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?