Chapter 16: Dyspnea

Chronic bronchitis

Inflammation, edema, and excessive mucus production in the bronchial tree Use their neck and chest muscles to assist with breathing --> appear to struggle to get air into their lungs Usually have a productive cough and a history of repetitive respiratory infections Often cough Rhonchi and wheezing may be heard on both inspiration and exhalation

Neck

Jugular veins for distention --> decompensated heart failure or pericardial tamponade

Vital signs

Tachycardia and tachypnea --> accompany dyspnea Hypotension --> trauma, anaphylactic shock, AMI Fever --> pulmonary causes, AMI

Suggestions of hypoxia

Tachypnea or bradypnea tachycardia cyanosis restlessness agitation confusion occasionally combative behavior

Accessory muscles

Use of the neck and chest wall muscles to assist with breathing --> work of breathing is too great for the diaphragm alone Abdominal breathing --> later sign that indicates the patient is beginning to tire

Hyperventilation

Usually brought on by psychological stress --> typically occurs in young, anxious patients May also be brought on by an overdose of aspirin or the need to compensate for metabolic acidosis Characterized by rapid, deep, or abnormal breathing

A patient with 6 gm/100 cc of hemoglobin

Won't be cyanotic if more than 1 gm/100 cc are oxygenated dramatically reduced oxygen-carrying capacity --> approx. 40-50% of normal Won't become cyanotic until carrying less than 9% oxygen of a normal healthy patient

If a tension pneumothorax is present

Immediate needle decompression of the chest is indicated

Signs of labored respirations

Use of accessory muscles Tracheal tugging Nasal flaring

Normal adult has how much hemoglobin?

12 to 15 gm/100 cc Severely anemic patient may have significantly less hemoglobin

Lungs

Evidence of abnormal breath sounds Noisy chest that became quiet --> sign of danger because the patient cannot generate enough airflow to create wheezes Patient is rapidly deteriorating and steps should be taken immediately to prevent loss of the airway Evidence of blunt or penetrating trauma --> intrathoracic injury, including pericardial tamponade, tension pneumothorax, and hemothorax

Chest pain associated with the dyspnea

Cardiovascular problems often cause the patient to experience difficulty in breathing Significant finding and may be the initial complaint

Pneumonia

Causes lung inflammation and fluid- or pus-filled alveoli --> inadequate oxygenation of the blood Most frequently caused b y a bacterial or viral infection May occur after aspiration of fluids (vomit) or inhalation of irritants (chemicals or smoke)

Respiratory patterns may indidcate

Central nervous system (CNS) impairment - Cheyne Stokes respirations Medical emergencies - Kussmaul's respirations

Pleural effusions

Collections of fluid, blood (hemothorax), or pus in the pleural space --> cause dyspnea by compressing the lungs Etiologies --> congestive heart failure, pneumonia, cancer, tuberculosis, and cirrhosis

Evidence of infection

Cough (esp. productive cough), fever, chills may indicate an infectious etiology such as pneumonia

Anemia

Decreased red blood cell mass --> results in a decreased oxygen-carrying capacity May result from inadequate red blood cell production, blood loss, or premature destruction of red blood cells May be chronic or acute

Abdomen

Diaphragmatic breathing --> problem with the CNS

Emphysema

Distention beyond the bronchioles with destruction of alveolar septa Usually thin as a result of weight loss and provide a history of dyspnea on exertion Exhalation is prolonged and difficult --> lung still expanded after exhalation --> Barrel-shaped appearance to the chest Respirations are rapid Breath sounds are distant and difficult to hear May appear short of breath and purse their lips during exhalation

Carbon Monoxide Poisoning

May cause hypoxia and therefore dyspnea

Absent breath sounds

May indicate a pneumothorax or tension pneumothorax

Severity

Mild - manifesting as dyspnea on exertion Severe - dyspnea occurs even at rest

Pulmonary embolism

Most often involves acute shortness of breath with tachycardia May complain of a pleuritic type of chest pain that may be increased on inspiration Common symptoms include chest pain, dyspnea, and cough Physical findings include tachypnea (RR >16), tachycardia, temperature greater than 100.04 F Risk factors include history of atrial fibrillation, obesity, pregnancy, prolonged immobilization, posttrauma, oral contraceptive use, postsurgery, and cancer.

Heart

Muffled heart tones --> pericardial tamponade

Pneumothorax

Occurs when air enters the pleural sac surrounding the lungs Can be caused by trauma or may occur spontaneously Tension pneumo --> usually results from trauma or from a spontaneous pneumo Physical findings of a simple pneumothorax include absent or diminished breath sounds, tracheal deviation, and hyperresonant percussion notes Physical findings of a tension pneumothorax include that of a simple pneumo also JVD

Acute pulmonary edema

Occurs when an excess of fluid builds up in the extravascular space in the lungs Usually results from a fluid overload in the pulmonary circulation due to an AMI-damaged left ventricle Inadequate cardiac output may cause dyspnea in patients with symptomatic tachycardias or bradycardias Also be caused by drowning, aspiration pneumonia, and smoke or toxin inhalation

Pericardial tamponade

Often complain of difficulty breathing May result from penetrating or blunt trauma to the chest May develop over a time period from minutes to approximately 1 week Muffled heart tones with JVD and narrowed pulse pressure --> Beck's Triad

Patient in distress

Rapid (greater than 25 breaths per minute) and deep pattern of breathing RR may be slow (less than 9 breaths) and shallow if respiratory drive has been depressed

Skin

Peripheral cyanosis

Extremities

Peripheral pulses may be absent as perfusion decreases --> trauma as a cause Assess fingers for clubbing and the nailbeds for cyanosis

Aspiration

Persistent localized wheezing --> esp. in patient who cannot protect their airways well Usually produces an obstruction of the upper airway --> likely to produce stridor than frank wheezing More likely to occur in young children and older debilitated patients who cannot protect their airway

Acute myocardial infarction

Primary symptom of dyspnea and admit to chest pain

Status asthmaticus

Prolonged and life-threatening form of asthma that cannot be controlled with epinephrine

Acute/sudden onset

Pulmonary embolism, pneumothorax, bronchospasm, and acute pulmonary edema

Causes

Pulmonary or cardiac disease Any mechanism that causes hypoxia

Mental Status

Signs of altered mental status --> sensitive indicator of inadequate cerebral perfusion and hypoxia

Other medical problems

Respiratory and cardiovascular diseases --> common causes of dyspnea Diabetes and AIDS --> result in difficulty breathing

Acute asthma

Reversible, episodic disease in which an obstruction results from one oro more of the three "Ss": Spasm, swelling, and secretions. Wheeze may be present, commonly in expiration, but also on inspiration. Severe bronchospasm --> there may be no wheezing

If an open pneumothorax is present

Sealed immediately (on three sides) with an air occlusive dressing

How do patients describe dyspnea?

Sensation of shortness of breath Feeling of "air hunger" Accompanied by labored breathing

Anaphylaxis

Wheezing may be a manifestation --> histamine release and inflammation lead to narrowing of the airways Rash, edema, hypotension.