Dyspnoea Flashcards
What are the symptoms of COPD?
Progressive dyspnoea over a period of years
Slowly worsening exercise tolerance
Chronic productive cough (may be unproductive), typically worse in the morning and after exercise
May be comorbidities; exacerbations present with fever, subacute increase in dyspnoea, increased sputum production, change in sputum character;
Severe degree of impairment in young patient or patient with minimal or no smoking history suggests alpha-1 protease deficiency
What are the signs of COPD?
Facial plethora (fullness of the face + pink) Cyanosis
Laryngeal height of 4 cm or more
Pursed lip breathing,
Hyper-expanded chest, Prolonged exhalation,
Rhonchi, and wheeze; may be clubbing
Severe cases: resting or exercise hypoxaemia; may be pulsus paradoxus, mental state changes
What first line investigations would you consider in COPD?
Spirometry: decreased forced expiratory volume in the first second of expiration (FEV1), decreased FEV1/forced vital capacity (FVC) ratio
Pulmonary function tests: increased residual volume (RV), increased total lung capacity (TLC), decreased carbon monoxide diffusing capacity
ABG: hypoxaemia, hypercapnia
What other investigations would you consider in COPD?
Chest x-ray: increased lung volume, flattened hemidiaphragms may be present
What are the risk factors for COPD?
Current or prior history of smoking
Family history of COPD,
Childhood respiratory infections
Occupational exposure to smoke, fumes, chemicals; may be comorbidities; exacerbations present with fever, subacute increase in dyspnoea, increased sputum production, change in sputum character; severe degree of impairment in young patient or patient with minimal or no smoking history suggests alpha-1 protease deficiency
What are the symptoms of congestive cardiac heart failure?
Orthopnoea Paroxysmal nocturnal dyspnoea Exertional dyspnoea, Dyspnoea may be chronic with acute exacerbations Chest pain Ankle swelling Rapidly progressive failure Dyspnoea dominates the clinical picture
What are the signs of congestive cardiac heart failure?
Distended neck veins, Fine bibasal rales, Displaced apex beat,
S3 gallop rhythm, Peripheral oedema, may be increased abdominal girth, may be cyanosis and altered mental state
What first line investigations would you consider in congestive cardiac failure
Chest x-ray: cardiomegaly, bilateral lower lobe shadowing, pleural effusion, enlarged hilar vessels, upper lobe diversion, fluid in horizontal fissure, Kerley B-lines
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echocardiogram: valvular heart disease or regional/global wall motion abnormalities
B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP): elevated
What other investigations would you consider in congestive cardiac failure?
serum electrolytes: may be hyponatraemia
bedside ultrasonography: may demonstrate the presence of B-lines
ECG: no specific pattern associated with heart failure exacerbation; Q wave, ST segment depressions, T wave inversion, left bundle branch block, and rhythm changes (atrial fibrillation and flutter) can all be seen
cardiac enzymes: may be elevated, as a reflection of myocardial strain and injury
What are the symptoms of asthma?
episodic wheezing, cough, chest tightness and dyspnoea, symptom variability - may be seasonal, or following viral infection or exposure to aeroallergen, cool air, or exercise; possible history of other atopic diseases; onset of symptoms normally in childhood
What are the signs of asthma?
may be normal in between exacerbations, prolonged expiratory phase, wheeze, and rhonchi; acute severe asthma attack may include: severe breathlessness (including too breathless to complete sentences in one breath), tachypnoea, tachycardia, silent chest, cyanosis, accessory muscle use, altered consciousness or collapse
What are the first lines investigations that you would do in asthma?
peak expiratory flow rate (PEFR): may be reduced; may be variability of measurements recorded at different times of the day
spirometry: may be decreased forced expiratory volume in the first second of expiration (FEV1), decreased FEV1/forced vital capacity (FVC) ratio; may show positive bronchodilator reversibility of obstructive spirometry results; may be normal
fractional exhaled nitric oxide test (FeNO): elevated FeNO (≥40 parts per billion) supports the diagnosis of asthma
What other investigation would you consider in asthma?
bronchoprovocation testing: airway hyper-responsiveness
FBC: normal or elevated eosinophils and/or neutrophilia
immunoassay for allergen-specific IgE: may be positive for allergen
skin prick allergy testing: may be positive for allergen
6-week trial of inhaled corticosteroids: symptomatic and objective improvement in response
What are the symptoms of pneumonia?
sudden or sub-acute onset of fever, chills, cough, pleuritic chest pain, and dyspnoea; cough typically produces purulent sputum, but may be dry in some viral pneumonias and early bacterial pneumonia; onset is more insidious in fungal and tuberculous infections
What are the signs of pneumonia?
fever, tachycardia, tachypnoea, crackles, may be focal chest signs of consolidation: dullness on percussion, decreased chest expansion, bronchial breathing; may be signs of effusion: focal decreased breath sounds, and decreased fremitus; less frequently, jaundice; severe cases: hypoxaemia, cyanosis, altered mental state, and respiratory failure
What first line investigations would you do in pneumonia?
chest x-ray: lobar infiltrate, cavitation, interstitial infiltrates
sputum Gram stain and culture: may demonstrate presence of bacteria
What other investigations would you do in pneumonia?
procalcitonin: elevated in bacterial pneumonia
FBC: elevated WBC with/without neutrophilia and left shift may be present
LFTs: elevated serum transaminases may be present with atypical pneumonia
ABG: hypoxaemia and respiratory alkalosis may be present in severe pneumonia
blood cultures: may be positive for specific organism
serum urea or serum urea/serum albumin ratio: elevated levels of either test predict poor prognosis
What other differentials should you consider?
ACS
Stable Angina
Anxiety and Panic Attack
What are the symptoms of Interstitial lung disease?
slowly progressive dyspnoea and a chronic, dry cough
What are the signs of interstitial lung disease?
dry crackles; hypoxaemia, cyanosis, and clubbing may be present
What are the risk factors for interstitial lung disease?
smoking, rheumatological diseases, exposure to solvents, organic dust, and moulds, chemotherapy and radiotherapy, and certain medications, although many cases are idiopathic
What first line investigations would you consider in interstitial lung disease?
chest x-ray: diffuse reticulonodular changes, decreased lung volume
CT chest: diffuse reticulonodular changes
What other investigations would you consider in interstitial lung disease?
lung biopsy: interstitial pneumonitis
pulmonary function tests: restrictive pattern; isolated reduction in carbon monoxide diffusing capacity may be the first sign
What are the symptoms of bronchiectasis?
chronic cough, chronic daily purulent sputum production, and dyspnoea; possible history of prior pulmonary infections or viral pneumonias in childhood
