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Clinical approach to a patient with shortness of breath

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Hazem Zoma

on 27 October 2013

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Transcript of Clinical approach to a patient with shortness of breath

Definitions of Dyspnea or air hunger
• It is the subjective experience of breathing discomfort of qualitatively distinct sensations that vary in intensity.
(American Thoracic Society Definition)

• Shortness of breath, or difficulty in breathing.
• Uncomfortable awareness of breathing.
• Disordered or inadequate breathing.

Physiological mechanisms of diseases causing dyspnea:
Clinical evaluation of dyspnea
Treatable vs Non treatable diseases
Clinical approach to a patient with shortness of breathing
Done by :

1-Hazem Khalil El-sayed >>>462
2-Habiba Salah El-deen Morsi>>>466
3-Hossam Hassan Korani>>>469
4-Hossam Refaat El-Hosieny>>>471
5-Hossam Abd El-nasser Hassan>>>472
6-Helmy Sobhy Helmy>>>481
7-Hazem Othman Ibrahim>>>463
Physiological mechanisms
Physical examination
accurate diagnosis
Mechanical interference with ventilation
As asthma, emphysema and kyphoscoliosis.
Weakness of respiratory pump
as poliomyelitis and neuromuscular disease.
Increased respiratory drive
As hypoxemia or metabolic acidosis.
Increased wasted ventilation
large vessel obstruction (pulmonary embolism) or small vessel destruction (emphysema and interstitial lung disease).
Psychological dysfunction
anxiety (hyperventilation syndrome) and depression.
• pulmonary embolism
• Bronchiolitis
• COPD, asthma, and other chronic lung problems
• Pneumonia
• Pulmonary hypertension
• Restrictive lung disorders
• Hereditary pulmonary diseases

• Heart attack or angina
• congenital heart disease
• Heart failure
• arrhythmias
• Coronary heart disease- myocardial infarction.
• Cardiomyopathy
• Valvular dysfunction
• Left ventricular hypertrophy
• Pericarditis

- COPD with pulmonary hypertension and cor-pulmonale.
- Chronic pulmonary emboli
- Trauma

Mixed cardiac and pulmonary causes
- Metabolic conditions e.g. anemia and diabetic ketoacidosis.
- Pain in chest wall or elsewhere in the body
- Neuromuscular disorders e.g. multiple sclerosis and muscular dystrophy
- Otorhinolaryngeal disorders e.g. nasal obstruction due to polyps or septal deviation, enlarged tonsils and supraglottic or subglottic airway stricture.
- Functional e.g. anxiety, panic disorders and hyperventilation.

Non cardiac non pulmonary
• Allergies
• Climbing to high altitudes (low O2)
• Compression of the chest wall
• Dust
• Hiatal hernia
• Obesity

Other problems
Physical examination
Dyspnea analysis
- Onset
- Course
- Duration
- Relation to : Time
- Continuous or Paroxysmal (precipitating factors)

Acute dyspnea
- Astma
-FB inhalation
-Pulmonary embolism
-Acute pulmonary edema
- Beta blockers may exacerebrate bronchospasm or limit exercise tolerance.
- Pulmonary fibrosis is a rare side effect of some medications.

Paroxysmal Dyspnea
-Allergic alveolitis
-Mediastinal syndrome
-Myasthenia gravis
-Showers of pulmonary emboli
Postural variation
-Mediastinal syndrome
occurs in supine position and relieved in prayers position
Grades of exertional dyspnea
G1 : on severe exertion
G2 : on moderate exertion
G3 : on mild exertion
G4 : at rest
Coronary artery disease
General examination
-Increased pulse and increased respiratory rate :
probable signs of organic disease.
-Increased Blood Pressure (BP) :
diastolic dysfunction or frank heart disease
-Excessive obesity and sleepiness :
obstructive sleep apnea (OSA) and obesity hypoventilation syndrome.
-Posture (leaning forward and using arms as tripods, pursed lip breathing, use of accessory muscles of respiration) :
-Pallor :

- Jaundice

liver disease
- Cyanosis :
-Rashes on skin :
dermatomyositis, vasculitis, purpura, amyloid, telangiectasia

-Nasal polyps, purulent nasal discharge

-Cigarette use
: breath odor or nicotine stains on fingers.

-Lip and tongue telangiectasia
: hereditary hemorrhagic telangiectasia (Osler –Weber-Rendu Disease)

-Central wheeze while ausculting
: tracheo- laryngeal or tracheal diseases.

-Jugular venous distention
: right heart failure (RHF).

-Examine carotid arteries for delayed upstroke and transmitted systolic murmur to neck :
aortic stenosis

ENT & Head and Neck examination
Chest examination

-Inspect for chest wall deformity
(kyphoscoliosis, pectus excavatum).

-Dullness to percussion and decreased breath sounds at base :
suggest a pleural effusion.

-Hyperresonance, hyperexpansion, prolonged expiratory phase, Hoover’s sign
(low chest wall retractions with inspiration) emphysema

-Expiratory wheezes
: airway obstruction.

Cardiac Examination:

-Palpation of a RV heave :
right ventricular hypertrophy (RVH)

-Palpable P2:
associated with pulmonary hypertension.

-Thrill of aortic stenosis.

-Arrhythmia of organic heart disease

-Accentuated S1:
in mitral stenosis

-Fixed splitting of S2 :
in atrial septal defect
-S2 muffled or absent in aortic area :
in severe aortic stenosis or aortic insufficency.

-S2 increased
: in pulmonary area with pulmonary hypertension.

-S3 gallop:
in CHF.

-Opening snap and diastolic rumbling murmur:
in mitral stenosis

-Diastolic rumbling murmur and no opening snap :
Austin-Flint murmur in aortic insufficiency

-Murmur of mitral insufficiency
-Murmur of aortic stenosis
-murmur of aortic insufficiency :
blowing diastolic murmur coming of S2, heard best at Erb's point with the patient leaning forward

Abdominal Examination

- Abdominal paradox :
bilateral diaphragmatic paralysis or severe weakness and fatigue
-Ascites :
liver disease

-Enlarged liver :
primary liver disease or liver engorgement from RV failure or impaired filling of right heart due to constrictive pericarditis.

Examination of Extremities

-Edema :
right heart failure (RHF)
-Clubbing :
lung cancer, right to left shunt, pulmonary fibrosis

-Active synovitis, chronic joint deformity, subcutaneous nodules, muscle tenderness :
rheumatologic disorders.

-Muscle weakness and atrophy :
hereditary neuromuscular disorders.

Pulse oximetry
and ongoing
with initiation of oxygen supplementation as necessary, while undertaking diagnostic workup for its cause.
1-Hypercapnia (PaCO2 >45 mmHg)

2-Hypocapnia >>>

3- Hypoxemia (PaO2 <70 mmHg at sea level)
-V/Q mismatching

4 -Alkalosis

5-Acidosis (pH <7.36)
-late phases of any process accompanying dyspnea
-idiopathic renal tubular acidosis

1- leukocytosis >>
infectious diseases

2- Eosinophilia >>
parasitic disease, certain vasculitides (e.g., Churg-Strauss syndrome), asthma, eosinophilic pneumonia, or cocaine use.

3-Anemia >>
the primary reason or may accompany it in drug-related lung injury, hereditary hemorrhagic telangiectasia, acute chest syndrome of sickle cell disease, pulmonary alveolar hemorrhage, or widespread infectious processes.

viral infections & adverse drug reactions

1- helps to diagnose
acute coronary syndromes
as the cause of dyspnea with ST segment changes.

2- Identifies
complete heart block, bradycardias, and tachyarrhythmias,
and detects changes suggestive of
pericarditis, cardiac tamponade
(low voltage), and

pulmonary embolism.

3- Changes in the p-wave morphology may help diagnose
right atrial enlargement
(typical of a chronic pulmonary process) or

left atrial enlargement
(typical of valvular heart disease).

4- Change in the QRS axis may indicate

right (COPD, pulmonary hypertension) or left (hypertension, valvular heart disease) ventricular enlargement or hypertrophy.

-This is important to exclude
spontaneous or secondary pneumothorax
-Pulmonary venous congestion and an enlarged heart suggest
congestive heart failure.

Pulmonary Function Tests: (The most common is spirometry):
An obstructive deficit
(low FEV1/FVC ratio, increased residual volume, increased total lung capacity), seen in asthma, bronchitis, and emphysema.

A restrictive deficit
(symmetric reduction of FEV1 and FVC, high FEV1/FVC ratio, low total lung capacity), seen in interstitial lung disease.

Cardiopulmonary exercise testing.
-A detailed analysis of the cardiorespiratory response to exercise.

-Allows the evaluation of
cardiac function, pulmonary gas exchange, and ventilation, and the detection of cardiac ischemia, exercise-related obstructive lung disease, and deconditioning

Subacute dyspnea
Same as acute +
- Pneumonia
- Acute bronchitis
- Salicylate poisoning

Non acute onset
- Obstructive lung disease
- Restrictive lung disease
- Pleural effusion
- Interstitial lung disease
- Ventricular dysfunction
- Pericardial effusion and tamponade
- Anemia

emphysema, chronic bronchitis, asthma
Allergies, wheezing, family history of asthma
High blood pressure
left ventricular hypertrophy, CHF.
hyperventilation, panic attacks
Recent trauma
pneumothorax, chest wall pain limiting respiration.
Occupational exposure to dust, asbestos, volatile chemicals:
Interstitial lung disease.
The choice of investigations is dictated by the clinical history and physical exam findings.
Physical examination
- Treatment of dyspnea is mainly directed at the cause.
>> bronchodilators and antiinflamatory.
>> chest tube.
Heart failure
>> diuretics and nitrate.
- Positioning (sitting up).
- Increasing air movements via a fan or open window.
- Decrease or discontinue use of IV fluids.
- Stop smoking immediately.

Treatment with opioids
- It’s the drug of choice for dyspnea.
- Low doses of oral (10-15 mg) or parenteral (2-5 mg) morphine will provide relief for most patients.
- When dyspnea is acute and severe, parenteral is the route of choice: 2-5 mg IV every 5-10 minutes until relief.
- The exact mechanism is not understood, may be through inhibition of respiratory drive or decrease work of breathing

General measures
Treatment with Oxygen
- Nasal cannula is better tolerated than a mask.
- Oxygen is not always helpful.

Treatment with other drugs:
can help with cough.
as scopolamine can help to reduce secretions.
as lorazepam can reduce anxiety component of dyspnea.

Thank you
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