Shortness of Breath Flashcards
What are the 4 major reasons for SOB?
- Insufficient O2 into lungs
- Insufficient O2 in blood
- Insufficient O2 getting around the body
- Increased respiratory drive
Why might there be not enough oxygen in lungs?
- Obstructed airways
- Decreased lung volume
- Decreased volume of functioning lung
- Inability to inflate lungs
What conditions give obstructed airways?
- Asthma
- COPD
- Obstruction tumour
- Airway oedema in anaphylaxis
What are the intrathoracic causes of not enough O2 into lungs?
- pneumothroax
2. pleural effusion
What are the extrathoracic causes of not enough O2 into lungs?
kyphoscolisosis
What would cause decreased volume of functioning lung?
- bullous/cystic disease
2. scarred or fibrosed lung in intersitital lung disease
When would your lungs have an inability to inflate lungs due to increased work to do?
- Obesity
2. ILD
When would your lungs have an inability to inflate lungs due weak resp muscles?
- GB
- Myasthenia gravis
When would your lungs have an inability to inflate lungs due to the, being already hyperinflated?
COPD
What would cause not enough O2 to get into blood?
- Damage alveolar membrane
- Fluid between alveolar wall and capillary
- Disrupted blood supply
What conditions would cause damage to alveolar membrane?
- emphysema
- fibrosis (ILD)
What conditions would cause fluid between the alveolar wall and capillary?
- oedema e.g. heart failure
- inflammatory e.g. pneumonia
What would cause disrupted blood supply?
PE
What would cause not enough O2 getting around the body?
- Reduced cardiac output
- Anaemia
- Shock
What would cause reduced cardiac output?
- heart failure
- aortic stenosis
- physical deconditioning
What would cause increased resp drive?
- hysterical hyperventilation
2. acidamia
What could be a cause of acidaemia?
diabetic ketoacidosis
What would you suspect if the SOB came on suddenly?
- PE
- Pneumothroax
- Foreign body
What SOB would present in months and years?
- lung cancer
2. pulmonary fibrosis
What conditions would have worse SOB when lying flat?
hear failure
What conditions would have worse SOB at certain times of year, place, early morning, exercise?
asthma
What condition of SOB is worse when stress?
psychogenic hyperventilation
What risk factors do you look for in SOB?
- smoking: 20 cig a day for a year = 1 pack year
- Pets
- Occupational history
- Medication
- Past MHx
Why do you check for occupational history?
pneumoconioses
Which drugs do you check for and why?
can cause hypersensitivity pneumonitis:
- nitrodurantonin
- amiodarone
- methotrexate
- bleomycin
What PMHx do you check and why?
SLE and RA can cause ILD and pleural effusions
What associated symptoms do you ask about with SOB?
- Cough
- Chest pain
- Muscular weakness or fatigue
- Tender limbs
- Weight loss
- Loss of blood
What questions do you ask about cough?
- Productive?
- Colour?
- Blood?
- When happen?
- What sound?
What would a persistent, productive cough over last few days suggest?
pneumonia
What would persistent, productive cough most days of the past 3 months + spanning years?
chronic bronchitis
What would dry cough mainly during SOB or at night suggest?
- Asthma
2. Left ventirclar failure
What would blood stained sputum suggest?
- PE
- lung cancer
- cabitating pneumonia
What does croup sound like (children)?
barking seal
What produces a bovine cough?
recurrent laryngeal nerve pals
What would plueritic chest pain suggest with SOB?
- Pneumonia
- PE
- Pneumothorax
What would non-plueritic chest pain indicate with SOB?
CV pathology
What neuromusclar conditions do you think of with SOB and muscular weakness or fatigue?
- GB
- myasthenia gravis
- LE syndrome
- polymyositis
- MND
What would tender limbs with SOB suggest?
PE from DVT - swollen, red, tender warm shiny looking limb
What would weight loss, loss of appetite and night sweat suggest with SOB?
highly metabolic, systemic inflammatory process going on (often cancer)
Why do you ask about loss of blood with SOB?
anaemia can exacerbate shortness of breath so ask heavy menstraul bleeding, fresh rectal bleeding, and melaene
What SOB conditions present in seconds to minutes?
- Bronchospasm (acute asthma or COPD)
- Anaphylaxis
- Laryngeal oedema (secondary to burns or chemical irritation)
- PE
- Pneumothorax
- Flash pulmonary oedema
- Hysterical hyperventilation
- Inhaled foreign body
- Tension pneuomothorax
- Acute epiglottitis/supraglottitis
What SOB conditions present in hours to days?
- Pneumonia
- Heart Failure
- Pleural effusion
- Post-operative atelectasis
- Chronic pulmonary emboli
- Altitude sickness
- GB syndrome
- Myasthenia gravis
- ARDS
- Lung collapse
What SOB conditions present in weeks to months?
- COPD
- Chronic asthma
- Heart failure
- Pulmonary fibrosis
- Anaemia
- Bronchiectasis
- Physcial deconditioning
- Obesity
- Pulmonary hypertension
- Mesothelioma
- Pulmonary TB
- Kyphoscoliosis
- Ankylosing spondylitis
- MND
What does COPD encompass?
chronic bronchitis and emphysema
What would history of chronic bronchitis be like?
productive cough of most days of 3 months for 2 consecutive years) and permanent, largely irreversible SOB
What are risk factors for COPD?
- Smoking (usually more than 20 pack years)
- Occupational exposure to lung irritants e.g. coal miners, tunnel workers
- Alpha 1 antitrypsin deficency (liver failurem) family hisotry
What are the signs on examination of COPD?
- Hyperexpanded chest
- Breathing through pursed lips
- Reduced air entry/chest expansion
- Prolonged expiratory phrase
- Hyper-resonant percussion note
What is the history of asthma like?
- wheeze, breathlessness
- chest tightness and/or cough
- often worse at night.early morning
- during exercise or when exposed to allergens or cold
What associated atopic conditions are there with asthma?
eczema, hayfever, allergies, nasal polyps
What drugs can exacerbate the symptoms of asthma?
- NSAIDs
- Beta blockers
- Aspirin
What is heard on auscultation of the lungs in asthma
wheeeeeze
What would the history be like for someone with ILD?
- exposure to asbestos, silica or coal (pneumoconioses causing ILD)
- exposure to drugs (e.g. methotrexate, amiodarone)
What are the signs of ILD on exmaination?
- Clubbing (in usual interstitial pneumonitis)
- Reduced air entry/chest expansion
- Late inspiratory fine crackles (heard at bases or apices)
What would the history of someone with heart failure be like?
- shortness of breath on exertion
- orthopnoea (breathless when lying flat)
- paroxysmal nocturnal dyspnoea (waking up short of breath)
- swollen ankles (if right and left heart failure)
What are the risk factors for heart failure?
- Ischaemic heart disease (smoking, DM, hypertension, hypercholesteroleamia, south asian descent, strong family history)
- Other atherosclerotic disease (e.g. stroke, TIA, limb claudication)
- Hypertension (can cause heart failure in the absence of isachaemic heart disease)
- Valvular disease (e.g. aortic stenosis)
- Cardiomyopathy
What are the signs found on examination for someone with heart failure?
- Displaced apex beat
- 3rd and 4th heart sounds
- crackles in both lung bases
- Raised JVP
- Hepatomegaly
- Peripheral oedema (ankles, sacrum)
What is the history of someone with anaemia like?
- bleeding (e.g. menorrhagia, melaena)
- SOB on exertion
- fatigue
What signs would you find for someone with anaemia?
- Signs of peripheral or central cyanosis
- Koilonychia
- glositism anuglar stomstitis
- Check for conjunctival pallor (unreliable)
What would the history of someone with bronchiectasis be like?
productive cough and recurrent chest infections or a history of cystic fibrosis
What conditions of SOB can be excluded on inspection?
- Obesity
- Kyphoscoliosis
- Ankylosing spondylitis
What blood tests do you run?
- FBC
- Blood cholesterol, glucose, HbA1c
- Thyroid function tests
- U+Es
- Brain Natriuretuc peptide (BNP)
Why do you carry out FBC?
look for anaemia
Why do you measure blood cholesterol, glucose and HbA1c?
- Know risk factors for IHD
- HbA1c to see diabetes control over last 60 days
Why do you measure U+Es?
before start diuretics for excess fluid check baseline electrolytes and renal function
What is BNP?
hormone released by ventricular cells during heart failure
Why do you measure BNP?
- modest rises may be seen in other causes of heart strain e.g. PE, cor pulmonlae in severe lung disease and other disease e.g. renal failure
- low specificty
Why would you do a chest radiograph?
look for signs of:
- pneumonia
- heart failure
- pulmonary fibrosis
- pleural effusion
- bronchiestasis
Why do you do an ECG?
abnormal in patients with heart failure
What is an important cause of heart failure?
necrosis to areas of heart caused by MI and diabetics have silent MI
What features on an ECG would suggest previous full thickness MI?
- pathological Q waves
- bundle branch block
What other tests do you do for SOB?
- PEFR
2. Spirometry
Why do you do PEFR?
stratify the severity of an asthma attack in chronic asthma
Why do you use spirometry?
used to distinguish between obstructive and restrictive lung disease
What are examples of obstructive airway disease?
- asthma
- COPD
- bronchieactasis
What are examples of restrictive airway disease?
pulmonary fibrosis
What happens in OAD?
bronchi are narrowed by mucus such that less air can be forcefully exhaled during a single second
What are the FEV values in OAD?
- FEV1<70%
- FVC >70% as total lung capacity not reduced (unless severe COPD)
What is RAD?
the total lung volume is reduced but amount of air that can be exhaled in the first second remains the same
What are FEV levels in RAD?
FVC <70%
FEV1 >70%
What are the signs of left ventricular failure?
- Bibasal crackles suggestive of pulmonary oedmea
- displaced apex beat
- chest radiograph showing bilateral pulmonary oedema
What are the signs of right ventricular failure?
- Peripheral oedema
2. Raised JVP
Is heart failure a diganosis?
no a syndrome!
What are the causes of heart failure?
- Hypertension
- Valvular disease
- Alcohol-induced cardiomyopathy
- Ischaemic heart disease (most common)
What are secondline investigations?
ECG. coronary angiography
How would you treat acute pulmonary oedema symptomatically?
- Sit upright
- Give oxygen
- Reduce cardiac preload with vasodilators such as nitrates and durossemide
- Consdier haemofiltration or CPAP
How would you treat chronic pulmonary oedema due to left ventricular failure symptomatically?
Loop diuretic (flurosemide) combined with a potassium sparing diuretic aldosterone receptor antagonist (e.g. spironolactone, eplerenone)
What does reduced cardiac output stimulate?
- renin-angiotensin system
- sympathetic (beta adrenergic receptors)
How do you reduce the oxygen demand on the heart?
Beta Blocker which slows the heart beat, start small dose and increase slowly - NOT in LV
How do you inhibit the RA system?
- ACE inihibtors
- Or ARBs
- Aldosterone antagonists such as spironolactone can be used in those with left ventircular ejection fraction <35%
How do you stop progression of atherosclerosis?
- Statins (reduce cholesterol level)
- Aspirin (reduce risk of thrombosis)
- Medication for DM
How do you treat advanced heart failure?
- Digoxin
- Cardiac resynchronization therapy
- ICDs
- Mechanical assit devices
- Heart transplant
What lifestyle changes do you suggest for someone with pulmonary oedema?
- Stop smoking
- Low salt diet
- Minimising alcohol
- Regular exercise
