evaluation of dyspnoea

1. EVALUATION OF
DYSPNOEA
DR. PRAPULLA CHANDRA

2. DEFINITION OF DYSPNOEA
Dyspnoea is a subjective experience of
breathing discomfort that is comprised of
qualitatively distinct sensations that vary in
intensity. The experience derives from
interaction among multiple physiological,
psychological, social, and environmental
factors, and it may induce secondary
physiological and behavioral responses.

3. MECHANISM OF DYSPNOEA

4. Receptors involved in mechanism of dyspnea
1) J receptors – alveolo-capillary junction
• Stimulated by pulmonary congestion ,oedema, micro emboli.
• Responsible for rapid shallow breathing
2) Stretch receptors – thoracic cage & lung
3) Chemoreceptors - carotid arteries, aorta & reticular substance of
medulla
Stimulated by hypoxia, excess of CO2, decrease in PH
4) Receptors in the respiratory muscle – immediate cause of
appreciation of dyspnea

5. COPD
Thorax is in hyperinflated position/Diaphragm
Work of breathing is high, O2 cost of breathing high
Derangement of dead space ventilation & alveolar capillary gas
exchange
Afferent stimuli to sensorymotor cortex
Dyspnoea

6. INTERSTITIAL LUNG DISEASE
Work of breathing & O2 cost of ventilation
increased
Effort of respiratory muscles in ventilation stimulate
afferent impulses
DYSPNOEA

7. Pleural effusion & Pneumothorax
collapse of the normal lung hypoxia
muscles at mechanical disadvantage
Dyspnoea
Anemia
Inadequate O2 delivery to respiratory muscles
increased respiratory drive
Dyspnoea

8. PULMONARY EDEMA
alveolar & interstitial edema stimulate J-receptors
Dyspnoea
MUSCULOSKELETAL DISORDERS
Hightened motor drive required to activate weakened
respiratory muscles
Dyspnoea

9. STEPWISE APPROACH
 history
 physical examination
 investigations
 treatment

10. HISTORY TAKING

11. Onset
Position
Timing
Severity
Ppt/Relieving factors
Associated symptoms

12. •
Minutes
• Pneumothorax
• Pulmonary oedema
• Major pulmonary embolism
• Foreign body
• Laryngeal oedema
Hours
• Asthma
• Left heart failure
• Pneumonia
Days
• Pneumonia
• ARDS
• Left heart failure
• Repeated pulmonary embolism
Weeks
• Pleural effusion
• Anemia
• Muscle weakness
• Tumours
ONSET OF DYSPNOEA

13. Months
• Pulmonary fibrosis
• Thyrotoxicosis
• Muscle weakness
Years
 Muscle weakness
 COPD
 Chest wall disorders

14. ACUTE DYSPNOEA
RESPIRATORY CAUSES
-PNEUMOTHORAX
-ACUTE ASTHMA
-ACUTE PULM.EMBOLISM
-UPPER AIRWAY OBSTRUCTION
-PULMONARY EDEMA
-TRAUMA
-FOREIGN BODY

15. CARDIAC CAUSES
Acute MI
Acute valvular insufficiency
Aortic dissection
 Complete heart block
Pericardial tamponade
Congestive heart failure

16. CHRONIC DYSPNOEA
AIRWAYS
1. Obstructive airway disease
2. Asthma
3. Chronic bronchitis
4. Empyema
5. Cystic fibrosis
PARENCHYMAL
1. ILD
2. Malignancy
-primary
-secondaries
PLEURAL
1. Effusion
2. Malignancy
3. Fibrosis
PULM-VASCULAR DISEASE
1. A-V Malformations
2. Vasculitis
3. Veno-occlusive disease

17. OTHER CAUSES
CONGESTIVE HEART FAILURE
CONSTRICTIVE PERICARDITIS
NEUROMUSCULAR DISORDERS
ANEMIA

18. POSITION

19. ORTHOPNOEA
• CCF
• LVF
• COPD
• Br.asthma
• Massive
pleural effusion
• Bil diaphragm
palsy.
• Ascites
• GERD
PLATYPNOEA
• Left atrial
myxoma
• Massive pulm.
Embolism
• Pulm. AV fistula
• Paralysis of
intercostal .m
• Hepato
pulmonary syn.
TREPOPNOEA
• DISEASE OF
ONE LUNG/
BRONCHUS
• CCF

20. TIMING

21. NOCTURNAL ONSET DYSPNOEA
- CHF
- COPD
- BRONCHIAL ASTHMA
- SLEEP APNOEA
- POST NASAL DRIP
- NOCTURNAL ASP. IN GERD

22. PAROXYSMAL NOCTURNAL DYSPNOEA
Severe difficulty in breathing that awakens the
patient from sleep and forces him to a sitting
or standing position.
Almost always implies underlying heart failure

23. POSTPRANDIAL DYSPNOEA
GERD
ASPIRATION
FOOD ALLERGY

24. GRADING

25. DYSPNOEA GRADING SCALES
Visual analogue scale
Borg scale
Bode index
Sherwood jones grading
American thoracic society scaling
NYHA Scale
MRC Classification
MMRC dyspnoea scale

26. EXAMPLE OF A VISUAL ANALOG SCORE. THESE CAN BE ADAPTED TO ANY
SYMPTOM AND CAN BE SUPPLEMENTED WITH ANCHORING VERBAL
OR VISUAL DESCRIPTORS AS SHOWN HERE.

29. SHERWOOD JONES GRADING
Grade 1a : housework/job with moderate difficulty
1b : with great difficulty
Grade 2a : confined to chair/bed but able to get
up with moderate difficulty.
2b : with great difficulty
Grade 3 : totally confined to chair/bed
Grade 4 : moribund

30. GRADE 1 –Dyspnoea only with unusual exertion.
GRADE 2 –Dyspnoea on doing ordinary activity
GRADE 3 –Dyspnoea on doing less than ordinary
activity.
GRADE 4 –Dyspnoea at rest.
NYHA SCALE

31. I. Not troubled by breathlessness with
strenuous exercise.
II. Shortness of breath when hurrying or walking up a slight
hill.
III. Walks slower than contemporaries on level ground
because of breathlessness or has to stop for breath when
walking at own pace.
IV. Stops for breath after walking about 100m or after a few
min. or level ground.
V. Too breathless to leave the house or breathless when
dressing or undressing.
MRC CLASSIFICATION

32. 0. Not troubled by breathlessness with strenuous exercise.
1. Shortness of breath when hurrying or walking up a slight hill.
2. Walks slower than contemporaries on level ground because
of breathlessness or has to stop for breath when walking at
own pace.
3. Stops for breath after walking about 100m or after a few
min. or level ground.
4. Too breathless to leave the house or breathless when
dressing or undressing.
MMRC SCALE

33. PPT/RELIEVING FACTORS

34.  Precipitating factors :
+ exercise
+ exposure – cigarette ,allergens
+ occupational exposure
+ obesity
+ severe weight loss
+ medication
 Relieving factors :
- rest
- medication

35. ASSOCIATED SYMPTOMS

36. -FEVER
-CHEST PAIN
-Central chest pain
-Pleuritic chest pain
-Pericardial pain
-WHEEZE

37.  Chronic sputum production
 Change in the pitch of voice
 Palpitations and syncope
 Haemoptysis
 Dysphagia or odynophagia
 Vomiting and diarrhoea

38. Heart burn
Muscle weakness or myalgias
Visual disturbances & headache
Bone pain

39. PAST MEDICAL HISTORY
SURGICAL HISTORY
DRUG HISTORY
OCCUPATIONAL HISTORY
SMOKING HISTORY

40. PHYSICAL EXAMINATION

41.  EXAMINE NOSE
 LOOK FOR CYANOSIS
 PALLOR
 ICTERUS
 CLUBBING
 EDEMA
 CERVICAL LYMPHADENOPATHY

42. RAISED JVP
PERIPHERAL PULSES AND BRUITS
GOITRE

43.  Hypotension, tachycardia, and tachypnea : acute
pulmonary edema , ARDS
 Hypertension in a dyspnoeic patients:
hypertension-related diastolic heart failure with
pulmonary oedema, hyperthyroidism, or
phaeochromocytoma
Pulsus paradoxus - asthma, COPD, cardiac tamponade.
BLOOD PRESSURE

44. Cardiovascular examination
Elevated neck veins, extra heart sound (S3 gallop rhythm),
and fluid retention - congestive heart failure.
Elevated neck veins, pulsus paradoxus, a pericardial
knock, pericardial rub, and the Kussmaul's sign -
Constrictive pericarditis and effussion
An irregular or fast heart beat - a tachyarrhythmia or atrial
fibrillation.
 A loud S2 -PAH
A systolic heart murmur- acute valvular insufficiency,
mechanical valve malfunction.

45. Respiratory examination
Pursed lip breathing - COPD.
A barrel chest - emphysema and cystic fibrosis.
Stridor -upper airway obstruction
Hoarseness - in laryngitis, laryngeal tumours, vocal cord
paralysis.

46. The trachea may deviate away from the lesion-
tension pneumothorax or a large pleural effusion.
Unilateral dullness to percussion - pleural effusion,
atelectasis, foreign body aspiration, pleural
tumours, or pneumonia.
 Hyper-resonance - pneumothorax or severe
emphysema.
 Subcutaneous emphysema -
pneumomediastinum

47. Neurological examination
Cranial nerve palsies associated with
dyspnoea -botulism.
Ptosis -myasthenia gravis, myotonic
dystrophy, or botulism.

48. Pneumothorax
 Sudden-onset dyspnoea associated with unilateral chest pain may
indicate acute pneumothorax.
 On examination, breath sounds are unilaterally absent, and
percussion of the ipsilateral chest may reveal tympany.
 The trachea may also be deviated away from the lesion.
Acute asthma
 Acute-onset dyspnoea associated with wheezing and cough,
especially in a person with prior history of asthma
 Asthma is diagnosed based on the history and demonstration of
airflow obstruction reversibility.
RESPIRATORY CAUSES

49. Anaphylaxis
 Exposed to a medication, food product, or insect bite.
 Sudden-onset dyspnoea is accompanied by cutaneous
manifestations , voice changes, a choking sensation, tongue and
facial oedema, wheezing, tachycardia, and hypotension.
 Nausea, vomiting, and diarrhoea
Pulmonary contusion
 History of trauma
 may present with dyspnoea, circulatory collapse, and shock.

50. Acute pulmonary embolism
Sudden dyspnoea and chest pain, associated
with tachycardia, tachypnoea, hypotension,
hypoxaemia, hemoptysis and calf tenderness.

51. Foreign body aspiration
History of epilepsy, syncope, altered mental status (e.g.,
intoxication, hypoglycaemia), or choking and coughing
after ingesting food (particularly nuts) may suggest
foreign body aspiration.
Cyanosis and stridor followed by hypotension and
circulatory collapse .

52. Upper airway obstruction
Significant dyspnoea, inspiratory stridor, and
occasionally expiratory wheezing, exacerbated
by exercise.

53. Acute myocardial infarction
 Presents with central chest pain radiating to the shoulders and
neck frequently accompanied by dyspnoea.
► O/E patient may be clammy and hypotensive.
 S3 or S4 gallop rhythm
 pulmonary rales.
 characteristic ECG changes,
 elevated cardiac enzymes
CARDIAC CAUSES

54. Acute valvular insufficiency
 Acute dyspnoea,
 systolic murmur and signs of acute cardiovascular collapse with
hypotension, tachycardia, and pulmonary rales.
 An echocardiogram is typically required to establish the diagnosis.
Aortic dissection
 Dyspnoea
 severe chest pain that may radiate to the back.
 hypotension and absent peripheral pulses.
 Emergency echocardiogram or a CT chest is used for diagnosis.

55. Congestive heart failure
 Presents with dyspnoea worsened by exertion, orthopnoea and
paroxysmal nocturnal dyspnoea, elevated neck veins, peripheral
fluid retention, an S3 gallop rhythm, and pulmonary congestion
(fine bibasal rales) .
 The CXR shows characteristic signs of pulmonary venous
congestion with cardiomegaly.
 Echocardiography.
 B-type natriuretic peptide >100 pg/ml

56. Complete heart block
 Dyspnoea with weakness, light-headedness, or syncope.
 ECG
Pericardial tamponade
 Dyspnoea accompanied by neck vein and facial engorgement,
shock, peripheral cyanosis, and tachycardia.
 An enlarged cardiac silhouette on CXR and a low-voltage ECG,
echocardiography.

57. INVESTIGATIONS

58. CBP – Anemia , polycythemia ( ch.Hypoxemia),
BIOCHEMICAL –
- Occult renal disease
- acid – base derangement
- collagen vascular disease
- thyroid disease
BNP – Secreted by ventricles in response to inc. ventr .
pressure .
- LVF ,COR PULMONALE
CXR –
SPIROMETRY – (airway & parenchymal diseases)

60. ECG - CAD, pulm HTN, arrhythymias
PFT –
- lung volume & flow rate
- DLco
- Arterial blood gases
- Cardiopulmonary exercise testing
- bronchial challenge
- maximal insp. Pressure
Imaging techniques
- VP scan
- CT (HRCT/contrast) CT angiogram
- Gallium scan
- Diaphragmatic fluoroscopy
BRONCHOSCOPY

61. CARDIAC EVALUATION –
-ECHO
-Thallium scan
-Holter monitoring(occult ischemia
/arrythmia)
-Cardiac monitoring
-Cardiac catherisation (with exercise)
CARDIOPULMONARY EXERCISE TESTING
ESOPHAGEAL EXAMINATION / pHmonitoring
ENT examination
Sleep studies
Psychological assessment

62. Treat the underlying cause
Pneumothorax - closed tube thoracostomy
Foreign body removal
Asthma – bronchodilators,steroids
Anaphylaxis – adrenaline & avoidance of
precipitating agent
TREATMENT

63. TREATMENT STRATEGIES
REDUCE VENTILATORY DEMAND
DECREASE SENSE OF EFFORT
IMPROVE RESP.MUSLE FUNCTION
PULMONARY REHABILITATION

64. REDUCE VENTILATORY DEMAND
-Treat airway disease
-Supplemental oxygen
-Opiates & sedatives.
-Exercise training.
-Cognitive behavioural therapy

65. DECREASE SENSE OF EFFORT & IMPROVE RESP. MUSCLE
FUNCTION
-Energy conservation (walk slowly)
-Breathing strategies ( pursed lip breath)
-Position ( leaning forwards)
-Correct obesity / malnutrition
-Inspiratory Muscle exercise
-Resp . Muscle rest(nasal /transtracheal O2)
-Medication (theophylline)

66. PULMONARY REHABILITATION
PATIENT EDUCATION
EXERCISE TRAINING
OPTIMIZE BODY COMPOSITION
PSYCHOSOCIAL SUPPORT
PHYSIOLOGIC ASSESSMENT