Objectives
1.Prevalence
2.Pathophysiology
3.History and Physical Examination
4.Investigations
5.Pharmacological and Non Pharmacological Management.
6.Case- study
2
Definition
▪Subjective experience of breathing discomfort
that consists of qualitatively distinct sensations
that vary in intensity.(The American Thoracic Society,
1999)
3
Prevalence and Dyspnoea symptom
burden
Cancer • 21%-79%
AIDs • 11%-62%
Acquired Immune deficiency
COPD • 90%
Chronic obstructive lung disease
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Patho physiology
5
Etiologies
6
Bio psychosocial Model of Dyspnea
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Total Dyspnoea
8
Anxiety and Dyspnoea Cycle
D
Y
S
P
N
E
A
9
History
Identification of underlying cause
10
History
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Dyspnoea Descriptors My chest feels
tight, I can’t
breathe
I feel like
suffocating
My breathing
My breathing
requires effort
is heavy
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Physical Examination
INSPECTION
▪Tracheal deviation (can
suggest of tension
pneumothorax
Percussion
-Hyper resonant
-Resonant
-Dull
-Stony Dull
Auscultation
-Vesicular, bronchial, Wheeze
-Stridor, crackles, vocal
resonance 16
Physical Signs and Interpretation
Disorder Mediastinal Chest wall Percussion Breath Adventitio
displacement movement Sounds us
Sounds
Consolidation None Reduced Crackles
Affected Dull
Collaspe Same side Reduced Nil
Dull
Pleural Opposite side Reduced Nil
Effusion Stony Dull
Pneumothorax Opposite side Hyper resonant Reduced Nil
Laboratory Radiological
Reversible Irreversible
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Treat Reversible Causes
20
Symptomatic Management
Pharmacological
Management
Non
Pharmacological
21
Non Pharmacological Interventions
Single component
Walking aids
Chest wall vibration
Music/Relaxation
Acupressure
Non Pharmacological Acupuncture
Interventions
Multi component
Counselling
Support
Breathing Training/Fan
24
Energy Conservation Techniques
Strategies Examples
1.Pace Activity ▪Break down activities into small
parts.
▪Alternate daily activities heavy
with light tasks.
▪Set small achievable goals
Airflow
▪Encourage cool airflow over
the face.
▪Open window and proper
ventilation.
Schwartzstein RM et al. (1987) Cold facial stimulation reduces breathlessness induced in normal subjects. Am Rev Respir Dis 136:
58–61
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Oxygen Therapy
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Anxiety Reduction
Interventions
▪ Diaphragmatic
breathing/purse lip
breathing
▪Visualization/imaginary
▪Distraction
▪Relaxation
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Assess Psychological Factors
Listen
Understand
Address
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Pharmacological Mechanism of Opioids
▪Exact mode of action unknown
Postulations
-Depress opioid receptors in lungs, spinal and
central respiratory centres.
-Reduces central perception
-Diminishes ventilation response to hypoxia and
hypercapnia.
-Venodilation of pulmonary vessels
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Opioids
For Opioids Naive/Elderly
▪Start oral morphine 2.5mg p.o or
regularly 4-h if dyspnea is
continuous.
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Benzodiazepines
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Corticosteroids
▪Reduce the oedema and
inflammation.
▪Particularly for
-Multiple lung metastases
-Stridor due to tracheal obstruction
-Superior vena cava obstruction Superior Vena Cava obstruction
-Lymphangities carcinomatosis.
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Management of Dyspnoea
Chronic Obstructive Lung Disease
Married with two school going children aged 10 years old and 4 years old.
You are his community palliative nurse who visits him at home.
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Questions
37
Case Study: Hyperlink slide
History Physical
Examination
Identify
reversible
cause
Pleural
Effusion
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History
▪Dyspnea getting progressively worse past
few days.
▪Feels like “Drowning”.
▪Mild at rest, worsen with movement and lying
down.
▪No upper respiratory tract symptoms.
▪Sometimes relieves with rest.
▪Affects sleep and appetite.
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Chest X-ray
Physical
Examination
Dyspnoeic
Reduced Air Entry Lt
lung
Auscultation Stony
Dullness
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Management
• Symptom • Coop
Loop
Medical Nursing
Functional Psychosocial
• ADLs • Financial
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Medical
Non
Pharmacological
Pharmacological
Fan
Start mist morphine Deep breathing
2.5mg Q4 prn. exercise
42