Definition, pathophysiology, history taking, examination, investigation and differential diagnosis.

1. ACUTE SHORTNESS OF BREATH
[DYSPNEA]
6 SEMESTER
[Sanjay Sharma, MBBS 15th batch]

2. Definition of Dyspnea
• According to the American Thoracic Society
dyspnea is defined as “subjective experience
of breathing discomfort that consist of
qualitatively distinct sensation that vary in
intensity. The experience derives from
interactions among multiple physiological,
psychological, social, and environmental
factors and may induce secondary
physiological and behavioral responses.”

3. • It is the symptom experienced by patient due to
effect in not only one system but due to
involvement of different systems of the body.
• So that there are multi-factorial causes of
dyspnea.
a] Respiratory causes
b] Cardiovascular causes
c] Musculoskeletal causes
d] CNS causes
e] GI causes
• When can we say that SOB is acute?
Onset of SOB should be sudden and for minutes
to days.

4. Differential diagnosis
Respiratory causes:
• Pneumothorax
• Pulmonary embolism
• Pulmonary edema
• ARDS
• Pneumonia
• Acute exacerbation of asthma
• Acute exacerbation of COPD
• Epiglottitis
• Laryngitis and laryngeal edema
• Carcinoma of lungs
• Alveolitis, pneumonitis, bronchitis, croup, aspiration,
foreign body, and chest trauma

5. Cardiovascular causes
• Ischemic heart disease
• Coronary artery disease
• Acute LVF
• Arrhythmia
• Acute coronary syndrome
• Acute valvular heart disease
• Pericarditis
• Myocarditis
• Deep vein thromboembolism

6. Others
• Anaphylactic reaction
• Neuromuscular diseases
• CO poisoning
• Thyroid storm
• Pschycological
• Anxiety, panic attack
• Drugs like aspirin, amiodarone, ACE inhibitors,
chemotherapy, beta blockers, cholinergics, etc

7. Pathophysiology
Involves following organs
• Peripheral chemoreceptor [carotid and aortic
body].
• Central chemoreceptor
• Medulla oblongata
• Pons and
• Receptors in chest wall

8. Normal breathing control

9. `

10. Approach to the patient with acute
dyspnea
In acute breathlessness history, rapid and careful
examination with routine investigations will
help rapid diagnosis .
Sometimes acute dyspnea may be the
emergency condition [eg tension
pneumothorax]

11. HISTORY TAKING
• Patient particulars
• Name
• Age
• Sex
• Religion
• Occupation
• Marital status
• Address

12. Chief complain :
should be in chronological order.
shortness of breath for how much time?
other major complains associated with
shortness of breath.

13. History of present illness
Elaborate chief complain.
For shortness of breath:
• Onset : sudden or gradual [in case of acute
shortness of breath onset is sudden]
• Ask questions like
Did it come suddenly or gradually?
What were you doing at that time?

14. • With in minute:
Pneumothorax , pulmonary embolism
inhalation of foreign body , laryngeal edema,
aspiration.
• Within hours to days:
ARDS, Bronchial asthma, pneumunia, left heart
failure etc.
• Weeks to month :
pleural effusion, anemia, thyrotoxicosis,
asthma etc.

15. • Duration : persistent or intermittent
• Ask question like
• Is shortness of breath on and off or is it present
throughout the day?
• Persistent in tension pneumothorax, pulmonary
thromboembolism, pleural effusion, myocardial
infraction, epiglottitis , anaphylaxis etc.
• If intermittent then ask about the frequency of
episodes [asthma, angina, etc].
• Progression :intensity and frequency of symptom
is increasing or not.
• Increasing in tension pneumothorax, acute
exacerbation of asthma and COPD, MI,
pulmonary infraction etc

16. Precipitating/ Aggravating factors
• Identify the factors which increase the
intensity and frequency of symptom [SOB].
• Aggravated by exertion [angina, pulmonary
thromboembolism, pulmonary edema,]
• Occurs even in rest: respiratory infections
,pneumothorax, pleural effusion, pulmonary
infraction, hyperventilatory syndrome,
myocardial infraction, acute exacerbation of
asthma and COPD, diabetic ketoacidosis,
psychogenic,

17. Orthopnea: Does lying down make it worse ?
How many pillows are used on bed?
In heart failure, excess mucus in lungs,
pulmonary edema, ascites etc.
Paroxysmal nocturnal dyspnea: does the
patient wake up at the night and go to the
window due to SOB. Occurs in left heart
failure.
diurnal variation : asthma, Sleep apnea.

18. Relieving factors
• Identify factors which decrease intensity and
frequency of SOB.
• At rest :In angina
• Medications like sublingual nitrates, inhalers
in angina and asthma respectively.

19. Severity
• Find out the severity of symptom.
• Which level of physical activity does make
patient breathlessness and fatigue?
• How far the patient can walk before having to
stop due to shortness of breath?
• Can patient do normal daily physical activity?
• Identify MMRC grading.

20. MMRC Grading

22. Other associated symptoms
• Chest pain : May be due to cardiac ischemia
onset, character, radiation, aggravating
factors, reliving factors, severity etc.
• Pleuritic :in pneumonia, pulmonary embolism,
pneumothorax, pleuritis.
• Non pleuritic: coronary disease, MI
• Fever : Pneumonia, anaphylaxis, MI ,Epiglottitis.
• Palpitation : awareness of own heart beats.
due to cardiac arrhythmia.
• Orthopnea : SOB during sleeping or lying down.

23. • PND: due to left ventricular failure
patient wake up at night due to SOB.
• Cough : onset, duration, character, aggravating and
reliving factors, severity.
• Sputum production: amount, colour, foul smelling,
• Hemoptysis : malignancy, pulmonary embolism,
pulmonary infraction, acute left ventricle failure etc.
• Wheeze: asthma ,
• Upper respiratory infections
• History of weight loss: hyperthyroidism, carcinoma of
lung
• Heat intolerance, tremor, sweating: hyperthyroidism

24. • History of calf pain [Deep vein thrombosis]
• Pitting Edema in the dependent part of body
• History of trauma or accident.
• Systemic review: CNS, GI, MSK, CVS etc.

25. Past history
• Chronic illness like hypertension, diabetes
mellitus, coagulopathy, tuberculosis, asthma,
COPD , metabolic disorders, SLE etc.
• Previous myocardial infarction, coronary
angiography, CABG surgery.
• Valvular heart disease , heart failure,
immobility, thromboembolic disease [DVT],
myasthenia gravis.
• Any malignancies

26. Medical history
• Use of antihypertensive drugs: amiodarone,
ACE inhibitors.
• Aspirin , chemotherapy.
• Oral contraceptive pills.
• Beta blockers

27. Personal history
• Smokers : carcinoma of lungs [>40 pack year] ,
COPD, coronary artery disease, MI etc.
• Alcohol consumption: pancreatitis leads to ARDS
• Diet
• Bowel and bladder habits
• Appetite and sleep pattern
• Occupation: asbestos exposure, mining,
hypersensitivity pneumonitis etc.

28. Family history
• Asthma, myocardial infraction
• Diabetes mellitus , metabolic disorders
• Hypertension , coronary artery disease
• Connective tissue disorder, SLE.

29. Socioeconomic history
• Dusty polluted environment.
• Pets in home.
• Housing .
• Fire wood for cooking.
• Life style

30. Drugs and allergic history
• Allergy to any drugs or known substances.
• Pollen allergy, pets fur allergy.
• Aspirin sensitive asthma.
• Sting bites.

31. Examination
• General :
• Look for appearance , built , consciousness,
co-operative, orientation to time, place and
person, and decubitus.
• Sometimes acute SOB is an emergency
condition .Identify patient is stable or
unstable.

32. Vitals
• Pulse : rate ,rhythm, volume, character, radio-
radial delay , radio-femoral delay, condition of
arterial wall, and palpation of peripheral pulses.
• Temperature:
• Blood pressure:
• Respiratory rate:
• JVP:
• SpO2:

33. Red flag sign in acute SOB
• Tachypnoea
• Nasal flaring
• Trachial tug
• Hypotension
• Cyanosis
• Intercostal , subcostal and sternal recession.
• Unilateral breath sound or absent of breath sound
• Pulsus paradoxus
• Silent chest
• Altered mental status

34. If patient is unstable then:
• Maintain :
• Airway
• Breathing
• Circulation.
• Give oxygen and correct the acute condition

35. PILCCOD
• Pallor: severe anemia,
• Icterus : hemolytic anemia,
• Cyanosis: central
• Lymphadenopathy: infections
• Clubbing:
• Edema :cardiac cause
• Dehydration : shock

36. Systemic examination
• Respiratory examination:
• Inspection :any mass and obstruction in the
nose, pharynx, pursed lip breathing, uses of
accessory muscles, stridor, intercostal
indrawing.
• Shape of the chest, movement of chest during
respiration,

37. Palpation
• Tracheal shift:
• Chest expansion:
• Movements of chest:
• Apex beat:
• Vocal fremitus:

38. Percussion
Percussion note :
• Normal: resonant
• Hyper-resonant: pneumothorax
• Woody dull: pulmonary consolidation,
pulmonary collapse, severe pulmonary
fibrosis.
• Stony dull: pleural effusion, haemothorax

39. Auscultation
• Vocal resonance:
• Diminished breath sound:
• Vesicular breath sound:
• Bronchial breath sound:
• Other added sounds:
wheeze
crackles or crepitations
pleural friction rub

41. Cardiovascular examination
Inspection :
• precordium: shape, bulging, pulsation [apex
beats, left sternal, epigastric, suprasternal],
distended vein, sinuses.
• Outside precordium: pulsation in aortic,
pulmonary, parasternal and suprasternal areas
and back[inferior angle of scapula in
coarctation of aorta/suzmans sign].

42. Palpation
• Apex beat: site , rate and character.
• Parasternal heave.
• Palpable pulsation: in epigastric , pulmonary,
suprasternal area
• Thrills/ palpable sounds, venous hum

43. Auscultation
• Mitral area
• Tricuspid area
• Aortic area
• Pulmonary area
• Murmurs

44. Other systemic examination
• Abdominal examination
• CNS examination
• Musculoskeletal examination

46. Investigations
Routine investigations :
• Chest X-ray
• 12 lead ECG
• Arterial blood gas sampling

47. Others
• A finger stick haemoglobin determination
• complete blood count
• Spirometry
• Exercise treadmill testing
• Echocardiography
• Cardiopulmonary function testing

48. Chest X-ray
Acute shortness of
breath
Perform Chest X-Ray
Normal chest X-ray
Perform spirometry
Normal
Arterial Blood
analysis and ECG
Abnormal
Bronchospasm
Abnormal chest x-ray
Arterial blood analysis
and ECG

49. Abnormal findings in chest xray
• Pneumonic consolidation → Pneumonia
• Cardiomegaly ,pleural effusion →pulmonary
edema,
• hyperventilation → acute asthma/COPD
• Increased translucency →pneumothorax

50. ECG findings with possible causes
Sinus tachycardia is seen in pulmonary edema,
acute severe asthma ,pneumonia (bradycardia
is present in extremis in acute severe asthma )
Sinus tachycardia, right bundle branch block
,S1Q3T3 pattern ↑T(V1-V4) is present in
patients with massive pulmonary embolism
ECG may be normal or signs of right
ventricular strain in acute exacerbation of
COPD

51. Arterial blood gas analysis(ABG)
ABG
Pao2 is decreased Pao2 is normal
• pulmonary edema
• Acute severe asthma ↓Paco2 ↓Paco2
• Acute exacerbation of COPD ↑ H+ ↓H+
• Pulmonary embolism ↓ HCO3- (Psychogenic
(Metabolic acidosis) hyperventilation)

52. Spirometry
• Spirometry helps to differentiate obstructive
lung diseases from the restrictive lung
diseases
• If bronchospasm is suspected then
measurement of peak expiratory flow is done
whenever possible as it assists in assessment
of severity

53. Exercise treadmill testing
• Targets ischemia as cause of dyspnea
• Is performed when symptoms are atypical for
exertional angina or when silent ischemia is
suspected as cause of dyspnea
• This test is relatively safe

54. Echocardiography
• Echocardiography can detect a valvular
abnormality and may be diagnostically helpful
in patients with questionable murmurs in
context of dyspnea
• Chamber size ,hypertrophy and left ventricular
ejection fraction can also be assessed

55. Cardiopulmonary exercise testing
• It quantifies cardiac function, pulmonary gas
exchange, ventilation and physical fitness
• Is used in selected cases when diagnosis is still
unclear after initial examination

57. Thank you