Shortness of breath (oxford clin cases) Flashcards
What are the 4 pathophysiological ways shortness of breath can occur?
Not enough o2 gets into the lungs
Not enough o2 gets into the blood
Not enough o2 gets around the body
Increased respiratory drive
What is an exacerbating factors for shortness of breath due to heart failure?
Its worse lying down
What is an exacerbating factor for shortness of breath due to asthma?
Worse when exercising, at night, when around dust, in colder climates
What does a persistent productive cough with shortness of breath for the past 3 days suggest is the diagnosis?
Pneumonia
What does a productive cough for most days in the past 3 months and spanning years suggest is the diagnosis?
Chronic bronchitis
What type of cough will someone with asthma have?
Dry cough for periods eg during exercise, at night
What does sputum with blood in it suggest could be the diagnosis?
PE
What type of chest pain is associated with shortness of breath?
Pleuritc
How will a patient describe pleuritic chest pain?
A sharp and intense stabbing or burning pain on inhalation or exhalation
What does pleuritic chest pain with shortness of breath point towards?
PE
Pneumothorax
Pneumonia
What does muscle weakness with shortness of breath point towards?
Neuromuscular disease eg Guillain Barre, myasthenia gravis, motor neurone disease
What do tender limbs with shortness of breath point towards?
PE due to DVT
What conditions will cause an acute onset shortness of breath (in seconds to mins)
Anaphylaxis
Bronchospasm
PE
Tension pneumothorax
What conditions will cause an onset of shortness of breath in hours to days?
Pneumonia ARDS Heart failure Pleural effusion Lung collapse
What conditions will cause an onset of shortness of breath in weeks to months?
Chronic asthma Pulmonary fibrosis COPD Heart failure Bronchiectasis
What are some signs of COPD
Breathing through pursed lips Hyper expanded chest Reduced chest expansion Prolonged expiration Hyperesonance to percussion
What are some investigations you might do if you suspect COPD?
Spirometry Pulse oximetry Standardised COPD score ABG Chest x ray
How is COPD managed?
Offer smoking cessation
Offer the flu jab
Pulmonary rehab if needed
Treat their co morbidities
What are medical treatments for COPD and when are they used?
If symptoms are not relieved and are affecting daily activities, offer SABA+SAMA
If still not relieved, offer LABA+LAMA and then ICS if still not better
How will someone with asthma present
Wheeze (more when expiring)
Cough worse at night/early morning, cold climates, after exposure to allergens
Chest tightness
Breathlessness
What are some risk factors for developing asthma?
Atopic conditions eg eczema/hayfever and family history of these
Allergies
Nasal polyposis
How is asthma treated in adults (and what age does this mean)
17 and above:
Start with SABA alone
If maintenance therapy is needed then ICS low dose with the SABA
If uncontrolled still offer LTRA
If still uncontrolled consider starting a MART regime
How is asthma treated in children and young adults (and what age does this mean)
5-17 year olds
Start by offering SABA alone
If maintenance therapy is needed give ICS and LTRA 4 week trial if bad
If still uncontrolled ICS and LABA
If uncontrolled consider starting MART regime
How is asthma treated in young children (and what age does this mean)
Under 5
Start with SABA alone
If maintenance is needed, do an 8 week trial of paediatric moderate dose ICS, then stop and observe symptoms:
If symptoms stop then resolve within 4 weeks of stopping, continue ICS
If symptoms stop then resolve after 4 weeks of stopping ICS, do another 8 week trial
If symptoms are not relieved during the trial, asthma is unlikely to be the diagnosis
If still uncontrolled, consider starting LTRA but few are appropriate for this age
What is bronchiecstasis?
A long term condition where there is widening of the airways which causes mucus production and leaves patients susceptible to chest infections
How would bronchiecstasis present?
History of recurrent chest infections Productive cough Fatigue Weight loss Haemoptysis
What might you hear on auscultation when examining someone with brochiecstasis?
Crackles
High pitched inspiratory wheeze
What are some risk factors for bronchiecstasis?
Cystic fibrosis
History of chest infections
Congenital disorders of the airways
How is bronchiecstasis managed?
Supportive care eg antibiotics for exacerbations
Airway clearance therapy
If very severe them surgery
What investigations are useful when you suspect bronchiecstasis?
Chest CT to diagnose it- you can see dilation of the airway and if there is thickening or not
Chest x ray to monitor it
Sputum testing (to identify causative agents of infections and decide what abx should be used)
How will someone with heart failure present?
Tiredness
Need pillows and to be propped up in order to sleep
Shortness of breath (especially on exertion)
Orthopnoea (worsening shortness of breath when lying down)
Leg oedema
Raised JVP
What are some investigations for heart failure?
ECG- will always be abnormal in heart failure
BNP- hormone released by ventricular cells common in heart failure
Bloods- FBC to check for anaemia, cholesterol, glucose levels
Serum electrolytes
Thyroid function tests
What are some risk factors for heart failure?
Previous MI Diabetes Smoking High cholesterol South asian descent
Are patients with heart failure hypo or hypertensive?
They can be either
How is heart failure managed?
Ace inhibitor if they can tolerate it
If not beta blocker and angiotensin II receptor antagonist
Diuretic if they have fluid overload
Vasoconstrictor or vasodilator
What will show up on an ECG of someone who has had a previous MI?
pathological q waves
bundle branch block
What is spirometry used to check?
If the disease is obstructive or restrictive
What is the pathophysiology of obstructive airway disease? Give an example of one
It is caused by narrowing of the airway so that less air can be exhaled eg asthma, COPD
What is the pathophysiology of restrictive airway disease? Give an example of one
It is caused by reduction of total lung volume eg pulmonary fibrosis
What happens to FEV1 and total lung capacity in obstructive disease?
FEV1= reduced
Total lung capacity= same
What happens to FEV1 and total lung capacity in restrictive disease?
FEV1= same
Total lung capacity= reduced
Failure of what part of the heart causes pulmonary oedema?
Left ventricles
Failure of what part of the heart causes peripheral oedema?
Right ventricle
Why do patients with heart failure experience shortness of breath?
Their heart is not pumping blood adequately. When there is increased return to the heart (lying down, exercising) the heart struggles to pump out the increased blood and it backlogs into pulmonary vasculature. As this happens fluid is forced out of the vasculature into alveoli causing a feeling of shortness of breath/drowning
Why does the apex beat become displaced in heart failure?
The heart failure causes the heart muscle to dilate (DO NOT confuse with hypertrophy)
What medication may be given in heart failure to prevent pulmonary oedema?
Vasoconstrictors eg nitrates and furosemide
Diuretics eg furosemide or spironolactone, epelerenone
What are the 2 ways in heart failure to reduce stress on the heart?
Reduce its oxygen demand
Inhibit renin-angiotensin
What medication reduces oxygen demand of the heart and how?
Beta blockers by slowing the heartbeat
What medication inhibits renin angiotensin?
ACE inhibitor
How will someone with lung cancer present?
Chest pain Dyspnoea Haemoptysis Weight loss Night sweats Fatigue Lymphadenopathy They are likely to have a history of smoking or exposure to tobacco, and be older
What are the 2 types of lung cancer and which is more common?
Non small cell (NSCLC)- more common (80%) Small cell (SCLC)
What type of cough indicates mucus in the lungs?
Rattling
When managing asthma, what system do medications target in order to dilate the airway?
Sympathetic
At what age can someone be diagnosed with asthma and why?
Over 1- asthma is to do with inflammation of the muscle in the airways, this muscle is not developed in babies under 1
What are the 3 layers that can cause narrowing of the airway?
Wall of airway
Airway muscle
Mucus build up
What does cigarette smoke inhibit in the lungs to cause loss of elasticity?
Alpha 1 antitrypsin
What happens to FEV1:FVC and FVC in COPD? Explain why
FEV1: FVC= reduced because airway is obstructed so less air can flow out as quickly
FVC= although lungs are hyperinflated, air is trapped in the lungs which reduces capacity when a patient inhales
What is the character of shortness of breath in COPD vs asthma?
COPD= persistent and irreversible Asthma= only during attacks/exacerbations and reversible
What is respiratory failure?
Failure of the lungs to adequately carry out gas exchange- can be acute or chronic which leads to hypoxia with or without hypercapnia
What are the types of respiratory failure and how are they defined?
Type I= hypoxia without hypercapnia (pO2= <8 kPa on room air at sea level)
Type II= hypoxia with hypercapnia (pCO2= >6.5 kPa on room air at sea level)
What may someone in respiratory failure present with?
Shortness of breath Confusion Tachypnoea Confusion Cardiac dysfunction/ arrest
What are risk factors for respiratory failure?
Infections like pneumonia and influenza
COPD
Young age or old age
What are the first line investigations for respiratory failure? What other investigations might you do?
First line= pulse oximetry and ABG
Others= ECG, FBC, D dimer (to check for PE), CXR, serum bicarbonate
How is respiratory failure managed?
Make sure their airway is cleared and patent
Give them supplemental oxygen (low flow with venturi mask, never 100% oxygen)
Give NIV if oxygen is not helping
Treat the underlying cause eg PE, infection
If they are unconscious then intubate them
How will a patient with pneumonia present?
Shortness of breath
Fever/hypothermia
Cough with sputum production
Chest pain
How will a patient with pneumonia present?
Shortness of breath
Fever/hypothermia
Cough with sputum production
Chest pain
How will a patient with pneumonia present?
Shortness of breath
Fever/hypothermia
Cough with sputum production
Chest pain
How will a patient with pneumonia present?
Shortness of breath
Fever/hypothermia
Cough with sputum production
Chest pain
What are the types of pneumonia and how are they defined?
Hospital acquired= within 48 hours of admission to hospital and not incubating at the time of admission
Community acquired= acquired outside of hospital
How is pneumonia managed?
Antibiotics need to be administered (within 4 hours of admission if they are in hospital)
If they are on antibiotics for 48 hours, reassess them and see if they can be switched to oral abx
Give supportive treatment eg oxygen if needed
What investigations may be carried out for pneumonia?
First line= oxygen saturation and chest xray
ABG
What is seen on chest x ray characteristically in pneumonia?
Shadowing of the alveoli
What is the most commonly used SABA for asthma and how does it work?
Ventolin (blue inhaler)- it is a beta 2 agonist and works by relaxing the airway smooth muscle
What do SABA, LABA and LAMA stand for?
SABA= short acting beta 2 agonist LABA= long acting beta 2 agonist LAMA= long acting muscarinic agent
What are some commonly used LABA for asthma?
Symbicort, seretide
What is the difference between bronchitis and pneumonia and how do symptoms in each differ?
Bronchitis= inflammation of the bronchi/airways Pneumonia= inflammation of the alveoli
In pneumonia gas exchange is impaired and will cause shortness of breath but in bronchitis there will mainly only be cough present
What are the causes of type I vs type II resp failure
Type I= any lung disease eg pulmonary fibrosis, pulmonary oedema, asthma, pneumonia
Type II= decreased respiratory drive (opiates, central neurological damage eg stroke/trauma) or impaired lung movement (COPD causing reduced compliance and expansion, obesity, motor neurone disease)
What are some differentials if someone has bibasal crepitations?
Pneumonia, bronchiecstasis
