Approach to patient with Dyspnea

ACUTE DYSPNEA - CARDIAC What is the diagnostic approach to a patient with heart failure as an underlying cause of dyspnea?

(1) Chest xray, (2) ECG, (3) BNP measurement, (4) Echocardiography

SUBACUTE DYSPNEA - PULMONARY (1) What are the suggestive findings of COPD exacerbation as an underlying cause of dyspnea? (2) What is the diagnostic approach as a

(1) Cough, productive or nonproductive; poor air movement; accessory muscle use or pursed lip breathing (2) Clinical evaluation; Sometimes chest x-ray and ABGs

ACUTE DYSPNEA - PULMONARY What is the diagnostic approach to a patient with dyspnea from toxic airway damage (eg, inhalation of chlorine, hydrogen sulfide)

Inhalation usually obvious by history. Chest x-ray. Sometimes ABGs, observation to determine severity

ACUTE DYSPNEA - PULMONARY What is the diagnostic approach to foreign body inhalation?

Inspiratory and Expiratory chest x-rays. Sometimes bronchoscopy

ACUTE DYSPNEA - CARDIAC What is the suggestive findings of acute myocardial ischemia or infarction as an underlying cause of dyspnea.

Substernal chest pressure with or without radiation to the arm or jaw, particularly in patients with risk factors for CAD

ACUTE DYSPNEA - PULMONARY What is the suggestive findings of toxic airway damage (eg, inhalation of chlorine, hydrogen sulfide)

Sudden onset after occupational exposure or inappropriate use of cleaning agents

ACUTE DYSPNEA - CARDIAC What is the suggestive findings of papillary muscle dysfunction or rupture as an underlying cause of dyspnea?

Sudden onset of chest pain, new or loud holosystolic murmur, and signs of heart failure, particularly in patients with recent MI.

ACUTE DYSPNEA What is the suggestive findings of foreign body inhalation?

Sudden onset of cough or stridor in a patient (typically an infant or young child) without URI or constitutional symptoms

INTERPRETATION of FINDINGS Hyperventilation syndrome is a diagnosis of exclusion. Because hypoxia may cause __________ and ________, it is unwise to assume every rapidly breathing, anxious young person merely has hyperventilation syndrome.

Tachypnea and Agitation

EXAMINATION - Physical Exam What does the extremity exam reviewed for?

The cervical, supraclavicular, and inguinal areas should be inspected and palpated for lymphadenopathy. Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema (both suggesting heart failure).

EXAMINATION - Physical Exam What are the VS are reviewed for? .

fever, tachycardia and tachypnea

EXAMINATION - Physical Exam What does the cardiovascular exam reviewed for?

Heart sounds should be auscultated with notation of any extra heart sounds, muffled heart sounds, or murmur. Testing for pulsus paradoxus (a > 12 mm Hg drop of systolic BP during inspiration) can be done by inflating a BP cuff to 20 mmHg above the systolic pressure and then slowly deflating until the first Korotkoff sounds are heard only during expiration. As the cuff is further deflated, the point at which the first Korotkoff sound is audible during both inspiration and expiration is recorded. If the difference between the first and second measurement is > 12 mm Hg, then pulsus paradoxus is present.

EVALUATION - History of Present Illness - What are the five things to investigate with the HPI in the evaluation of dyspnea?

History of Present Illness - should cover the (1) duration, (2) temporal onset (eg, abrupt, insidious), and (3) provoking or exacerbating factors (eg, allergen exposure, cold, exertion, supine position). (4) Severity can be determined by assessing the activity level required to produce dyspnea (ie, dyspnea at rest is more severe than dyspnea only with climbing stairs). (5) For patients with baseline dyspnea, the physician should note how much dyspnea has changed from the patient's usual state.

TESTING in DYSPNEA What are the indications for ordering ABGs and what are they used for in the patient with dyspnea?

In patients with severe or deteriorating respiratory status, ABGs should be measured to more precisely quantify hypoxemia, measure PaCO2, diagnose any acid-base disorders stimulating hyperventilation, and calculate the alveolar-arterial gradient.

ACUTE DYSPNEA - CARDIAC What is the diagnostic approach for suspected myocardial ischemia or infarction as a cause of dyspnea?

ECG and Cardiac Enzyme Testing

EXAMINATION - Physical Exam What does the pulmonary exam reviewed for?

A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor, and wheezes. Signs of consolidation (eg, E to A change, dullness to percussion) should be sought.

SUGGESTIVE FINDINGS - ACUTE DYSPNEA What are the suggestive findings of pulmonary embolism?

(1) Abrupt onset of sharp chest pain tachypnea, tachycardia (2) Often risk factors for pulmonary embolism (eg, cancer, immobilization, DVT, pregnancy, use of oral contraceptives or other estrogen-containing drugs, recent surgery or hospitalization, family history).

SUGGESTIVE FINDINGS - ACUTE DYSPNEA What are the suggestive findings of pneumothorax?

(1) Abrupt onset of sharp chest pain, tachypnea, diminished breath sounds, hyperresonance to percussion (2) May follow injury or occur spontaneously (especially in tall, thin patients who smoke and in COPD patients).

ETIOLOGY of DYSPNEA Dyspnea has many pulmonary, cardiac, and other causes, which vary by acuity of onset (see Table 1). What are the five most common causes of dyspnea?

(1) Asthma (2) COPD (3) Pneumonia (4) Myocardial Ischemia (5) Deconditioning

ETIOLOGY of DYSPNEA How are the causes of dyspnea classified?

(1) By acuity of onset (a) acute onset (within minutes), (b) subacute onset (hours to days) (c) chronic onset (hours to years (2) Sub-classified by organ systems (a) Pulmonary Causes (b) Cardiac Causes (c) Other Causes

SUGGESTIVE FINDINGS - ACUTE DYSPNEA What is the initial diagnostic approach to patient with suspected pneumonthorax?

(1) Chest xray

CHRONIC DYSPNEA - CARDIAC (1) What are the suggestive findings of Heart Failure as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected heart failure as an underlying cause of dyspepsia?

(1) Crackles, S3 gallop, and signs of central or peripheral volume overload (eg, elevated neck veins, peripheral edema) - - Dyspnea with lying flat (orthopnea) or that appears 1-2 h after falling asleep (paroxysmal nocturnal dyspnea) (2) Chest xray, ECG, Echocardiography

What are the SEVEN RED FLAG FINDINGS to watch for in a patient presenting with dyspnea?

(1) Dyspnea at rest during examination (2) Decreased level of consciousness or agitation or confusion (3) Accessory muscle use, poor air excursion (4) Chest Pain (5) Crackles (6) Weight Loss (7) Night Sweats

CHRONIC DYSPNEA - OTHER CAUSES (1) What are the suggestive findings of anemia as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected anemia as an underlying cause of dyspnea?

(1) Dyspnea on exertion progressing to dyspnea at rest - Normal lung examination and pulse oximetry measurement - Sometimes systolic heart murmur from increased flow. (2) CBC

CHRONIC DYSPNEA - OTHER CAUSES (1) What are the suggestive findings of deconditioning as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected deconditioning as an underlying cause of dyspnea?

(1) Dyspnea only on exertion in patients with sedentary lifestyle (2) Clinical Evaluation

ETIOLOGY of DYSPNEA The most common cause of dyspnea in patients with chronic pulmonary and/or cardiac disorders is what?

(1) Exacerbation of their disease NOTE - However, such patients may also acutely develop another condition (eg, a patient with long-standing asthma may have an MI, a patient with chronic heart failure may develop pneumonia).

CHRONIC DYSPNEA (HOURS to YEARS) - PULMONARY CAUSES (1) What are the suggestive findings of obstructive lung disease? (2) What is the diagnostic approach for obstructive lung disease as an underlying cause of dyspnea?

(1) Extensive smoking history, barrel chest, poor air entry and exit. (2) Chest x-ray, Pulmonary function testing (on initial evaluation)

SUBACUTE DYSPNEA - PULMONARY (1) What are the suggestive findings of pneumonia as an underlying cause of dyspnea? (2) What is the diagnostic approach for a patient with suspected pneumonia as an underlying cause of dyspnea?

(1) Fever, productive cough, dyspnea, sometimes pleuritic chest pain. Focal lung findings, including crackles, decreased breath sounds, and E to A change on auscultation. (2) Chest x-ray; sometimes blood and sputum cultures; WBC count

CHRONIC DYSPNEA - PULMONARY (1) What are the suggestive findings of interstitial lung disease as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected interstitial lung disease as an underlying cause of dyspnea?

(1) Fine crackles on auscultation (2) High-resolution chest CT

TREATMENT of DYSPNEA Primary goal is treatment of underlying disorder. Hypoxemia is treated with supplemental O2 as needed to maintain SaO2 > __% or PaO2 > __ mmHg, as levels above these thresholds provide adequate O2 delivery to tissues. Levels below these thresholds are on the steep portion of the O2-Hb dissociation curve, in which small declines in arterial O2 tension result in large declines in Hb saturation, O2 saturation should be maintained at > __% if myocardial or cerebral ischemia is a concern.

(1) Hypoxemia is treated with supplemental O2 as needed to maintain SaO2 > 88% or PaO2 > 55 mmHg. (2) O2 saturation should be maintained at > 93% if myocardial or cerebral ischemia is a concern.

TREATMENT of DYSPNEA Morphine 0.5 to 5mg IV helps reduce anxiety and the discomfort of dyspnea in various conditions, including (1), (2), and the dyspnea that commonly accompanies terminal illness. However, opioids can be deleterious in patients with acute airflow limitation eg, (3), (4) because they suppress the ventilatory drive and worsen respiratory acidemia.

(1) MI (2) PE (3) Asthma (4) COPD

SUBACUTE DYPSNEA - CARDIAC (1) What are the suggestive findings of pericardial effusion or tamponade as an underlying cause of dyspnea? (2) What is the diagnostic approach of pericardial effusion or tamponade?

(1) Muffled heart sounds or enlarged cardiac silhouette in patients with risk factors for pericardial effusion (eg, cancer, pericarditis, SLE). Pulsus paradoxus may be present (2) Echocardiography

CHRONIC DYSPNEA - PULMONARY (1) What are the suggestive findings of pleural effusion as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected pleural effusion as an underlying cause of dyspepsia?

(1) Pleuritis chest pain, lung field that is dull to percussion with diminished breath sounds. Sometimes history of cancer, heart failure, RA, SLE, or acute pneumonia (2) Chest x-ray, Often chest CT and thoracentesis

CHRONIC DYSPNEA - PULMONARY (1) What are the suggestive findings of restrictive lung disease as an underlying cause of dyspnea? (2) What is the diagnostic approach for restrictive lung disease as an underlying cause of dyspnea?

(1) Progressive dyspnea in patients with known occupational exposure or neurologic condition (2) Chest x-ray; Pulmonary function testing (on initial evaluation)

ETIOLOGY of DYSPNEA - What are the acute (within minutes) causes of dyspnea?

(1) Pulmonary Causes - (a) pneumothorax, (b) pulmonary embolism, (c) asthma, bronchospasm, or reactive airway disease, (d) foreign body inhalation, (e) Toxic airway damage (eg, inhalation of chlorine, hydrogen sulfide) (2) Cardiac Causes - (a) Acute myocardial ischemia or infarction, (b) Papillary muscle dysfunction or rupture, (c) heart failure. (3) Other Causes - (a) Diaphragmatic paralysis, (b) Anxiety disorder - hyperventilation.

ETIOLOGY of DYSPNEA - What are the chronic (hours to years) causes of dyspnea?

(1) Pulmonary causes - (a) Obstructive lung disease, (b) Restrictive lung disease, (c) Interstitial lung disease, (d) Pleural effusion. (2) Cardiac causes - (a) Heart failure, (b) Stable angina or (c) CAD (3) Other causes - (a) Anemia, (b) Physical deconditioning

ETIOLOGY of DYSPNEA - What are the subacute (hours to days) causes of dyspnea?

(1) Pulmonary causes - (a) Pneumonia, (b) COPD exacerbation (2) Cardiac causes - (a) Angina or CAD, (b) Pericardial effusion or tamponade.

What is the diagnostic approach to patient with dyspnea?

CT angiography or V/Q scan; Doppler or duplex studies of extremities showing positive findings of DVT.

What are the FIVE KEY POINTS to remember in the approach to patient with dyspnea?

(1) Pulse oximetry is a key component of the examination (2) Low O2 saturation (< 90%) indicates a significant problem, but normal saturation does not rule one out. (3) Accessory muscle use, low O2 saturation, or decreased level of consciousness requires emergent evaluation and hospitalization. (4) Myocardial ischemia and PE are relatively common, but symptoms and signs can be nonspecific (5) Exacerbation of known conditions (eg, asthma, COPD, heart failure) is common, but such patients also may develop new problems.

ACUTE DYSPNEA - OTHER CAUSES (1) What are the suggestive findings of anxiety disorder-hyperventilation? (2) What is the diagnostic approach for a patient with anxiety disorder-hyperventilation?

(1) Situational dyspnea often accompanied by psychomotor agitation and parestesias in the fingers or around the mouth. Normal examination findings and pulse oximetry measurements. (2) Clinical evaluation and diagnosis of exclusion

CHRONIC DYSPNEA - CARDIAC (1) What are the suggestive findings of stable angina or CAD as an underlying cause of dyspnea? (2) What is the diagnostic approach for suspected stable angina or CAD as an underlying cause of dyspnea?

(1) Substernal chest pressure with or without radiation to the arm or jaw, often provoked by physical exertion, particularly in patients with risk factors for CAD (2) ECG, Cardiac Stress Testing, Sometimes cardiac catheterization

SUBACUTE DYSPNEA - CARDIAC (1) What are the suggestive findings of Angina or CAD as an underlying cause of dyspnea? (2) What is the diagnostic approach of Angina or CAD as an underlying cause of dyspnea?

(1) Substernal chest pressure with or without radiation to the arm or jaw, often provoked by physical exertion, particularly in patients with risk factors for CAD (2) ECG, Cardiac stress testing; Cardiac catheterization

ACUTE DYSPNEA - OTHER CAUSES (1) What are the suggestive findings of diaphragmatic paralysis as an underlying cause of dyspnea? (2) What is the initial diagnostic approach to patient with diaphragmatic paralysis?

(1) Sudden onset following trauma affecting the phrenic nerve. Frequent dyspnea with lying flat (orthopnea) (2) Chest X-ray and Fluoroscopic sniff test

EVALUATION - Physical Examination What are the seven systems evaluated in the physical exam for dyspnea?

(1) Vital Signs (2) General Appearance (3) Pulmonary exam (4) Cardiovascular Exam (5) Extremity Exam (Neck Veins, Lymphadenopathy and Lower extremity edema) (6) Eye Exam - Conjunctiva (7) Rectal Exam - stool guaiac testing

INTERPRETATION of FINDINGS Several Findings are Significant (1) Wheezing suggests what? (2) Stridor suggests what? (3) Crackles suggests what?

(1) asthma or COPD (2) extrathoracic airway obstruction (eg, foreign body, epiglottitis, vocal cord dysfunction). (3) left heart failure, interstitial lung disease, or if accompanied by signs of consolidation, pneumonia.

TESTING in DYSPNEA Patients who have no clear diagnosis after chest x-ray and ECG and are at moderate or high risk of having PE (from the clinical prediction rule--see Chest Pain, Table 2) should undergo (test1) or (test2). Patients who are at low risk may have (test3) (to detect the presence of clot), a normal level effectively rules out PE in a low-risk patient. Chronic dyspnea may warrant additional tests, such as (test4), (test5), (test6) or (test7) .

(test1) ventilation/perfusion scanning or (test2) CT-angiography (test3) D-dimer testing (test4) CT scanning, (test5) pulmonary function tests, (test6) echocardiography (test7) bronchoscopy

Describe the pathophysiology of dyspnea

Although dyspnea is a relatively common problem, the pathophysiology of the "uncomfortable sensation of breathing" is poorly understood. Unlike those for other types of noxious stimuli, there are no specialized "dyspnea receptors". The experience of dyspnea likely results from a complex iteraction between chemoreceptor stimulation, mechanical abnormalitiees in breathing, and the perception of those abnormalities by the CNS.

ACUTE DYSPNEA - CARDIAC What is the diagnostic approach for suspected papillary muscle dysfunction or rupture as an underlying cause of dyspnea?

Auscultation and Echocardiography

EXAMINATION - Physical Exam What is the eye exam reviewed for?

Conjunctiva should be examined for pallor. (Suggesting Anemia)

ACUTE DYSPNEA - CARDIAC What are the suggestive findings of heart failure as an underlying cause of dyspnea?

Crackles, S3 gallop, and signs or central or peripheral volume overload (eg, elecated neck veins, peripheral edema). Dyspnea with lying flat (orthopnea) or that appears 1-2 h after falling asleep (paroxysmal nocturnal dyspnea)

Define dyspnea.

Dyspnea is unpleasant or uncomfortable breathing. It is experimental and described differently by patients depending on the cause.

TESTING in DYSPNEA What are the indications for ordering an ECG and cardiac markers in a patient presenting with dyspnea?

Most adults should have an ECG to detect myocardial ischemia (and serum cardiac marker testing if suspicioun is high) unless myocardial ischemia can be excluded clinically.

What is an important consideration to remember in the work-up of dyspnea

Most patients should have pulse oximetry and, unless symptoms are clearly a mild exacerbation of known chronic disease, chest x-ray.

TESTING in DYSPNEA What are the indications for ordering a pulse oximetry and chest x-ray in the work-up of dyspnea?

Pulse oximetry should be done in all patients, and a chest x-ray should be done as well unless symptoms are clearly caused by a mild or moderate exacerbation of a known condition.

EXAMINATION - Physical Exam What is the rectal exam reviewed for?

Rectal examination and stool guaiac testing should be done.

INTERPRETATION of FINDINGS However, the signs and symptoms of life-threatening conditions such as myocardial ischemia and PE can be nonspecific.Furthermore, the severity of symptoms is not always proportional to the severity of the cause (eg, PE in a fit, healthy person may cause only mild dyspnea). Thus, a high degree of suspicion for these common conditions is prudent. It is often appropriate to rule out thses conditions before attributing dyspnea to a less serious etiology. A clinical prediction rule can help estimate the risk for PE (see also Chest Pain, Table 2 and Fig. 1). Note that a normal O2 saturation does not exclude PE.

SIT BACK AND TAKE IT IN... THIS ONES ON THE HOUSE

EVALUATION - Past Medical History Should cover disorders known to cause dyspnea, such as (1), (2), and (3). As well as risk factors for the different etiologies: (4), (5), and (6). Also ask about certain exposures (7).

Should cover disorders known to cause dyspnea, including (1) asthma, (2) COPD, and (3) heart disease, as well as risk factors for the different etiologies: (4) Smoking History - for Cancer, COPD, and Heart Disease; (5) Family History, Hypertension, and High Cholesterol levels -- for coronary artery disease; (6) Recent immobilization or surgery, recent long-distance travel, cancer or risk factors or signs of occult cancer, prior or family history of clotting, pregnancy, oral contraceptive use, calf pain, leg swelling, and known deep venous thrombosis--for PE. (7) Occupational exposures (eg, gases, smoke, asbestos) should be investigated.

EVALUATION - Review of Systems Should seek symptoms of underlying causes. What is the FIVE sets of symptoms reviewed, and their associated underling causes, in the ROS for dyspnea?

Should seek symptoms of possible causes, including (1) chest pain or pressure (pulmonary embolism [PE], myocardial ischemia, pneumonia); (2) dependent edema, orthopnea, and paroxysmal nocturnal dyspnea (heart failure); (3) fever, chills, cough, and sputum production (pneumonia); (4) black, tarry stools or heavy menses (occult bleeding possibly causing anemia); and (5) weight loss or night sweats (cancer or chronic lung infection).