approach to dyspnea

1. Approach to
Dyspnea
Dr.Bilal Natiq Nuaman,MD
C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.
Lecturer in Iraqia Medical College
2016-2017

2. Dyspnea; Breathlessness; Shortness of
Breath(SOB)
• ‘’Dyspnea’’
Dys: difficult, painful
Pneumea:breath
• Breathlessness or dyspnea can be defined as the feeling
of an uncomfortable need to breathe.

3. DEFINITION OF DYSPNEA
• Clinical : A subjective experience of breathing discomfort that
consists of (qualitatively) distinct sensations that vary in
intensity.
• Physiological: The stimulation of pulmonary and extra
pulmonary afferent receptors and the transmission of afferent
information to the cerebral cortex, where the sensation is
perceived as uncomfortable or unpleasant

4. Patients perceptions:
✓ Unsatisfied inspiration
✓ Chest tightness
✓ Sensation of feeling breathless
✓ Cannot get enough air
✓ Hunger for air
✓ Incomplete exhalation

5. Pathophysiology :
Respiratory diseases
➢ stimulating intrapulmonary sensory nerves (e.g. Pneumothorax,
interstitial inflammation and pulmonary embolus)
➢ increasing the mechanical load on the respiratory muscles (e.g.
airflow obstruction or pulmonary fibrosis)
➢ Causing hypoxia, hypercapnia or acidosis, stimulating
can stimulate breathing and dyspnea by:
interstitial inflamm
airflow obstruction
chemoreceptors.

6. Common Pulmonary Causes
• Obstructive lung disease
• Asthma/COPD (Chronic Bronchitis ,Emphysema)
• Pneumonia
• Pulmonary embolism
• Pneumothorax

7. cardiac failure can stimulate breathing and dyspnea by:
➢ pulmonary congestion reduces lung compliance and can
also obstruct the small airways.
➢ In addition, during exercise, reduced cardiac output
limits oxygen supply to the skeletal muscles, causing
early lactic acidaemia and further stimulating breathing
via the central chemoreceptors.

8. Common Cardiac Causes
• Acute coronary syndromes
• CHF
• Dysrhythmias
• Valvular heart disease

9. Stages of dyspnea
1-EXERTIONAL DYSPNEA- DYSPNEA DUE TO
EXERCISE
2-ORTHOPNEA – SOB LYING FLAT AND BETTER
SITTING UP (CHF, pregnancy, resp.muscle weakness)
3-PND - PAROXYSMAL NOCTURNAL DYSPNEA
characterized by acute shortness of breath almost always
accompanied by coughing and wheezing. This respiratory
distress usually occurs when a person is already sleep in
a reclining position (HEART FAILURE-early night ,
ASTHMA-late night )
4-RESTING DYSPNEA- DYSPNEA AT REST

11. Common Miscellaneous Causes
• Metabolic acidosis
• Severe anemia
• Pregnancy
• Hyperthyroidsm
• Hyperventilation syndrome

12. Differential diagnosis of dyspnea
Patients with breathlessness present either with
Chronic exertional dyspnea
Or
Acute dyspnea,
when symptoms are prominent even at rest.

16. • Chronic: Dyspnea >30 days
that develops over weeks, months or years.
• COPD
• Left ventricular failure
• Lung fibrosis
• Asthma (uncontrolled)
• Pleural effusion

27. The following should be assessed and documented:
Clinical assessment
1- level of consciousness
2-degree of central cyanosis
3-evidence of anaphylaxis (urticaria or angioedema)
4-patency of the upper airway
5-ability to speak (in single words or sentences)
6-cardiovascular status (heart rate and rhythm, blood pressure
and degree of peripheral perfusion).

29. Pulmonary oedema is suggested by pink, frothy sputum and
asthma or COPD by wheeze and prolonged expiration;
pneumothorax by a silent resonant hemithorax; and
pulmonary embolus by severe breathlessness with normal
Leg swelling may suggest cardiac failure or, if asymmetrical,
venous thrombosis causing pulmonary embolism.
Urgent endotracheal intubation may become necessary if the
bi-basal crackles;
breath sounds.
Arterial blood gases, a chest X-ray and an ECG should be
obtained to confirm the clinical diagnosis, and high
concentrations of oxygen given pending results.
conscious level declines or if severe respiratory acidosis is
present.

30. Physical signs in dyspnic patient

31. Investigations
Chest radiograph (CXR): weather cardiac or pulmonary
Cardiac Causes! Pulmonary causes!
ECG Pulmonary function test(PFT)
(abnormally significant) (abnormally significant)
Echo CT scan of chest
(abnormally significant) (abnormally significant)
Coronary angiography Lung Biopsy

32. CXR