Dyspnea

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Dyspnea
by Dr Asadollah Asadian
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• Dyspnea - common complaint/symptom
• shortness of breath or breathlessness
• Defined as abnormal/uncomfortable breathing
• Multiple etiologies -
• 2/3 of cases - cardiac or pulmonary etiology

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How to describe these sensations

• Cannot get enough air
• Air does not go all the way down
• Smothering feeling in the chest
• Tightness in the chest
• Fatigue in the chest

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• Normal person may experience the physiologic
  dyspnea during heavy exercise

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Differential Diagnosis

• Composed of four general categories
• Cardiac
• Pulmonary
• Mixed cardiac or pulmonary
• non-cardiac or non-pulmonary

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Pulmonary Etiology

• COPD
• Asthma
• Restrictive Lung Disorders
• Hereditary Lung Disorders
• Pneumonia
• Pneumothorax

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Cardiac Etiology

• CHF
• CAD
• MI (recent or past history)
• Cardiomyopathy
• Valvular dysfunction
• Left ventricular hypertrophy
• Pericarditis
• Arrhythmias

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Mixed Cardiac/Pulmonary Etiology

• COPD with pulmonary HTN and/or cor pulmonale
• Chronic pulmonary emboli
• Pleural effusion

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Noncardiac or Nonpulmonary Etiology

• Metabolic conditions (e.g. acidosis)
• Pain
• Trauma
• Neuromuscular disorders
• Functional (anxiety,panic disorders,
  hyperventilation)
• Chemical exposure

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Toxic dyspnea

• In the metabolic acidosis (uremiaand
• diabetic acidosis, the acid metabolites
  stimulate the respiratory center, causing deep
  and regular respiration (Kussmanul) with
  snoring.

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Acute Dyspnea

• PTE
• Pneumonia
• Asthma
• Anxiety
• MI

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• There is no one specific cause of dyspnea and no
  single specific treatment
• Treatment varies according to patients condition
• chief complaint
• history
• exam
• laboratory study results

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• V/Q mismatch

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• intracardiac
• any cause of a right to left shunt eg Fallot's
  tetralogy, Eisenmenger's syndrome
• pulmonary
• pneumonia
• pulmonary oedema
• atelectasis
• collapse
• pulmonary haemorrhage
• pulmonary contusion

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Causes of hypoventilation

• Brainstem
• brainstem injury due to trauma, haemorrhage,
  infarction, hypoxia, infection etc
• metabolic encephalopathy
• depressant drugs
• Spinal cord
• trauma, tumour, transverse myelitis
• Nerve root injury
• Nerve
• trauma
• neuropathy eg Guillain Barre
• motor neuron disease
• Neuromuscular junction
• myasthenia gravis
• neuromuscular blockers
• Respiratory muscles
• fatigue
• disuse atrophy
• myopathy

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Nero-Psychogenic dyspnea

• Patient suffer from hysteria will be seen
• repetitive deep, signing respiration with
• numbness of extremities or lips, spasm.

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Haematologicl dyspnea

• The decrease of oxygen-carrying capacity and
  oxygen content develop abnormal respiration and
  increase heart rate, such as severe anemia,
  carbon monoxide.
• Hypotension can stimulate respiration when
  patient suffer from shock.

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Accompanying symptoms

• Paroxysmal dyspnea with wheezing, It is
  present in bronchial asthma and cardiac asthma.
  Paroxysmal severe dyspnea is often seen in acute
  larynx edema(spontaneous pneumothoraxmassive
  pulmonary embolism.

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Accompanying symptoms

• Dyspnea with chest pain. It is frequently
  observed in lobar pneumoniapulmonary
  infarction(), spontaneous pneumothorax, acute
  exudative pleurisy), acute myocardial
  infarctionand bronchial carcinoma
  

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Accompanying symptoms

• Dyspnea with fever. It is commonly noted in
  pneumonia, lung abscesspulmonary
  tuberculosispleurisy, acute pericarditisand
  nervous system diseases.

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Accompanying symptoms

• Dyspnea with cough and purulent sputum. It is
  often present in chronic bronchitis, obstructive
  pulmonary emphysema with infection, purulent
  pneumonia, and lung abscess Dyspnea with large
  amount of foamy sputum is often seen in acute
  left ventricular heart failure and
  organophosphorus poisoning

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Accompanying symptoms

• Dyspnea with coma. It suggests cerebral
  hemorrhage(pneumonia with shock, uremia, diabetic
  ketoacidosis, and acute poisoning.

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Common causes of type I (hypoxemic) respiratory
failure

• Chronic bronchitis and emphysema (COPD)
• Pneumonia
• Pulmonary edema
• Pulmonary fibrosis
• Asthma
• Pneumothorax
• Pulmonary embolism
• Pulmonary arterial hypertension
• Pneumoconiosis
• Granulomatous lung diseases
• Cyanotic congenital heart disease
• Bronchiectasis
• Adult respiratory distress syndrome
• Fat embolism syndrome
• Kyphoscoliosis
• Obesity

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Common causes of type II (hypercapnic)
respiratory failure

• Chronic bronchitis and emphysema (COPD)
• Severe asthma
• Drug overdose
• Poisonings
• Myasthenia gravis
• Polyneuropathy
• Poliomyelitis
• Primary muscle disorders
• Porphyria
• Cervical cordotomy
• Head and cervical cord injury
• Primary alveolar hypoventilation
• Obesity hypoventilation syndrome
• Pulmonary edema
• Adult respiratory distress syndrome
• Myxedema
• Tetanus

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Easily Performed Diagnostic Tests

• Chest radiographs
• Electrocardiograph
• Screening spirometry

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ABGs

• Commonly used to evaluate acute dyspnea
• can provide information about altered pH,
  hypercapnia, hypocapnia or hypoxemia
• normal ABGs do not exclude cardiac/pulmonary dx
  as cause of dyspnea
• Remember- ABGs may be normal even in cases of
  acute dyspnea

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• Bilateral airspace infiltrates on chest
  radiograph film secondary to acute respiratory
  distress syndrome that resulted in respiratory
  failure

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• A 44-year-old woman developed acute respiratory
  failure and diffuse bilateral infiltrates. She
  met the clinical criteria for the diagnosis of
  acute respiratory distress syndrome. In this
  case, the likely cause was urosepsis

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QUESTIONS?