Shortness of Breath Flashcards
In broad terms, what pathological processes can cause shortness breath
Insufficient oxygen entering the lungs
Insufficient oxygen entering the blood from the lungs
Insufficient oxygen being delivered to the body
Increased respiratory drive
What may cause insufficient oxygen from entering the lungs
Obstruction (asthma, COPD, tumour, anaphylaxis)
Reduced lung volume (pneumothorax, effusion, kyphoscoliosis)
Reduced functioning lung volume (bullous, cystic disease, ILD)
Inability to inflate (obesity. ILD, GBS, MG, COPD)
What may cause insufficient oxygen from entering the blood from the lungs
Damage to the alveolar membrane (emphysema, fibrosis in ILD)
Fluid between the alveolar walls and capillaries (oedema, inflammation)
Disrupted blood supply - PE
What may cause insufficient oxygen from being delivered to the body
Reduced cardiac output - HF, aortic stenosis
Anaemia
Shock
What may cause an increased respiratory drive
Hysterical hyperventilation, psych disorders, anxiety
Acidaemia (metabolic) - DKA
What questions should be asked about SOB itself
Timing and Onset - acute is more mechanical or vascular, chronic more lung cancer, fibrosis
Alleviating or exacerbating factors e.g. lying flat (HF), certain times of year or on exercise (asthma), Anxiety and stress (psychogenic)
What questions should be asked about risk factors for SOB
Smoking
Pets
Occupation - in particular coal, silica, asbestos
Medication - nitrofurantoin, amiodarone, methotrexate, bleomycin -> EAA
Past medical history - autoimmune conditions e.g. RA< SLE
What associated symptoms should be asked about with SOB presentation
Cough Chest pain Muscular weakness or fatigue Tender limbs Constitutional symptoms Loss of blood
What does a cough with SOB suggest
Suggests resp pathology
Persistent, productive cough over days - pneumonia
Persistent productive cough over months = bronchitis
Dry cough with SOB episodes - asthma or LVF
Bloodstained sputum - LVF, PE, cancer, cavitating lesion
What does chest pain with SOB suggest
Pleuritic - PE, pneumothorax
NOn pleuritic - cardio
What does muscular weakness of fatigue with SOB suggest
GBS Myasthenia gravis Lambert Eaton Syndrome Polymyositis MND
What does tender limbs with SOB suggest
PE, esp if lower limbs (DVT)
What does loss of blood with SOB suggest
Anaemia will exacerbate SOB, ask about menstrual bleeding, haematochezia and melaena
What are the differentials for SOB that develops in seconds to minutes
Bronchospasm (asthma or COPD exacerbation) Anaphylaxis Laryngeal oedema PE pneumothorax (+ tension) hyperventilation Inhaled foreign body Epiglottitis
What are the differentials for SOB that develops in hours to days
pneumonia Heart failure pleural effusion post-op atelectasis chronic pulmonary emboli GBS/MG ARDS Lung collapse
What are the differentials for SOB that develops in weeks to months
COPD Asthma HF Pulmonary fibrosis Anaemia Bronchiectasis Obesity/physical deconditioning Pulmonary HTN Mesothelioma TB MND
What are the main features of COPD that may distinguish it from other causes of SOB
Hx of chronic bronchitis and permanent irreversible SOB
Presence of risk factors - smoking (>20PY), occupational exposure, alpha-antitrypsin deficiency
What are the signs of COPD
Hyperexpanded chest Breathing through pursed lips Reduced expansion Prolonged expiratory phase Hyper-resonant precussion note
What are the main features of chronic asthma that may distinguish it from other causes of SOB
Hx of wheeze, SOB, chest tightness, cough (often worse at night/early morning/during exercise/exposure to allergens or cold)
Associated atopic conditions or FHx e.g. eczema, hayfever, nasal polyps, allergies
Exacerbation by NSAIDs or beta blockers
Wheeze on auscultation
What are the main features of interstitial lung disease that may distinguish it from other causes of SOB
Hx of exposure to asbestos, silica, coal (pneumoconiosis) or exposure to drugs (methotrexate, amiodarone)
What are the signs of ILD on examination
Clubbing
Reduced chest expansion
Late inspiratory fine crackles (base OR apices)
What are the main features of heart failure that may distinguish it from other causes of SOB
SOB on exertion, orthopnoea, PND, swollen ankles
Risk factors: IHD ( smoking, DM, cholesterol, HTN, south east asian, FHx), stroke, TIAs, limb claudication, HTN, valvular disease, cardiomyopathy
What are the features of heart failure on examination
Ascites, hepatosplenomegaly, peripheral oedema, raised JVP
Bi-basal crackles that do not move on coughing (pulmonary oedema)
Displaced apex beat
Third or fourth heart sounds
What are the main features of anaemia that may distinguish it from other causes of SOB
Hx bleeding (menorrhagia, melaena), fatigue, SOB on exertion Signs of cyanosis, koilonychia, glossitis, angular stomatitis
What are the main features of bronchiectasis that may distinguish it from other causes of SOB
Hx of productive cough and recurrent chest infection
Hx cystic fibrosis
Bi basal crackles that move on coughing
What blood investigations should be arranged for suspected congestive heart failure
FBC (anaemia)
Cholesterol, glucose and HbA1c (risk factors)
TFTs (potential cause)
U+Es (before starting diuretics)
Brain Natriuretic peptide (BNP) - hormone released by ventricular cells in HF
What imaging should be arranged for suspected congestive heart failure
CXR (signs of HF, pneumonia, effusion, bronchiectasis, fibrosis)
ECG (BBB, pathological Q waves from previous MI)
Echo (ventricular function + confirm low CO and HF)
Coronary angiography (? coronary artery disease)
What other tests could be arranged for SOB, excluding bloods and imaging
PEF - Asthma
Spirometry - obstructive vs restrictive
What drugs should be prescribed for heart failure
Symptomatic relief: pulmonary oedema - sit up, oxygen, morphine, nitrate/furosemide.
Long-term: furosemide +/e spironolactone
Path: beta-blocker and ACEi/ARB
Cause: statin, aspirin, DM control
What may cause SOB post-op
Atelectasis Pneumonia Pulmonary oedema PE Anaemia Pneumothorax
What is atelectasis
Pain prevents patients from breathing adequately and excoriating any mucus in their lungs.
The mucus eventually plugs the bronchioles, preventing air entry, and areas of the lung collapse
How does post-op atelectasis present
Mucous: Rattling cough
Collapsed lung: Reduced chest expansion
Crackles
Dull percussion
What is the management for post-op atelectasis
Physiotherapy + mobilisation
Analgesia
Oxygen
Incentive spirometry
What is the management for asthma
Avoidance of triggers
Bronchodilation with beta agonists, theophyllines, antimuscarinics
Reduction of immune response: corticosteroids, leukotriene receptor antagonists
What is the management for COPD
Smoking cessation Inhaled corticosteroids Pulmonary rehabilitation Vaccination NIV for exacerbations Long term oxygen
What is the management plan for a patient with TII resp failure
Controlled oxygen therapy
NIV if needed
Treat underlying cause
What is the classical presentation of pneumocystis jiroveci pneumonia
Young patient from Africa
Dry cough, SOB,
Low sats and desaturation on exercise
Diffuse interstitial shadowing on CXR
What investigations are done for suspected pneumocystis jiroveci pneumonia
Microscopy + silver staining
Culture on sputum and BAL
HIV testing
TB testing (Microscopy with Ziehl-Neelson)
What presentation might suggest interstitial lung disease
Chronic progressive SOB, worse one exertion. BG of a cause Fine crackles all over the lungs Spirometry suggests restrictive disease Absence of other obvious diagnoses
What conditions may cause ILD
Congenital - neurofibromatosis, Gaucher
Inflammatory - RA, ankylosing spondylitis, sarcoidosis
Chemical irritation - asbestos, silica, coal, chlorine
Drugs - methotrexate, amiodarone
radiation
How is ILD confirmed
HRCT lung - linear reticular opacities and ground0glass appearance
What is diagnostic of Hodgkin’s lymphoma
Presence of binucleated lymphocytes (Reed-Sternberg cells) on lymph node biopsy
What are the type of medications used for COPD and asthma
Short acting bronchodilators Inhaled steroids Long acting bronchodilators Oxygen Others
Give examples of short acting bronchodilators used for COPD and asthma
Salbutamol/ventolin, blue, beta2 agonist
Ipratropium/atrovent, white green, antimuscarinic
Combination/combivent, white and orange
Give examples of inhaled steroids used for COPD and asthma
Beclometasone, Budesonide - brown
fluticasone - orange
Give examples of long acting bronchodilators used for COPD and asthma
Salmeterol - formoterol - LABA
Tiotropium - LAMA
Give examples of other drugs used for COPD and asthma
Oral steroids
Xanthine derivatives e.g. theopylline
Leukotriene antaongists - montelukast
Phosphodiesterase inhibitos - roflumilast
What is the difference between bronchitis and pneumonia
Both LRTI
Bronchitis is disease of the airways, pneumonia disease of the alveoli
Bronchitis - inflammation -> mucous production and obstruction -> cough
Pneumonia -> pus accumulates in alveoli
What are the causes of type I and II resp. failure
Type I: asthma, COPD, pneumonia, pulmonary fibrosis, pulmonary oedema
Type II: Opiates, central neuro damage (stroke, trauma), COPD, deformity, obesity, MND
What are the causes of crepitations on examinations
Pulmonary oedema
Interstitial lung disease
Bronchiectasis
Pneumonia
What do the following presentations match (with crepitations):
Displaced apex beat, raised JVP, ankle oedema, orthopnoea, IHD Hx
Reduced expansion, clubbing, does not vary with cough
Chronic productive cough, wheeze, crepitations vary with cough, clubbing
Acute productive cough, fever, chest pain, bronchial breathing, dull percussion
Displaced apex beat, raised JVP, ankle oedema, orthopnoea, IHD Hx - pulmonary oedema
Reduced expansion, clubbing, does not vary with cough - interstitial lung disease
Chronic productive cough, wheeze, crepitations vary with cough, clubbing - bronchiectasis
Acute productive cough, fever, chest pain, bronchial breathing, dull percussion - pneumonia
What is the management for a post-op patient with pulmonary oedema
Sit patient up
Furosemide
Oxygen
Nitrates
What is the management for a post-op patient with a PE
LMWH
Start warfarin
TED stockings
What is the management for a post-op patient with atelectasis
Analgesia
Oxygen
Chest physio
What is the management for a post-op patient with pneumonia
Antibiotics
Oxygen
IV fluids
