General on Dyspnea

Question 1

Dyspnea

Answer 1

a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity

Question 2

Chronic vs. Acute dysnea

Answer 2

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.

Question 3

Orthopnea

Answer 3

Dyspnea when lying down flat, which occurs with congestive heart failure “CHF” due to buildup of pulmonary edema fluid on the lungs

Question 4

One sign of orthopnea is folks propping themselves up to sleep. What are other things that will cause a patient to do this?

Answer 4

Keep in mind that gastroesophageal reflux disease (GERD) or post-nasal drip (PND) from allergies can also make people have to sleep upright

Question 5

Explain PND and its association with CHF

Answer 5

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

Question 6

Besides CHF, what else can cause PND?

Answer 6

Obstructive sleep apnea (OSA), GERD, asthma or even vivid nightmares associated with post-traumatic stress disorder (PTSD) can also cause these episodes

Question 7

What is Platypnea and in whom do we see it

Answer 7

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

Question 8

What makes BNP and why is it made?

Answer 8

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.

Question 9

A BNP level of <100 pg/mL makes congestive heart failure _____.

Answer 9

Unlikely. This is a low level

Question 10

Besides CHF, what else raises BNP levels?

Answer 10

Values can be raised with congestive heart failure (CHF) but also pulmonary embolism and renal failure

Question 11

What is VCD and what is it often confused with?

Answer 11

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).

Question 12

Diagnosing VCD

Answer 12

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

Question 13

Treating VCD and other diagnoses that can be similar

Answer 13

Treatment is speech therapy as well as addressing any underlying triggers such as allergies, GERD, psychological stressors.

Question 14

Describe Deconditioning

Answer 14

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”.

Question 15

ADLs

Answer 15

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.

Question 16

This breathing pattern is associated with CHF and pulmonary valvular disease

Answer 16

Rapid breathing

Question 17

This breathing pattern is associated with Asthma

Answer 17

Incomplete exhalation, heavy breathing, chest tightness

Question 18

This breathing pattern is associated with asthma, neuromuscular or chest wall disease

Answer 18

shallow breathing

Question 19

This breathing pattern is associated with COPD, interstitial lung disease, asthma, neuromuscular issues

Answer 19

Increased work or effort

Question 20

This breathing pattern is associated with COPD and CHF

Answer 20

Feeling of suffocation

Question 21

This breathing pattern is associated with COPD, CHF, and pregnancy

Answer 21

Air hunger

Question 22

Patients with vocal cord dysfunction (VCD) may describe a _____ sensation and/or trouble with _____________.

Answer 22

Patients with vocal cord dysfunction (VCD) may describe a choking sensation and/or trouble getting air in

Question 23

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.

Answer 23

CHF

Question 24

Possible history details with someone who has CHF

Answer 24

Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, lower extremity swelling

Question 25

Auscultation of CHF

Answer 25

murmurs or a “gallop” on cardiac auscultation (a third (S3) or fourth (S4) heart sound)

Question 26

Leading cause of death in the U.S.

Answer 26

Acute coronary syndrome

Question 27

History complaints for Acute Coronary Syndrome

Answer 27

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

Question 28

How can nephrotic syndrome lead to a PE?

Answer 28

patient’s lose their anti-clotting proteins in the urine

Question 29

Common history complaints for pulmonary embolism

Answer 29

Sudden onset of SOB, syncope, pleuritic chest pain (pain worse with inspiration or coughing). May have fever. May have hemoptysis

Question 30

What side of the heart could be affected with a PE and what might we hear on heart sounds?

Answer 30

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

Question 31

Describe palpable cord

Answer 31

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

Question 32

Homan’s sign is an archaic way of checking for a PE. Discuss it

Answer 32

“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

Question 33

There is one ocaasional finding and two rare findings on CXR associated with PE. Discuss them

Answer 33

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.

Question 34

Usefulness of a D-Dimer?

Answer 34

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)