ACUTE DYSPNEA

TEAM 6
HOFILENA, MARIE CHIN
ILAGAN, JONATHAN
ISLA, FROELAN
KHADKA,UMESH
JATTURAWUTTICHAI,NUTTORN
LAOHASINNURAK,NONLAPHAN
MOHAMED, MOHAMED HUSSEIM
AMNUAYNGERNTRA,AMONTHEP

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OUTLINE ACUTE DYSPNEA

I.
II.
III.
IV.
V.
VI.
VII.

SYNOPSIS/ DEFINITION
EPIDEMIOLOGY
MECHANISM OF SHORTNESS OF BREATH
DIFFERENTIAL DIAGNOSIS
RED FLAGS
DIAGNOSTIC/LABORATORY
DIFFENTIALS

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OUTLINE ACUTE DYSPNEA

VIII. HX OF PRESENT ILLNESS
IX. PHYSICAL EXAMINATION
X. ALGORITHM
XI. HYPOTHETICAL CASE
XII. EVIDENCE BASED MEDICINE
XIII. REFERENCES

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Acute Dyspnea
The American Thoracic Society
defines dyspnea as a "subjective
experience of breathing discomfort
that consists of qualitatively distinct
sensations that vary in intensity.
Harrisons Principle of Internal Medicine 18th edition

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Epidemiology
Shortness of breath is the primary reason 3.5% of people present to
the emergency department in the United States. Of these
approximately 51% are admitted to hospital and 13% are dead within
a year.

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Anatomy

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Overview of Respiratory muscles

Google image
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Anatomy of the Lungs

Google images
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Mechanisms of shortness of Breath

Desciptor

Clinical example

Pathophysiology

Chest tightness or constriction

Asthma, CHF

Bronchoconstriction, Interstitial
edema

Increase work or effort of breathing

Asthma, neuromuscular disease,

chest wall restriction

Airway obstruction, neuromuscular

disease

Air hunger need to breath,urge to

breathe

CHF, Pulmonary embolism, asthma,

pulmonary fibrosis

Increase drive to breathe

Inability to get a deep breath,

unsatisfying breath

Moderate to severe
asthma,pulmonary fibrosis, chest
wall disease

Hyperflation and restricted tidal

volume

Heavy breathing,rapid breathing,

breathing more

Sedentary status in healthy

individual or patient with
cardiopulmonary disease

Deconditioning

Harrisons Principles of Internal Medicine 19th edition

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Differential Diagnosis
Respiratory :- Acute exacerbation of asthma, and COPD,
pnemothorax, pulmonary embolism, foreign body, pleural
effusion
Cardiovascular :- Coronary artery disease ( angina and MI),
congestive heart failure, arrhythmia, pericardial disease,
anemia , Pulmonary HPN
Psychogenic:- Panic attack, hyperventilation
Others :- severe pain, poisoning ( OP, CO ),

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Asthma
Characterized by inflammatory hyperactivity of the respiratory
tree to various stimuli, resulting in reversible airways obstruction.
symptoms :- wheeze, chest tightness, breathlessness and cough.
Severe attack :- use of accessory muscle of respiration, diminished
breath sound, loud wheezing, hyperresonence, intercostal
retraction.

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Asthma
reduction in FEV1
Diagnosis is supported by increase FEV1 of < 12% and 200 cc after 24 puffs of short acting bronchodilator.

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Chronic Obstructive Pulmonary Disease ,COPD

Include chronic bronchitis and emphysema
Both are nonreversible obstruction of the airways ( unlike asthma )
Cigarette smoking represents the most significant risk factor for COPD
Use of accessory respiratory muscle, hyperinflated barrel shaped chest,
cyanosis, Hyper resonance , reduced breath sound, prolonged expiration
Clubbing is not a feature of COPD.
Decreased FEV1
Chronic bronchitis : Blue blotters
Emphysema : Pink puffer

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Pleural effusion
dyspnea usually develop > 0.5-1L of fluid, pluritic chest pain,
medistinal shifting ,decreased expansion of chest , stony dull ,
absent breath sound and vocal resonance
Pneumothorax
medistinal shifting , hyperresonence , decreased breath sound
and vocal fremitus

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Pulmonary embolism
tachycardia, hypotension, JVP, rightventricular gallop rhythm, loud
P2, severe cyanosis,
Pulmonary Hypertension
Elevation of the mean pulmonary arterial pressure
> 25 mm hg at rest ( normal mean 15 ( 25/8) mm hg.
dyspnea , syncope, edema, loud S2 ;esp P2 component, sign of Rt.
Heart failure( inc. JVP, hepatomegaly, pulsatile liver, pedal edema
etc.)

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Red Flags
Altered mental status.
Stridor and breathing effort without air movement.(suspect
upper airway obstruction)
R/R > 40/min
cyanosis
Unilateral tracheal deviation.(suspect tension pnemothorax)
Low 02 saturation.
Diaphoresis ( asthma )
Pulsus paradoxus

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Diagnostics
chest x-ray
Electro cardiogram
Spirometry
http://www.mdguidelines.com/dyspnea

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Diagnostics
a D-dimer test may be done to detect clot formation if
pulmonary embolism is suspected.
Bronchoscopy: may be done in severe cases or to rule
out airway obstruction
PFT (pulmonary function test)
echocardiogram for suspected cardiac temponade
CTscan
http://www.mdguidelines.com/dyspnea

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laboratory
Laboratory tests may include: CBC
ABG
blood carbon monoxide levels, and renal function
studies. Blood oxygen saturation is measured using
an infrared light sensor device on the finger. (Pulse
Oximeter)
Creatinine sodium potassium and glucose
http://www.mdguidelines.com/dyspnea
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Risk Factors for dyspnea

Exposure to toxic irritants such as tobacco smoke
Industrial toxins
Obesity
Inhaling organic and inorganic dusts
Toxic fumes
Environmental pollutants
Irritant gases .

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Acute Dyspnea Differentials

Acute asthma
COPD exacerbation
Pneumonia
Congestive heart failure
Pulmonary embolism
Pneumothorax
http://www.mdguidelines.com/dyspnea

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Acute Dyspnea Differentials

Epiglottitis
Bronchiolitis
Hyperventilation
Foreign body aspiration
Congestive heart failure
http://www.mdguidelines.com/dyspnea

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Comprehensive adult health history

7 component:
1.Identifying data and source of the history: reliability
2.Chief complaint(s)
3.Present illness
4.Past history
5.Family history
6.Personal and social history
7.Review of systems

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History Acute Dyspnea

1. Emphasize Coexisting caediac and pulmonary s/sx. Determine
onset, duration, and occurrence at rest or exertion.
2. Chest pain during dyspnea may be caused by coronary or pleural
disease, depending on the quality and description of the pain.
3. Sudden shortness of breath at rest is suggestive of pulmonary
embolism or pneumothorax.
http://www.aafp.org/afp/2003/1101/p1803.html

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History Acute Dyspnea

4. Chest pain is almost universal in spontaneous pneumothorax,
while dyspnea is the second most common symptom.
5. Consider spontaneous pneumothorax in patients with COPD, cystic
fibrosis, or acquired immunodeficiency syndrome.
6. Inquire about indigestion or dysphagia, which may indicate
gastroesophageal reflux or aspiration.

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General
Weight loss or gain
Fatigue
Fever or chills
Weakness
Trouble sleeping

Skin
Rashes
Lumps
Itching
Dryness
Color changes
Hair and nail
changes
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Head
Headache
Head injury
Dizziness
lightheadedness
Respiratory
Cough
Sputum
Coughing up blood
Shortness of breath
Wheezing
Painful breathing

EYES
Vision Loss/Changes
Glasses or contacts
Pain
Redness
Blurry or double vision
Flashing lights
Specks
Glaucoma
Cataracts
Last eye exam

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Ears
Decreased hearing
Ringing in ears
Earache
Discharge
Vertigo
Nose
Stuffiness
Discharge
Itching
Hay fever
Nosebleeds
Sinus pain

Throat/Mouth/Pharynx
Bleeding
Dentures
Sore tongue
Dry mouth
Sore throat
Hoarseness
Thrush
Non-healing sores

Cardiovascular
Chest pain or discomfort
Tightness
Palpitations
Shortness of breath with
activity
Difficulty breathing lying
down
Swelling
Sudden awakening from
sleep with shortness of
breath

Neck
Lumps
Swollen glands
Pain
Stiffness

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 Gastrointestinal
Swallowing difficulties
Heartburn
Change in appetite
Nausea
Change in bowel habits
Rectal bleeding
Constipation
Diarrhea
Yellow eyes or skin

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Urinary
Frequency
Urgency
Burning or pain
Blood in urine
Incontinence
Change in urinary
strength
Vascular
Calf pain with walking
Leg cramping
varicose veins
swelling w redness or
tenderness
change in fingertips or toes
during cold weather

PHYSICAL EXAMINATION
ACUTE DYSPNEA

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PHYSICAL EXAMINATION ACUTE DYSPNEA

1.
2.
3.

4.

Begin during interview of the patient.

Inability to speak in full sentences before stopping to get deep
breath?
Evidence of increased work of breathing? indicative of
increased airway resistance or stiffness of the lungs and the chest
wall.
VS

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PHYSICAL EXAMINATION ACUTE DYSPNEA

5.

6.

During general examination, signs of anemia ( pale conjunctivae),

cyanosis, and cirrhosis ( spider angiomata, gynecomastia) should
be sought.
Chest: symmetry of movement; percussion (dullness is indicative
of pleural effusion; hyperresonance is a sign emphysema); and
auscultation (wheezes, rhonchi, prolonged expiratory phase, and
diminished breath sounds are clues to D/O of the airways; rale
suggest interstitial edema or fibrosis).

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PHYSICAL EXAMINATION ACUTE DYSPNEA

7.
8.

Cardiac: focus on signs of elevated right heart pressures, left

ventricular dysfunction, and valvular diseases.
Abdomen: patient in the supine position, physician should note
whether there is paradoxical movement of the abdomen: inward
motion during inspiration is a sign of diaphragmatic weakness,
and rounding of the abdomen during exhalation is suggestive of
pulmonary edema.

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PHYSICAL EXAMINATION ACUTE DYSPNEA

9.

Clubbing of digits may be an indication of interstitial pulmonary

fibrosis, and joint swelling or deformation as well as changes
consistent with raynauds disease may be indicative of a collagenvascular process that can be associated with pulmonary disease.

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PHYSICAL EXAMINATION ACUTE DYSPNEA

10. Patients with exertional dyspnea should be asked to walk under
observation in order to reproduce the symptoms.

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Adapted from MA Gillette, RM Schwartzstein, in SH Ahmedzai, MF, Muer [eds].

Supportive Care in Respiratory Disease. Oxford, UK, Oxford University Press, 2005
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Case

A 75-year-old man with presents with a 1-day history of dyspnea,

rightsided chest pain, and cough with rustcolored sputum. Further
history reveals subjective fever and chills.
His physical activity level has diminished over the last 2 days. Physical
examination reveals the patient to be mildly tachypneic and afebrile
but in no acute distress.
Cardiac examination is without significant findings. There are crackles
and a friction rub in the right anterior lung field.
Laboratory examination demonstrates a mild leukocytosis and a Pao2
of 60 mm Hg.

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Hypothetical Case
I. Chief Complaint- Difficulty of breathing.
II. Hx of Present Illness- While walking, the patient presented with
difficulty of breathing with right sided chest pain. He also complain of
coughing with rust colored sputum, thus leading to consultation. His
physical activity level has diminished over the last 2 days
. III. Past Hx- (-) DM, No known HPN,
V. Family Medical Hx- Parents are both hypertensive, No known
cancer, DM, allergy, TB, thyroid problem or genetically transmitted
disease among family members

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Hypothetical Case Continuation

VI. Personal/Social Hx-He is a engineer, smoker for 20 pack years,
Goes to catholic church every Sunday, drinks alcohol (beer)
occasionally, and once a week.
VII. Physical Exam Findings- Febrile, ambulatory with the ff : Vitals
Signs: BP: 90/60mmHg, RR: 32 T: 38 degree celsius HR:126beats per
minute
HEENT: Normal JVP, No cervical lymphadenopathy, No thryromegaly,
(-) anecteric sclera,(-) carotid bruits
Chest/Lungs: symmetrical, Increased tactile fremitus right, (+)
retractions, (-) lag, (-) spider angiomas, dullness on the right side,(+)
crackles, (-) wheezes

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Continuation
VII. Physical Exam Findings:
Heart: adynamic precordium; apex beat at 4th to 5th ICS LMCL, (-)
thrills, normal S1 and S2, No murmurs
Abdomen: abdominal girth normal, flat, (-) caput medsau;
normoactive bowel sounds, soft, non tender tymphanic, no
organomegaly, normal bowel movements
Extremities: (-) deformities, (-) clubbing, (-) cyanosis, with the ff
pulses:

DP

PT

++

++

++

++

++

++

++

++

++

++

++

++

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Continuation
Rectal: (-) anal tag, good sphincter tone, rectal vault not collapse,
(-) hemorrhoids nor mass noted; brownish stool in tactating finger.
Neurologic Exam:
Cerebrum: conscious, oriented to 3 spheres
Cerebellum : (-) nystagmus ; can do heel to shin test ; intact
Rombergs test ; can do rapid alternating movements ; can do
finger to nose test

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Cranial nerves :
I can smell coffee
II, III pupils equally reactive to light
III, IV, VI intact extraoccular muscles
V intact corneal reflex , bilateral ; intact masseter muscle contraction
VII (-) facial asymmetry
VIII can hear, bilateral
IX, X intact gag reflex
XI can shrug shoulders , bilateral
XII - tongue midline on protrusion
(-) Babinski ;(-) nuchal rigidity( -) Brudzinski (-) Kernigs sign Dermatomal test :
equal and intact on all levels Motor Sensory DTR

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Hypothetical Case
II. Primary Working Impression: Community Acquired Pneumonia,
COPD
III. Laboratory Examinations:ECG, ABG, CBC, Creatinine, Chest Xray

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Laboratory Results
Sinus Tachycardia ECG
ABG:
pH increased
PCO2 decreased
HCO3 normal

Repiratory Alkalosis
CBC: increased neutrophil count
Creatinine: Normal
Chest Xray: Right upper lobe consolidation

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Final Diagnosis:
Community Acquired Pneumonia Right Upper Lobe Moderate Risk

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Evidence-Based Medicine

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We ask this question during our meeting in

group.

How would
apprehensiveness affect
the patient suffering from
dyspnea?

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