class IV (severe CHF)

Unable to carry on any physical activity without discomfort, symptoms of CHF present at rest

Question 20

What does DLCO mean on pulmonay function tests?

Answer 20

• Diffusing capacity of the lungs for carbon monoxide (DLCO).
• It is also known as the transfer factor.
• DLCO is a measurement to assess the lungs’ ability to transfer gas from inspired air to the bloodstream

Question 21

Answer 21