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Similaire à Cardiology 1.2. Dyspnea - by Dr. Farjad Ikram
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Cardiology 1.2. Dyspnea - by Dr. Farjad Ikram
- 1. Good Morning! I am Dr. Farjad Ikram House Officer, Cardiology, Shalamar Hospital
- 2. DYSPNEA
- 4. Biodata × Mr. Arshad Khan × 60 years / Male × Retired, married × Weight 80 kg × Height 152 cm Past history × Anterior wall STEMI - 4 years ago, SK given × Diabetes for 15 years × Ex-smoker E.R presentation Shortness of breath - for 4 hours, on rest Orthopnea, PND Vitals × Pulse – 100 b/m - regular, bounding × B.P – 100/50 mmHg × Resp. Rate – 30 b/m × SpO2 – 90% × Afebrile × BSR – 240 mg/dl Examination × Raised JVP × Bipedal pitting edema × Apex beat 6 ICS, left AAL × S1 + S2 + PSM × Bibasilar rales (fine) × Rt. subcostal tenderness × GCS 15/15 Investigations ordered × Troponin I × 12 lead ECG × Chest X-ray PA view × Echocardiography Case Scenario
- 6. Definition ×Dyspnea is an uncomfortable sensation or awareness of breathing. × The term is used interchangeably with: • Shortness of breath • Difficulty in breathing • Breathlessness
- 7. “Dyspnea is a term used to describe subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. - American Thoracic Society
- 8. “×These distinct sensations include: • increased effort for breathing • chest tightness • air hunger (feeling of not enough oxygen) - American Thoracic Society
- 9. 3-6% E.R visits 30 % cases are multi-factorial 15-20% hospital admssions
- 10. Etiology × Dyspnea is a normal symptom of heavy exertion. × Dyspnea becomes pathological if it occurs in unexpected situations, on light exertion, or at rest. × It is a symptom of many organ systems, especially cardiovascular and respiratory causes.
- 11. Etiology ×In 85% of the cases it is due to: • Asthma • Pneumonia • Ischemic heart disease • Interstitial lung disease • Congestive heart failure • COPD • Psychogenic causes
- 13. Pathophysiology Dyspnea results when a stimulus activates the respiratory center beyond a certain threshold
- 16. Tachypnea × Tachypnea is rapid breathing (respiratory rate is > 20 breaths per minute) • Causes: exercise, labor in pregnancy, CO poisoning, pneumonia in children • Children have higher resting resp. rate that decline rapidly by first 3 yrs of life × Hyperpnea is breathing that is more rapid and deeper, than at rest • Physiologic - after heavy exertion, high altitude • Pathologic - anemia, sepsis, metabolic acidosis × Hyperventilation (over-breathing) so that PCO2 is decreased • Hypocapnia leads to respiratory alkalosis (tingling, dizziness, weakness, tetany, nausea, vomiting) × Kussmaul breathing is rapid, deep, laboured breathing seen with worsening metabolic acidosis i.e. diabetic ketoacidosis, kidney failure
- 17. Bradypnea × Apnea is cessation of breathing • Sleep apnea – pauses in breathing 20-30 times per hour during sleep • Apnea of prematurity – pauses in breathing in premature infants for >20 sec × Bradypnea is breathing that is more rapid and deeper, than at rest • A rate of < 12 breaths for age >12 years × Hypopnea is bradypnea with overly shallow breathing than at rest • Causes – sedatives, alcoholism, adenoiditis, aging, obesity, hypo-thyroidism, hypokalemia, neuromuscular diseases (GB syndrome, myasthenia, ALS) × Hypoventilation (under-breathing) so that PCO2 is increased • Hypercapnia leads to respiratory acidosis (headache, anxiety, confusion, blurred vision). Hypoventilation can lead to hypoxia.
- 18. Respiratory Distress × Respiratory distress • Physical presentation of respiratory distress is “labored breathing” • Subjective sensation or awareness of respiratory distress is “dyspnea” × Examples: • Adults – Acute Respiratory Distress Syndrome (ARDS) • Premature infants – Infant Respiratory Distress Syndrome (IRDS) also called Hyaline Membrane Disease due to surfactant deficiency
- 19. Paraoxysmal Nocturnal Dyspnea × Paraoxysmal nocturnal dyspnea (PND) • attacks of severe dyspnea that occur suddenly during sleep hours, • causing the person to wake and sit up, • associated with cough and wheeze × Pathophysiology of PND • In horizontal position, there is redistribution of blood from lower extremities into the pulmonary circulation • In patients who have already reduced pulmonary compliance and left ventricular dysfunction, will develop pulmonary congestion • Congestion decreases when patient assumes a more erect position
- 20. Differentials 5
- 21. PULMONARYCARDIAC MIXED NON CARDIO PULMONARY Causes of dyspnea can be divided into four categories
- 22. Cardiac causes × Congestive heart failure × Ischemic heart disease × Valvular dysfunction × Cardiomyopathies × Pericardial diseases × Tachydysrhythmias × Congenital heart disease
- 24. Pulmonary causes × COPD and astma excacerbations × Lower RTI × Restrictive lung diseases × Interstitial lung diseases × Bronchiectasis and emphysema × Pneumothorax × Pleural effusion, Hemothorax, Pyothorax
- 25. Mixed cardio-pulmonary causes × COPD with pulmonary HTN and cor pulmonale × Chronic pulmonary emboli × Deconditioning (decreased physical activity) × Trauma
- 26. Non-cardiopulmonary causes × Metabolic acisosis (DKA, sepsis, renal failure) × Oto-rhino-laryngeal disorders × Neuromuscular disorders (GBS, ALS, MG, dystrophies) × Respiratory depression (opiates, benzodiazepines) × Hematologic disorders (anemias, polycythemia, ACS) × Psychiatric disorders (anxiety, panic disorders) × Other: obesity, cirrhosis, thyrotoxicosis, CO poisoning, anaphylaxis
- 27. History 6
- 28. History Evaluation × Chronicity × Onset × Positionality × Severity × Associated symptoms × Past medical and surgical history × Past gynecological and obstetric history × Family history × Occupational history × Drug use / abuse history × Social history (smoking, alcoholism)
- 29. acute (in matter of minutes) sub-acute (over hours to days) chronic (over weeks to months) History - Chronicity
- 30. History - Chronicity ACUTE (in matter of minutes) SUB-ACUTE (over hours to days) CHRONIC (over weeks to months) Acute pulmonary embolism Pulmonary edema Congestive heart failure Acute coronary syndrome COPD exacerbation COPD Acute asthma exacerbation Lower RTI Chronic pulmonary emboli Acute heart valve insufficiency Pleural effusion Valvular heart disease Pneumothorax Sepsis Renal failure Foreign body aspiration Diabetic ketoacidosis Interstitial lung diseases Acute anxiety Myocarditis/Pericarditis Cardiomyopathies Cardiac tamponade Cardiac tamponade Neuromuscular disorders Paroxysmal tachydysrhythmias Thyrotoxicosis Tuberculosis Anaphylaxis, Ascites, Cirrhosis Guillain Barre syndrome Obesity, Deconditioning
- 31. History - Onset × Dyspnea on exertion • i.e. IHD, CHF, valvular insufficiency, interstitial lung disease etc × Dyspnea on rest • i.e. ACS, severe anxiety, acute asthma exacerbation etc × Any triggers • i.e. recent trauma, emotional stress, cold, wind, dust, mould, drugs, any new pets or plants, smoke inhalation, any phobias × Any diurnal variation • i.e. PND is seen in CHF × Any seasonal variation • i.e. seasonal variant asthma
- 32. History - Positionality × Orthopnea – dyspnea which occurs when lying supine Seen with pulmonary edema i.e. due to left ventricular failure × Platypnea – dyspnea that is relieved by lying down × Orthodeoxia – low oxygen saturation in upright position × Platypnea – Orthodeoxia syndrome Seen in postional right-to-left shunt (ASD, PFO), constrictive pericarditis, severe V/Q mismatch (mutliple pulmonary emboli), hepatopulmonary synd. × Trepopnea – dyspnea sensed while lying on one side but not the other Seen in heart failure, or due to disease of one lung / bronchus / pleura (i.e. unilateral pleural effusion)
- 33. History - Severity × Severity of dyspnea is subjective to the perception of the patient. × It is important to establish degree of severity of dyspnea in patients with chronic causes like heart failure, COPD or interstitial lung disease, as these can affect the quality of life. × We can use the following scales: • New York Heart Association (NYHA) functional classification - used mainly for patients with heart failure • Medical Research Council (MRC) scale - used mainly for patients with COPD • Veterans Specific Activity Questionnaire (VSAQ) - estimates aerobic capacity in meters
- 34. NYHA Class
- 35. MRC scale
- 36. History – Associated symptoms Chest pain Pleuritic chest pain Chest tenderness Fever Cough Sputum Hemoptysis Stridor Coryza Wheeze Palpitations Headache Syncope Diaphoresis • Dizziness • Dysphagia • Nausea, vomiting • Altered bowel habits • Fatigue • Gen. weakness • Gen. swelling • Myalgia, arthralgia • Abdominal pain • Weight loss • Decreased appetite • Blurred vision • GI bleed • Rash
- 37. History – Misc. × Past medical history • any medical conditions, past admissions, recent trauma or immobilization etc × Past surgical history • any major operations, history of difficult intubation or catheterization etc × Past gynecological and obstetric history • menstrual history, current or recent pregnancy and related complications etc × Family history • IHD, sudden cardiac death, TB, asthma, cancer, hematologic disorders etc × Occupational history • long standing/sitting hours, pneumoconiosis, carcinogen exposure etc × Drug use and abuse history • sedatives (narcotics, benzodiazepines), beta blockers, contraceptives etc × Personal history - diet, exercise, smoking, alcohol consumption
- 38. Dyspnea features in common diseases
- 39. Examination 7
- 40. General physical examination Sign Seen in • Pyrexia pulmonary embolism (PE), infections • Clubbing COPD, cirrhosis, lung cancer, ILD, pulmonary AV fistulas • Cyanosis COPD, PE, foreign body aspiration, congenital heart diseases • Jaundice liver failure, leptospirosis, hemolytic anemia • Goitre thyrotoxicosis, airway obstruction • Cold peripheries hypotension • Facial edema superior vena cava syndrome, anaphylaxis • Lower limb edema CHF, volume overload, MI, arrhythmias, valvular insufficiency • Urticarial rash anaphylaxis • Calf pain/tenderness DVT (Homans sign)
- 41. Cardiovascular examination Sign Seen in • Hypotension PE, MI, acute valvular insufficiency, cardiac tamponade, sepsis • Hypertension hypertensive heart failure, hyperthyroidism, pheochromocytoma • Pulsus paradoxus asthma, COPD, cardiac tamponade • Loud S2 pulmonary hypertension, cor pulmonale • Irregular heart beat tachydysrhythmias • Murmurs valvular insufficiency • Pericardial rub pericarditis • Muffled heart sounds cardiac tamponade • Engorged neck veins CHF, pneumothorax, tamponade • Kussmaul’s sign increased JVP on inspiration in constrictive pericarditis
- 42. Respiratory examination Sign Seen in • Pursed lip breathing COPD • Laryngeal descent COPD • Stridor upper airway obstruction • Hoarseness laryngitis, laryngeal tumours, vocal cord paralysis • Kyphoscoliosis restrictive lung disease, neuromuscular disorders • Barrel chest emphysema, cystic fibrosis • Tracheal deviation away from affected side in tension pneumothorax, hemothorax, pleural effusion • U/L dull percussion pleural effusion, atelectasis, pneumonia, F.B aspiration • Hyper-resonance pneumothorax, severe emphysema
- 43. Chest ascultation Sign Seen in • Reduced breath sounds pleural effusion, atelectasis, F.B aspiration, pneumothorax • Wheezing asthma, COPD, CF, anaphylaxis, PE, pulmonary congestion • Fine rales pulmonary edema (bibasal), • Coarse rales pneumonia • Velcro crackles interstitial lung disease • Pleural rub pleurisy
- 44. Neurological examination Sign Seen in • B/L progressive limb weakness with hyporeflexia Guillain–Barré syndrome • Cranial nerve palsies CNS infections, botulism • Ptosis myasthenia gravis, myotonic dystrophy, botulism • Pinpoint pupils opiate overdose • Altered mental state • hypoxaemic resp. failure related to CHF, pulmonary edema • asthma, COPD, pneumonia • sepsis, CNS infections
- 45. Investigations 8
- 46. PERC Rule × Low clinical pre-test probability × Plus: • Age < 50 years • Pulse < 100 b/m • SpO2 > 94% • No leg swelling • No hemoptysis • No recent trauma / surgery • No prior PE / DVT • No hormone use 8,138 patients Sensitivity 97.4 % False negative 0.9 %
- 47. Diagnostic tests × Nearly in all patients - Pulse oximetry - 12 lead ECG - Chest X-ray × In selected patients - Complete blood count (CBC) - Arterial blood gaes (ABGs) - Peripheral blood picture - Peak flow spirometry - Cardiac biomarkers - D-dimer - Brain natriuretic peptide (BNP) - Echocardiography - Ultrasound abdomen and pelvis - CT angiography (coronary) - CT angiography (pulmonary)
- 48. D-dimer × A fibrin degrataion product (FDP) - released after a blood clot undergoes fibrinolysis × Its blood levels are raised in - thromboembolic conditions - pro-thrombotic conditions × A negative test is useful in ruling out the following: - Deep venous thrombosis (DVT) - Pulmonary embolism (P.E) - Ischemic stroke - Disseminated intravascular coagulation (DIC) × A positive test warrants further investigation for underlying causes ELISA D-dimer Sensitivity 96 % Specificity 45 %
- 49. Brain natriuretic peptide × BNP is secreted by heart ventricles in repsonse to excessive stretching of cardiomyocytes × PreproBNP ProBNP BNP + NT-proBNP × Physiologic actions of BNP are: - vasodilation (decrease systemic vascular resistance) - natriuresis and diuresis (reduction in blood volume) × Net effect – decrease cardiac output and blood pressure × Useful in differentiating heart failure from other causes of dyspnea - Normal BNP levels ( < 100 pg/ml ) rule out acute heart failure - Raised levels ( > 500 pg/ml ) are not useful in diagnosis of acute HF - Raised levels are useful in prognosis in heart failure Sensitivity 100 % Specificity 85 % Half life 20 m