Eval of Dyspnea (Final) Flashcards
What is dyspnea?
A subjective sensation of shortness of breath or breathing discomfort
Chronic dyspnea = symptoms greater than ___
1 month
The underlying cause of dyspnea is NOT directly related to?
duration or severity!
How might a patient describe the sensation of dyspnea?
Varies widely from “I can’t catch my breath” to “chest tightness”
Dyspnea accounts for what percentage of all FP visits?
4%
At what ages does dyspnea most commonly occur?
Pediatrics and Ages 55-69
(bell shaped presentation)
What type of disorder will a large percentage of dyspneic patients already have diagnosed?
Cardiopulmonary disorder - which accounts for the dyspnea
*REMEMBER, patients can have more than one issue!
Approximately 2/3rds of dyspnea cases are caused by what two disorders?
Pulmonary or Cardiac
Of the 2/3rds of dyspnea cases caused by pulmonary or cardiac disorders, 85% of them have what conditions?
- Asthma
- CHF
- COPD
- PNA
- Cardiac ischemia
- Interstitial lung disease
1/3 of dyspnea causes have nothing to do with the heart and lungs, and include what conditions?
- Metabolic (DKA)
- Deconditioning
- Anemia
- Psychogenic
What should be on your DDX for cardiac causes of chronic dyspnea?
- CHF
- CAD
- Cardiac arrhythmias
- Pericardial dz
- Valvular heart dz
What should be on your DDX for pulmonary causes of chronic dyspnea?
- COPD
- Asthma
- Interstitial lung dz
- Pleural effusion
- Malignancy
- Bronchiectasis
What fraction of patients will have another complaint other than dyspnea?
2/3rds
Patients with dyspnea often complain of what other symptoms?
- Cough 17%
- CP 5%
- Fatigue 3.5%
- Out of medication 3.2%
- Wheezing 2.5%
- Peripheral edema 2%
The cause of dyspnea is ___ in 1/3 of patients
Multifactoral (Jaynstein’s favorite word ever)
*ie COPD with concurrent URI
The diagnoses of dyspnea can be made in ___ of all patients with ___ alone!
The diagnoses of dyspnea can be made in half of all patients with history alone!
A patient with a h/o smoking is more likely to have lung or cardiac disease?
Lung
A patient with a h/o HTN, CAD, obesity, valve disorder is more likely to have lung or cardiac disease?
Cardiac
A patient with a slower onset of symptoms is more likely to have lung or cardiac disease?
Lung
A patient with a more rapid onset of symptoms is more likely to have lung or cardiac disease?
Cardiac
A patient with dyspnea at rest is more likely to have lung or cardiac disease?
Lung
A patient with dyspnea with exertion is more likely to have lung or cardiac disease?
Cardiac
A patient with a productive cough is more likely to have lung or cardiac disease?
Lung
A true cough is rare in lung or cardiac disease?
Cardiac
What is on the top of your DDX for a patient who presents with increased work of breathing, feeling of suffocation, and air hunger?
COPD
What dyspnea symptoms would a patient with CHF commonly present with?
- Rapid breathing
- Feeling of suffocation
- Air hunger
What dyspnea symptoms would a patient with interstitial lung dz commonly present with?
Increased work of breathing
What dyspnea symptoms would a patient with Asthma commonly present with?
- Incomplete exhalation
- Shallow breathing
- Increased work of breathing
- Chest tightness
- Heavy breathing
What dyspnea symptoms would a patient with neuromuscular and chest wall disease commonly present with?
- Shallow breathing
- Increased work of breathing
What dyspnea symptoms would a patient with pregnancy commonly present with?
Air hunger
What dyspnea symptoms would a patient with pulmonary vascular disease commonly present with?
Incomplete exhalation
What dyspnea symptoms should alert you to send your patient to the ED immediately?
- Acute respiratory distress
- (CP)
- (Hypoxic)
What are signs that your patient is in acute respiratory distress?
- Labored breathing
- Cyanotic (fingertips)
- Word dyspnea
What are you determining when performing a PE on a dyspneic patient?
Sick vs not sick
- Vital signs!
- Obtain objective info to evaluate subjective complaints
What symptoms are highly correlated with COPD according to LRs?
- Wheezing - LR +15
- Smoking - LR +8
- Rhonchi - LR +8
- Hyperresonance to percussion - LR +5.3
- Forced expiratory time > 9 secs - LR +4.8
A LR of 10 is good but anything around what number is considered helpful in medicine?
5
What is the diagnostic test of choice for COPD
PFTs
What is the earliest symptom for CHF
DOE
What is the more specific symptom for CHF
Paroxysmal nocturnal dyspnea (PND)
What symptoms are highly correlated with CHF according to LRs?
- S3 Gallop - LR +24
- Displaced PMI - LR +16.5
- JVD - LR +8.5
A S3 gallop is heard so what is at the top of your DDX?
CHF until proven otherwise
The finding of a S3 gallop, displaced PMI, or JVD in a patient who presents with dyspnea increases the likelihood of CHF as the dx by what percentage?
80%!!!
What do we need to remember about asthma patients?
- Get a good History and do a PE (unless acutely wheezing)
- Asthma patients return to 100% normal baseline between episodes
What symptoms would a patient with interstitial lung disease present with?
- Slow progression of exertional dyspnea
- Persistent inspiratory crackles - in 80%
- Clubbing 25-50%
A patient presents with inspiratory crackles and you have them cough. You listen again and crackles are no longer present. This indicates what type of condition?
An underlying infectious cause NOT interstitial lung disease
On PE a normal SaO2 implies a ___ disorder
Mild - such as exercise-induced bronchospasm
On PE an abnormal SaO2 with exertion implies a ___ cardiopulmonary disease
mild to moderate
On PE an abnormal SaO2 at rest implies a ___ cardiopulmonary disease
moderate to severe
What must you always remember to do during your PE of a dyspneic patient?
GET A WALKING O2!
*SpO2 correlates with severity of illness
Patients who present with dyspnea as a primary complaint are more likely to get an EKG than lung function testing. What’s wrong with this?
We need to change this because lung function results are what pave the way for the rest of your work up!
If a patient presents with dyspnea and their lung function tests are normal what does this indicate?
The patient is very unlikely to have a significant cardiopulmonary disease with the expectation of asthma
What PFT results are diagnostic of obstructive lung disease
- FEV1 < 80%
- FEV1/FVC < 70%
What PFT results are diagnostic of restrictive lung disease?
FEV1 < 80%
FEV1/FVC > 70%
What lung diseases are obstructive?
- COPD
- Asthma
- Bronchiectasis
*cannot get air OUT
What lung diseases are restrictive?
- Interstitial lung disease
- Pulmonary fibrosis
- Obesity
- Autoimmune diseases (sarcoidosis)
- Pleural effusion and heart failure
*cannot get air IN
Obtaining an EKG in the evaluation of dyspnea is indicated for what conditions?
- Cardiac ischemia or infarction
- Ventricular hypertrophy
- Pericardial disease (effusion)
Obtaining a CXR in the evaluation of dyspnea is indicated for what conditions?
- Chest wall abnormalities
- Hyperinflation
- CM or pleural effusions
- Mass/Mets
- PNA
When would you want to obtain a CTA PE?
Evaluation of vascular issues
High res CT chest imaging is reserved for?
- When you have no idea what’s causing the patients dyspnea
- interstitial lung disease, bronchiectasis, PE
- A lot of radiation exposure so talk to a radiologist first!
Ordering a CBC in the evaluation of dyspnea is indicated for what conditions?
- Anemia
- Infection (careful in non sick)
- COPD (polycythemia)
Ordering a BMP in the evaluation of dyspnea is indicated for what conditions?
- Acid-Base disturbance
- Elevated bicarb - Metabolic alkalosis
- COPD, interstitial lung dz, neuromuscular disorders
- Metabolic acidosis
- DKA
- Elevated bicarb - Metabolic alkalosis
What cardiac tests may you want in the evaluation of dyspnea?
- Troponin
- BNP
- Echo (structural or functional issues)
What diagnostic test is the most specific for the evaluation of CHF?
BNP!
BNP >100 is 82% sensitive, 99% specific for CHF
The magnitude of elevation of BNP is ___ to the severity of heart failure
proportional
What type of afib can cause dyspnea?
Paroxysmal
What is your diagnostic test of choice in evaluation of paroxysmal afib?
Holter Monitor
Ordering a lung biopsy in the evaluation of dyspnea is indicated for what conditions?
- Interstitial lung disease
- Malignancy
In patients who have a diagnosed cardiopulmonary disorder who have chronic dyspnea despite maximal therapy, you should STRONGLY consider the presence of a ___
Cofactor such as
- Obesity
- Deconditioning
- Emotional response to illness
When do you refer a patient with dyspnea?
- Underlying cause of dyspnea is unclear
- Sxs disproportionate to the apparent severity of the disease
- For lung biopsy
- Patient not adequately responding to tx
*make sure you get a PFT prior to sending
