Dyspnea
Interstitial edema
What are J receptors sensitive to?
Episodes of myocardial ischemia Bronchospasm Pulmonary embolism
What are acute, intermittent episodes of dyspnea more likely to reflect?
Myasthenia gravis, Guillain-Barré syndrome, spinal cord injury, myopathy
What are conditions that add increased effort to breathe due to ventilatory muscles weakness?
Unsatisfied inspiration Feeling of suffocation Need for more air Cannot get enough air Hunger/starve for air Breath does not go all the way
What are possible patient perceptions of dyspnea?
Acute changes in pulmonary artery pressure
What are pulmonary vascular receptors activated by?
Severe respiratory distress Distended neck veins Hypotension Tachycardia Cyanosis Diphoresis
What are the clinical features of a tension pneumothorax?
if the resting O2 saturation is 89% or if the patient's saturation drops to these levels with activity
When should supplemental O2 be administered?
Located in skeletal muscle, are activated during exercise, contribute to the breathing discomfort
Where are Metaboreceptors and what do they do?
Constrictive pericarditis and cardiac tamponade
Which pericardial diseases cause dispnea?
A modified Borg scale (or visual analogue) -Borg - ask before treatment and after to see if you helped
How do you measure sensory intensity of dyspnea?
Impairment of the ventilatory pump with reduced vital capacity
If a patient has inability to speak in full sentences, what does this suggest?
Mechanical ventilation
Treatment for ARDS
Bronchodilators, inhaled corticosteroids, antibiotics, +/- NIPPV
Treatment for COPD exacerbations
Bronchodilators, inhaled corticosteroids
Treatment for asthma
Bronchoscopy
Treatment for foreign body aspiration
Diuretics
Treatment for heart failure, pulmonary edema
Pleural drainage
Treatment for hemothorax
Antibiotics
Treatment for pneumonia
Chest tube
Treatment for pneumothorax
Anticoagulation
Treatment for pulmonary embolism
Yes
Can lung parenchyma disease add to increased work to breathe and decreased compliance of the lungs?
Hyper-resonance on percussion
50 year old male with history of COPD - emphysema comes to ER with acute chest pain and difficulty breathing. The most important clinical sign likely to be present to confirm Diagnosis is
Anticoagulation with IV heparin or LMWH followed by long term warfarin
PE treatment
Airway obstruction or Bronchospasm (Asthma, COPD) Parenchyma (Pneumonia, pneumothorax, atelectasis, pleural effusion, pulmonary edema, ARDS, Pulmonary hemorrhage) Chest trauma Aspiration Pulmonary embolism Chest wall (Trauma, weakness, pain, restriction of movement (binding)) Diaphragm (elevation (ascites), weakness or paralysis) Neuromuscular disorders (myasthenia, GBS) Inhalation of toxic or irritant chemicals Lung cancer
What are the common causes of dyspnea?
Asthma and COPD
What are the most common obstructive lung diseases?
Tracheal and mediastinal shift Decreased chest expansion Decreased vocal fremitus Stony dull percussion note Decreased breath sounds
What are the physical exam findings of pleural effusion?
Tachypnea and respiratory distress Prominence of hemithorax Decreased movement of involved hemithorax Decreased tactile and vocal fremitus Hyper-resonant percussion note Decreased or distant breath sounds
What are the physical exam findings of pneumothorax?
Prior venous thromboembolism Immobilization, including air-travel Cancer Fractures, orthopedic surgery Medical conditions: CVA, CHF, hospitalization Surgery needing > 30 min of anesthesia Pregnancy, estrogen therapy Thrombophilia Age > 40 years
What are the risks for PE?
Asymptomatic Dyspnea Dry cough Pleuritic pain
What are the symptoms of pleural effusion?
Acute onset of dyspnea Pleuritic chest pain
What are the symptoms of pneumothorax?
Kyphoscoliosis, obesity, pleural effusion
What conditions add increased effort to breathe due to a reduction in chest wall compliance?
CHF Asthma
What does Nocturnal dyspnea suggest?
Interstitial pulmonary fibrosis
What does digit clubbing suggest?
Pulmonary venous hypertension
What does the presence of prominent pulmonary vasculature in the upper lung zones on a CXR indicate?
Air hunger
What elicits the strongest affective response regarding dyspnea?
Expiratory airflow obstruction
What feature are asthma and COPD characterized by?
Sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position
What is Paroxysmal nocturnal dyspnea (PND)?
Left atrial myxoma Hepatopulmonary syndrome
What is Platypnea (dyspnea in the upright position with relief in the supine position) indicative of?
Accumulation of abnormal and excessive amounts of fluid in pleural cavity
What is a pleural effusion?
Blood clot in pulmonary arterial circulation often originating in the leg Causes right ventricular overload and hypoxemia
What is a pulmonary embolism and what does it cause?
Compression of lung and mediastinal shift to contralateral side
What is characteristic of a tension pneumothorax?
COPD Interstitial lung disease Chronic thromboembolic disease
What is chronic persistent dyspnea is typical of?
Deviations from normal function in the cardiopulmonary systems
What is dyspnea the consequence of?
Blunt or penetrating trauma
What is hemothorax usually a consequence of?
Presence of blood in the pleural space
What is hemothorax?
Sensation of increased work of breathing and an inability to get a deep breath
What is hyperinflation?
Congestive heart failure (CHF) Mechanical impairment of the diaphragm associated with obesity Asthma triggered by esophageal reflux
What is orthopnea indicative of?
Is the sensation of breathlessness in the recumbent position, relieved by sitting or standing?
What is orthopnea?
*Thoracentesis* Thickness > 1 cm on decubitus film Classifies pleural effusion into transudate and exudate
What is the key test for pleural effusion?
Quality of sensation Use a questionnaire if tough for the patient to describe
What is the most important thing to consider when assessing dyspnea?
Immediate evacuation of air using a 14-G catheter, placed through second intercostal space in mid clavicular line After initial decompression, place standard chest tube
What is the treatment for a tension pneumothorax?
Pulmonary thromboemoblic disease and primary diseases of the pulmonary circulation (primary pulmonary hypertension, pulmonary vasculitis)
What pulmonary vascular diseases can cause dyspnea?
Activated by hypoxemia, acute hypercapnia, and acidemia
What states activate the chemoreceptors in the carotid bodies and medulla?
Bronchospasm - leads to chest tightness
What stimulates the mechanoreceptors in the lungs?
Focal oligemia (Westermark's sign) Progressive enlargement of central pulmonary artery (Fleischner's sign) Pleural based consolidation with rounded apex pointing to hilum (Hampton's hump)
What will some CXR findings be from a PE?
Tachycardia (HR > 100) Tachypnea (RR>20) Unilateral leg swelling-DVT
What will the physical exam findings be of a patient with PE?
during exercise, due to decreased oxygen carrying capacity
When does anemia cause dyspnea?
high cardiac output and impaired ventilatory pump function (decreased compliance of the chest wall)
When does obesity cause dyspnea?