Evaluating Patients with Dyspnea

Question 1

how is tachypnea defined?

Answer 1

RR > 20

Question 2

in what kind of acid-base disturbance can a patient be observed to be breathing rapidly but may NOT feel short of breath?

Answer 2

metabolic acidosis - increased ventilation as a compensatory mechanism

Question 3

what are the ABC’s of evaluating a patient with dyspnea?

Answer 3

Airway - obstruction?

Breathing - can patient speak full sentences?

Circulation

Question 4

name a pulmonary cause of dyspnea for each category:
a. airway
b. parenchyma
c. vascular
d. pleura

Answer 4

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

Question 5

how can anemia be a cause of dyspnea?

Answer 5

not enough hemoglobin to transport sufficient oxygen

Question 6

where does pleuritic chest pain come from?

Answer 6

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

Question 7

what are the clinical features (symptoms) of pleural inflammation that can differentiate it from cardiac chest pain?

Answer 7

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

Question 8

at what point does a chronic cough typically necessitate further investigation? (when cough is only presenting symptom)

Answer 8

chronic cough of 8 weeks or more

Question 9

what are the 3 phases of the cough reflex?

Answer 9

1. inspiratory phase
2. closure of glottis and diaphragmatic relaxation
3. rapid contraction of expiratory muscles, causing a rise in intra-abdominal and intra-pleural pressures, followed by opening of the glottis

Question 10

what is the most common etiology of acute (<3 weeks) vs subacute (3-8 weeks) vs chronic (>8 weeks) cough?

Answer 10

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

Question 11

hemoptysis

Answer 11

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

Question 12

what are the 3 B’s of hemoptysis that is tracheobronchial in origin?

Answer 12

1. Bronchitis
2. Bronchogenic carcinoma
3. Bronchiectasis (inflammation of airways, e.g. cystic fibrosis)

[hemoptysis = coughing up blood]

Question 13

what does strider indicate?

Answer 13

upper airway obstruction

high-pitched musical sound, intense and heard without stethoscope

more clearly heard during inspiration, most prominent over neck

Question 14

hyperpnea

Answer 14

increased tidal volume, often associated with increased respiratory rate

seen with acidosis

Question 15

Kussmaul’s vs Cheyne-Stokes respiration?

Answer 15

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)

Question 16

what pattern of abnormal breathing is associated with congestive heart failure?

Answer 16

Cheyne-Stokes: constant rate with variable depth and apneic periods

Question 17

what extra accessory muscle for breathing is activated when patients stand/sit in a tripod position (hands on knees)?

Answer 17

pectoralis major - helps lift chest

Question 18

what does prolonged exhalation indicate?

Answer 18

usually inspiration is longer/louder than expiration

prolonged expiration indicates obstruction - emphysema, asthma

Question 19

what does purse-lip exhalation indicate? what is the effect of breathing like this?

Answer 19

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

Question 20

what does paradoxical breathing indicate?

Answer 20

normally, diaphragm descends with inspiration

paradoxical breathing: diaphragm RISES with inspiration, due to respiratory fatigue or diaphragmatic weakness

Question 21

match:
barrel chest or kyphosis
with
restrictive or obstructive lung disease

Answer 21

barrel chest - obstructive (hyperinflation)

kyphosis (sharp curve of spine) - restrictive

Question 22

what does finger clubbing represent?

Answer 22

capillaries in nail bed expand due to angiogenesis, responding to low oxygen tensions in the blood

Question 23

why is cyanosis difficult to detect in patients with severe anemia?

Answer 23

there is not enough hemoglobin

need 5gm/dL of reduced hemoglobin for cyanosis to be detected - need a fixed amount of hemoglobin

Question 24

which will be a stronger indication of hypoxemia, central or peripheral cyanosis?

Answer 24

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

Question 25

what would increased tactile fremitus indicate?

Answer 25

consolidation of lung parenchyma, as with pneumonia (increased tissue density)

*only asymmetric tactile fremitus is a pathological finding

Question 26

how will obesity and bronchial obstruction affect tactile fremitus?

Answer 26

anything that separates the lung from the chest wall will decrease tactile fremitus

effusion, obesity, etc

Question 27

which of these would cause hyper-resonance upon posterior chest percussion?
a. consolidation
b. air-trapping
c. atelectasis
d. pleural effusion

Answer 27

air-trapping

others cause dullness

Question 28

how does the rhythm of breathing vary between tracheal, bronchial, bronchovesicular, and vesicular breath sounds?

Answer 28

tracheal (outside of chest): inspiration = expiration

bronchial (manubrium): inspiration &laquo_space;expiration

bronchovesicular (within lung): inspiration = expiration

vesicular (lung bases, peripheral fields): inspiration&raquo_space;> expiration

*these are all normal lung sounds as long as they are heard in the correct locations!

Question 29

vesicular vs bronchial breath sounds

Answer 29

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

Question 30

you are auscultating your patient’s lungs when you notice bronchial breath sounds over the lung periphery - what does this indicate?

Answer 30

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

Question 31

what is wheezing associated with? when is it heard and how does it sound?

Answer 31

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)

Question 32

what are rhonchi associated with?

Answer 32

rhonchi: low-pitched version of wheeze that sounds like snoring, can clear with coughing

associated with rupture of fluid films/ abnormal airway collapse

Question 33

what are fine vs coarse crackles caused by?

Answer 33

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

Question 34

differentiate the clinical characteristics of fine vs coarse crackles on lung auscultation (how do they differ in sound and timing)?

Answer 34

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)

Question 35

what egophony change is noted with lung consolidation?

Answer 35

“eee” to “aaa” change

whispered sounds are also heard clearly and distinctly (“99”)

Question 36

how do the following affect breath sounds, tactile fremitus, and percussion?
a. consolidation
b. pleural effusion
c. pneumothorax
d. atelectasis

Answer 36

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

Question 37

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

Answer 37

c. consolidation: bronchial breath sounds (in periphery, rather than vesicular), increased tactile fremitus, dullness on percussion (rather than resonance)

Question 38

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

Answer 38

e. pneumothorax: deceased breath sounds, decreased tactile fremitus, hyper-resonance on percussion