Evaluating Patients with Dyspnea Flashcards
how is tachypnea defined?
RR > 20
in what kind of acid-base disturbance can a patient be observed to be breathing rapidly but may NOT feel short of breath?
metabolic acidosis - increased ventilation as a compensatory mechanism
what are the ABC’s of evaluating a patient with dyspnea?
Airway - obstruction?
Breathing - can patient speak full sentences?
Circulation
name a pulmonary cause of dyspnea for each category:
a. airway
b. parenchyma
c. vascular
d. pleura
a. airway: asthma, bronchiectasis, COPD, foreign body, anaphylaxis
b. parenchyma: interstitial lung disease (fibrosis), acute lung injury (ARDS), pneumonia
c. vascular: pulmonary embolism, pulmonary artery HTN
d. pleura: pleural effusion, pneumothorax
how can anemia be a cause of dyspnea?
not enough hemoglobin to transport sufficient oxygen
where does pleuritic chest pain come from?
lung parenchyma and visceral pleura do not have pain fibers
pleuritis is chest pain caused by inflammation of the parietal pleura - receives systemic circulation and has somatic nerve fibers, pain afferents go to intercostal and phrenic nerves
what are the clinical features (symptoms) of pleural inflammation that can differentiate it from cardiac chest pain?
sharp, severe pain that is well localized and can be lateral (one lung vs other)
worse with breathing, coughing, laughing, any chest wall movement
improves with shallow breathing and limiting movement
*recall pleuritic chest pain signals originate from parietal pleura, as there are no pain fibers in lung parenchyma or visceral pleura
at what point does a chronic cough typically necessitate further investigation? (when cough is only presenting symptom)
chronic cough of 8 weeks or more
what are the 3 phases of the cough reflex?
- inspiratory phase
- closure of glottis and diaphragmatic relaxation
- rapid contraction of expiratory muscles, causing a rise in intra-abdominal and intra-pleural pressures, followed by opening of the glottis
what is the most common etiology of acute (<3 weeks) vs subacute (3-8 weeks) vs chronic (>8 weeks) cough?
acute: most often viral URI
subacute: often post-infectious origin, secondary to asthma or bacterial sinusitis
chronic: post nasal drip (upper airway cough syndrome), asthma, GERD
hemoptysis
coughing or spitting up blood derived from lungs or bronchial tubes, secondary to pulmonary or bronchial hemorrhage
bronchial artery hemorrhage (90%) is worse because it is at systemic pressure, while pulmonary arteries are at much lower pressure
what are the 3 B’s of hemoptysis that is tracheobronchial in origin?
- Bronchitis
- Bronchogenic carcinoma
- Bronchiectasis (inflammation of airways, e.g. cystic fibrosis)
[hemoptysis = coughing up blood]
what does strider indicate?
upper airway obstruction
high-pitched musical sound, intense and heard without stethoscope
more clearly heard during inspiration, most prominent over neck
hyperpnea
increased tidal volume, often associated with increased respiratory rate
seen with acidosis
Kussmaul’s vs Cheyne-Stokes respiration?
Kussmaul: increased rate and depth of inspiration
Cheyne-Stokes: constant rate with variable depth and apneic periods (neurological disorders, congestive heart failure, high altitude, normal aging)
what pattern of abnormal breathing is associated with congestive heart failure?
Cheyne-Stokes: constant rate with variable depth and apneic periods
what extra accessory muscle for breathing is activated when patients stand/sit in a tripod position (hands on knees)?
pectoralis major - helps lift chest
what does prolonged exhalation indicate?
usually inspiration is longer/louder than expiration
prolonged expiration indicates obstruction - emphysema, asthma
what does purse-lip exhalation indicate? what is the effect of breathing like this?
purse-lip exhalation maintains positive airway pressure during expiration - helps to improve gas transfer (increase arterial O2, decreases CO2)
present with obstructive lung disease - emphysema, asthma
what does paradoxical breathing indicate?
normally, diaphragm descends with inspiration
paradoxical breathing: diaphragm RISES with inspiration, due to respiratory fatigue or diaphragmatic weakness
match:
barrel chest or kyphosis
with
restrictive or obstructive lung disease
barrel chest - obstructive (hyperinflation)
kyphosis (sharp curve of spine) - restrictive
what does finger clubbing represent?
capillaries in nail bed expand due to angiogenesis, responding to low oxygen tensions in the blood
why is cyanosis difficult to detect in patients with severe anemia?
there is not enough hemoglobin
need 5gm/dL of reduced hemoglobin for cyanosis to be detected - need a fixed amount of hemoglobin
which will be a stronger indication of hypoxemia, central or peripheral cyanosis?
finding of central cyanosis increases probability of hypoxemia (face, tongue, mucous membranes)
peripheral cyanosis can be due to peripheral vasoconstriction or stasis of blood in extremities
what would increased tactile fremitus indicate?
consolidation of lung parenchyma, as with pneumonia (increased tissue density)
*only asymmetric tactile fremitus is a pathological finding
how will obesity and bronchial obstruction affect tactile fremitus?
anything that separates the lung from the chest wall will decrease tactile fremitus
effusion, obesity, etc
which of these would cause hyper-resonance upon posterior chest percussion?
a. consolidation
b. air-trapping
c. atelectasis
d. pleural effusion
air-trapping
others cause dullness
how does the rhythm of breathing vary between tracheal, bronchial, bronchovesicular, and vesicular breath sounds?
tracheal (outside of chest): inspiration = expiration
bronchial (manubrium): inspiration «_space;expiration
bronchovesicular (within lung): inspiration = expiration
vesicular (lung bases, peripheral fields): inspiration»_space;> expiration
*these are all normal lung sounds as long as they are heard in the correct locations!
vesicular vs bronchial breath sounds
vesicular: inspiration longer/stronger than expiration (2:1), normal finding in lung periphery
bronchial: expiration longer/stronger than inspiration (1:2) with pause between, harsh like Darth Vader, normal finding in trachea
you are auscultating your patient’s lungs when you notice bronchial breath sounds over the lung periphery - what does this indicate?
bronchial breath sounds are harsh and have longer expiration and are normally heard around trachea; vesicular breath sounds have longer inspiration and are heard in lung periphery
bronchial breath sounds over lung periphery is associated with consolidation —> indicates pneumonia
what is wheezing associated with? when is it heard and how does it sound?
obstructive disease, heard all over chest or localized
always associated with airflow limitation (but may be absent with severe obstruction)
long, continuous, musical sound, most often expiratory (airways get smaller)
what are rhonchi associated with?
rhonchi: low-pitched version of wheeze that sounds like snoring, can clear with coughing
associated with rupture of fluid films/ abnormal airway collapse
what are fine vs coarse crackles caused by?
crackles = rales: discontinuous sounds caused by opening of collapsed distal airways/alveoli (sound like velcro)
fine: interstitial lung disease, pneumonia, CHF
coarse: intermittent airway opening, may be related to secretions, associated with fluid in larger bronchi
differentiate the clinical characteristics of fine vs coarse crackles on lung auscultation (how do they differ in sound and timing)?
fine: sounds like velcro, mid-to-late inspiration, unaffected by cough
(interstitial lung disease)
coarse: short/explosive, early inspiration/throughout expiration, affected by cough
(intermittent airway opening, fluid)
what egophony change is noted with lung consolidation?
“eee” to “aaa” change
whispered sounds are also heard clearly and distinctly (“99”)
how do the following affect breath sounds, tactile fremitus, and percussion?
a. consolidation
b. pleural effusion
c. pneumothorax
d. atelectasis
a. consolidation: bronchial breath sounds, increased fremitus, dullness on percussion
b. pleural effusion: decreased breath sounds, decreased fremitus, dullness
c. pneumothorax: decreased breath sounds, decreased fremitus, hyper-resonance on percussion
d. atelectasis: decreased breath sounds, decreased fremitus, dullness
on physical exam, you note bronchial breath sounds and increased tactile fremitus. which of the following is most likely?
a. pleural effusion
b. atelectasis
c. consolidation
d. normal lung
e. pneumothorax
c. consolidation: bronchial breath sounds (in periphery, rather than vesicular), increased tactile fremitus, dullness on percussion (rather than resonance)
on physical exam, you note hyper-resonance on percussion. which of the following is most likely?
a. pleural effusion
b. atelectasis
c. consolidation
d. normal lung
e. pneumothorax
e. pneumothorax: deceased breath sounds, decreased tactile fremitus, hyper-resonance on percussion
