Approach to a patient with breathlessness

1. Approach to a patient with BREAthLESSNESS Aayush Kapoor Roll No.2

2. DYSPNOEA • Dyspnoea is defined as unpleasant subjective awareness of sensation of breathing. • It can also be defined as an uncomfortable need to breathe.

3. CAUSES of Acute Dyspnoea • Cardiovascular Causes • Acute pulmonary oedema(LVF) • Myocardial ischemia(angina equivalent) • Respiratory Causes • Acute severe asthma • acute exacerbation of COPD • Pneumothorax • Pneumonia • Pulmonary emboli • ARS • Inhaled foreign Body • Lobar collapse • Laryngeal oedema(anaphylaxis)

4. Others • Metabolic acidosis (DKA,Lacticacidosis,uraemia,overdoseof salicylate) • Psychogenic hyperventilation (anxiety or panic-related

5. CAUSES of Chronic Dyspnoea • CVS • Chronic heart failure • Myocardial ischemia • Respiratory • COPD • Chronic asthma • Bronchial carcinoma • Interstitial lung disease • Chronic pulmonary Thromboembolism • Large pleural effusion • Others • Severe anaemia • Obesity

6. History • The development of the dyspnoea • When did it start?  • Was it years, months, weeks or hours ago (acute/chronic) • Rate of onset ? : steady progression, attacks, acute exacerbations

9. Affecting Factors • Provoking factors: • Dust, smoke, cold weather, feather, any allergy, • H/O smoking • Relieveingfactors: • Rest, sitting upright, more pillows, bronchodilators

10. Associated symptoms • Cough, which can point to • Pneumonia • Asthma • CCF • Interstitial lung disease • Fever,pointing to • Pneumonia causing exacerbation of asthma / COPD • Orthopnoea& PND, which can point to • Heart Failure

11. Associated symptoms • Chest pain Pleuritic • Pulmonary embolism (PE) • Pneumonia, • Pneumathorax Angina • Mycardial Ischemia

12. Contributing Factors Medicines: • B-blockers causing bronchospasm • Previous medications for asthma / COPD Age: • Children; suspect foreign body. • Elderly; suspect malignancy History of other disease: • Diabetes, renal, anaemia • Post –op or bed-bound patient suspect • pulmonary embolism Anxiety:Causes the patient to hyperventilate

13. Assessment of severity • Respiratory effort, • Level of consciousness • Degree of central cyanosis • Evidence of anaphylaxis (urticaria/ angio-oedema) • Ability to speak (single words or sentence) For Cardiovascular System • Heart Rate • High Blood Pressure

14. Examination

15. Assess severity of condition by • Level of consciousness • Degree of central cyanosis • Patency of upper airway • Evidence of anaphylaxis (urticaria/ angio-oedema) • Ability to speak (single words or sentences) CVS status • Heartratetachycardia ( LVF, Pulmonary embolism, pneumonia, acute asthma ) • High BP ( causing LVF ) • low BP ( shock in pulmonary embolism )

16. General Examination • Vitals • Cyanosis • Anaemia • Clubbing (malignancy,ILD) • Barrel chest (COPD) • Kyphoscoliosis (restrictive lung disease)

17. Cardiovascular Examination Signs of heart failure: • Raised JVP • Oedemaof the body • Enlarged liver or spleen. • Engorged veins on the neck or upper chest (corpulmonmale) • Patient sitting and leaning forward LVH : • S4, Apical impulses

18. Respiratory system Inspection • Respiratory rate and pattern of breathing • Decreased chest expansion • Accessory muscle use • Shape of the chest (e.g.Barrel: Asthma) Palpation7 • Trachea (deviated in pnumothorax,pleuraleffusion,fibrosis) • Chestexpansion(decreased in COPD) • Vocal fermitus(increased in consolidaion & decreased in effusion or pneumothorax Percussion Percuss for dullness. Hyper-resonance suggests pneumatisation

19. Auscultation Wheeze -Asthma,COPD, anaphylaxis Stridor -upper airway obstruction, Foreign body or tumour , acute epiglottitis, anaphylaxis, Bronchial breathing -Pneumonia Crepitations -Heart failure, pneumonia, bronchiectasis, fibrosis Chest clear - Pulmonary embolism, hyperventilation, anaemia, metabolic acidosis (may cause air hunger) Absentbreathsounds - Pneumothorax, pleural effusion

20. INVESTIGATIONS Labs Hb: Anaemia, polycythemia WBCs: Pneumonia ECG Pulmonary emboli, cor-pulmonale, metabolic abnormalities, cardiac conditions Arterial Blood Gases Respiratory failure

21. INVESTIGATIONS Pulse oximeter detects oxygen saturation Spirometry Measurements of: • Forced vital capacity (FVC) • Forced expiratory volume in one second (FEV1) to diagnose both • Obstructive (decreased FEV1 and decreased FEV1/FVC ratio) & • Restrictive (decreased FVC and normal or increased FEV1/FVC ratio) lung disease.

22. Chest x ray Chest X ray

29. management

30. General Measures • High concentrations of oxgen pending results • Opioids for symptomatic control

31. ASTHMA / COPD Assess severity of attack Bronchodilators Nebulization with salbutamol / ipratropium bromide Steroids(hydrocortisone/prednisolone)

32. HEART FAILURE Diuretics (frusemide 40-80mg iv slow) Nitrates ;GTN 2 tabs SL start nitrate infusion if systolic >100mmHg Digoxin if AF

33. PULMONARY EMBOLISM Heparin unfractioned 10,000U iv bolus then 15-25U/kg/h LMW 175U/kg/24hr SC continued for 5 day

34. PNEUMOTHORAX Percutaneous needle aspiration Mild to moderate pneumothorax(upto 2.5 litre) Spontaneous pneumothorax Chest drain Underlying lung disease Tension pneumothorax PLEURAL EFFUSION Aspiration if symptomatic Treat the cause

35. Mechanical Ventilation Intubation & assisted ventilation The last resort Indications for assisted ventilation Repiratoryarrest Deterioration in Arterial Blood Gases Exhaustion,confusion,drowsiness Coma