General on Dyspnea Flashcards
Dyspnea
a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity
Chronic vs. Acute dysnea
Chronic dyspnea: Dyspnea that has been going on for more than one month. This is important, since acute dyspnea (less than one month) may be more likely to be imminently life threatening—for example with acute coronary syndrome or pulmonary embolism.
Orthopnea
Dyspnea when lying down flat, which occurs with congestive heart failure “CHF” due to buildup of pulmonary edema fluid on the lungs
One sign of orthopnea is folks propping themselves up to sleep. What are other things that will cause a patient to do this?
Keep in mind that gastroesophageal reflux disease (GERD) or post-nasal drip (PND) from allergies can also make people have to sleep upright
Explain PND and its association with CHF
awakening at night suddenly due to short of breath. This is a more “specific” finding with CHF, meaning not everyone with CHF has it, but if a patient does have it, then it strongly suggests CHF
Besides CHF, what else can cause PND?
Obstructive sleep apnea (OSA), GERD, asthma or even vivid nightmares associated with post-traumatic stress disorder (PTSD) can also cause these episodes
What is Platypnea and in whom do we see it
Dyspnea that worsens in the upright position (the opposite of orthopnea) may be related to “orthodeoxia” = a drop in arterial pO2 in the upright position associated with arteriovenous malformations or other right to left shunts and can be seen with advanced liver disease
What makes BNP and why is it made?
BNP: Brain (or “B-type”) natriuretic peptide is a neuro-hormone synthesized by the myocytes (muscle cells) of the ventricles in response to pressure or volume overload and can be measured in the blood.
A BNP level of <100 pg/mL makes congestive heart failure _____.
Unlikely. This is a low level
Besides CHF, what else raises BNP levels?
Values can be raised with congestive heart failure (CHF) but also pulmonary embolism and renal failure
What is VCD and what is it often confused with?
Vocal cord dysfunction (VCD): A condition in which the vocal cords close upon inspiration, in response to stress or other irritants, and can cause shortness of breath and wheezing. It may be mistaken for asthma or co-exist with asthma (perhaps 30% of the time).
Diagnosing VCD
Diagnosis is suggested by the flow-volume loop chart made when a patient has pulmonary function tests done or by examining the vocal cords with a laryngoscope when they are having symptoms
Treating VCD and other diagnoses that can be similar
Treatment is speech therapy as well as addressing any underlying triggers such as allergies, GERD, psychological stressors.
Describe Deconditioning
Patients may have dyspnea because of sedentary lifestyle and weight gain. This is common but you must consider other causes since deconditioning is a “diagnosis of exclusion”.
ADLs
ADLs: Activities of Daily Living, such as getting dressed or preparing meals. Sometimes dyspnea— or any disability– can be so severe as to impact these.
This breathing pattern is associated with CHF and pulmonary valvular disease
Rapid breathing
This breathing pattern is associated with Asthma
Incomplete exhalation, heavy breathing, chest tightness
This breathing pattern is associated with asthma, neuromuscular or chest wall disease
shallow breathing
This breathing pattern is associated with COPD, interstitial lung disease, asthma, neuromuscular issues
Increased work or effort
This breathing pattern is associated with COPD and CHF
Feeling of suffocation
This breathing pattern is associated with COPD, CHF, and pregnancy
Air hunger
Patients with vocal cord dysfunction (VCD) may describe a _____ sensation and/or trouble with _____________.
Patients with vocal cord dysfunction (VCD) may describe a choking sensation and/or trouble getting air in
One of the most common causes of dyspnea. 1.2% of the population has it and 80% of them are more than 65 years old. Risk factors include hypertension, coronary artery disease and smoking.
CHF
Possible history details with someone who has CHF
Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, lower extremity swelling
Auscultation of CHF
murmurs or a “gallop” on cardiac auscultation (a third (S3) or fourth (S4) heart sound)
Leading cause of death in the U.S.
Acute coronary syndrome
History complaints for Acute Coronary Syndrome
Radiating chest pressure or pain, diaphoresis (sweating), and, of course, shortness of breath (SOB). SOB may precede chest discomfort or occur in absence of classic angina pectoris
How can nephrotic syndrome lead to a PE?
patient’s lose their anti-clotting proteins in the urine
Common history complaints for pulmonary embolism
Sudden onset of SOB, syncope, pleuritic chest pain (pain worse with inspiration or coughing). May have fever. May have hemoptysis
What side of the heart could be affected with a PE and what might we hear on heart sounds?
May have signs of right heart failure (pumping against the clot in the pulmonary arteries) to include distended neck veins and edema, a right sided S4 sound or increased pulmonic component to the S2
Describe palpable cord
With a PE, check for signs of associated deep venous thrombosis to include edema, warmth, swelling and a “palpable cord” (which is the clotted vein) in the leg
Homan’s sign is an archaic way of checking for a PE. Discuss it
“Homan’s sign” is of historical interest, and is pain in the leg when the foot is dorsiflexed, but it is not an accurate test
There is one ocaasional finding and two rare findings on CXR associated with PE. Discuss them
Can show atelectasis (subtle decrease in lung size), effusions, infiltrates, and “classically” but only very rarely a “Westermark’s sign” which is a loss of pulmonary vasculature markings due to the “oligemia” or low blood flow beyond the clot, or “Hamptom’s hump” which is a wedge or triangular shaped opacity (white area) that may look like a pneumonia and is due to an infarction or damage to the edge of the lung from decreased blood flow due to the clot.
Usefulness of a D-Dimer?
D-dimer is a blood test that is usually elevated in patients with blood clots (but can be abnormal for other reasons like recent surgery or cancer, too)
