Dyspnea

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Dyspnea
??? 91-01-29
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Definition

• The conscious awareness of the labored breathing
  or air hunger in conditions other than heavy
  exercise
• The subjective sensation of breathlessness
• An awareness of breathing that is both unpleasant
  and unanticipated

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Definition

• Patients term Chest tightness, shortness of
  breath, Air hunger, and difficulty or discomfort
  in breathing
• Dyspnea represents the physical sign of labored
  breathing
• Severity depends on a number of factors
• The patients level of anxiety
• Perception of danger
• Stimulus invoking the dyspnea
• Behavioral influences
• Cultural background.

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Acute Dyspnea

• Pulmonary Causes
• Traumatic Causes
• pneumothorax, hemothorax, pulmonary contusion,
  flail chest, cardiac tamponade, and diaphragmatic
  perforation or rupture, neurologic injury
• Nontraumatic Causes of Dyspnea
• Pulmonary Embolus
• Asthma
• PneumoniaAspiration
• Pneumonia
• Pleural Effusion
• Acute Lung Injury

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Acute Dyspnea

• Cardiac Causes
• Acute Cardiogenic Pulmonary Edema
• Other Causes of Acute Dyspnea
• Psychogenic Dyspnea (hyperventilation syndrome)
• Guillain-Barré Syndrome
• Myasthenia Gravis

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Chronic Dyspnea

• Pulmonary Causes
• Chronic Obstructive Pulmonary Disease
• Cardiac Causes
• Valvular Heart Disease
• Mitral Stenosis
• Mitral RegurgitationAortic Stenosis
• Other Causes of Chronic Dyspnea
• Abdominal Loading
• Neuromuscular Disorders

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Pulmonary embolism

• major life-threatening cause of dyspnea
• Dyspnea 84
• Chest pain 88
• Tachypnea the most common sign, RR gt20, 82
• Pleuritic chest pain
• Local wheezing
• rarely occurs in the absence of dyspnea,
  tachypnea, chest pain, or documented deep vein

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Other emboli

• Less common causes of dyspnea include the fat
  emboli syndrome, bone marrow emboli, amniotic
  fluid emboli, foreign body emboli, and air emboli

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Fat emboli syndrome

• The fat emboli syndrome generally occurs after
  long bone fractures.
• Within 12 to 36 hours patients develop marked
  dyspnea, tachypnea, tachycardia, mental status
  changes, and fever.
• Treatment is generally supportive.

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Amniotic fluid emboli

• Amniotic fluid emboli usually occur during or
  just after delivery.
• The clinical presentation consists of sudden
  onset of dyspnea, restlessness, chills, and
  vomiting.
• Noncardiogenic pulmonary edema develops quickly.
  Treatment consists of mechanical ventilation,
  diuresis, and supportive care.
• The mortality rate is 80 to 90

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Asthma

• Asthma is a chronic disease with acute
  exacerbations.
• Clinical picture acute episodes alternating with
  symptom-free periods
• Pathophysiology
• Bronchial smooth muscle constriction
• Edema and mucous plugging of the small airways.
• Prolonged expiratory phase, hyperinflation,
  increased work of breathing, hypoxia, and
  ventilation-perfusion mismatches.
• These factors may lead to atelectasis, promote
  the development of bronchitis

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Asthma

• Wheezes is not asthma
• Congestive heart failure (CHF)
• Chronic obstructive pulmonary disease (COPD)
• Pulmonary embolus
• Airway foreign bodies
• Certain pneumonias

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Pneumonia

• Clinical features
• Respiratory distress
• Tachypnea or dyspnea
• Increased airway secretions
• Productive cough
• Systemic response
• Chills, fever, and leukocytosis

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Atypical pneumonias

• Unlike typical pneumonias, atypical pneumonias
  are acquired from inhalation of organisms from
  the environment, rather than aspiration of airway
  secretions.
• Mycoplasma, viruses, chlamydia, and legionella
  are atypical pneumonias.
• These pneumonias may cause symptoms that are less
  characteristic of typical pneumonias, including
  nonproductive cough, headache, mayalgias, and
  arthralgias

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Mycoplasma pneumonia

• Mycoplasma sp. pneumonia is associated with the
  presence of serum cold hemagglutinins in up to
  60 of cases, but they may also be present in a
  number of viral infections.
• Mycoplasmal pneumonia accounts for 10 to 20 of
  all pneumonias and occurs most commonly in 5- to
  18-year-old patients.
• The onset is gradual and insidious, unlike the
  abrupt onset of its bacterial counterpart.

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• Prodromal symptoms include fever, headache, and
  malaise followed several days later by a
  nonproductive, hacking cough.
• Other symptoms of infection may include
  hoarseness, sore throat, and chest pain but
  coryza is unusual.
• Children with mycoplasma generally appear
  nontoxic.
• 75 of patients have rales
• wheezing occurring less often.

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• Pneumocystis carinii, mycobacterial, or fungal
  pneumonia usually have a more insidious onset of
  fever, weight loss, nonproductive cough, easy
  fatigability, and dyspnea on exertion.

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• Pharyngitis, cervical lymphadenopathy,
  conjunctivitis, bullous myringitis, and otitis
  media occur occasionally.
• Rash is present in10 of patients and may be
  urticarial, erythema multiforme, maculopapular,
  or vesicular.
• Physical findings are generally less impressive
  than the radiographic picture involvement is
  usually unilateral and in the lower lobes.

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• However, the radiographic findings are protean
  and may show lobar consolidation, scattered
  segmental infiltrates, or interstitial disease.
• Pleural effusions occur in 5
• The WBC count is usually normal however, the
  erythrocyte sedimentation rate tends to be
  elevated.
• Laboratory diagnosis is problematic.
• Although used in the past, bedside cold
  agglutination testing is a poor indication of
  infection with only 75 sensitivity and
  specificity at best.

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• Infection is often diagnosed clinically and
  treated empirically.
• Diagnosis may be confirmed with acute and
  convalescent antibody titers.
• Complications are varied but unusual and include
  hemolytic anemia, myopericarditis, neurologic
  disease (meningoencephalitis, Guillain-Barré
  syndrome, transverse myelitis, cranial
  neuropathy), arthritis, and rash

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Aspiration pneumonia

• Generally reserved for pneumonias that depend on
  gastric juice, food products, or other foreign
  material
• First 1 to 3 hours after aspiration clinically
  well.
• Subsequently, dyspnea and tachypnea appear
• May develop severe respiratory distress and
  hemodynamic changes
• CXR patterns usually not distinctive, but may
  resemble pulmonary edema
• The right lung is often more severely involved
• The apexes are rarely involved.

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Aspiration pneumonia

• Particulate matter severe dyspnea, depending on
  the size of the object and the level of airway
  obstruction
• Large objects lodge the larynx or trachea ?
  sudden cyanosis and severe dyspnea ? may be fatal
  without emergent intervention
• Small particulate matter obstruction in the
  smaller airways? dyspnea, cough, wheezing,
  cyanosis, and vomiting

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Pleural Effusion

• chest pain, a dry nonproductive cough, and
  dyspnea.
• reduces lung volume
• the degree of dyspnea is commonly out of
  proportion to the size of the pleural effusion
• It may be related to chest pain with resultant
  splinting, or concomitant parynchemal disease

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Pleural Effusion

• With large pleural effusions, dyspnea may result
  from impeding ventricular filling with a
  consequent fall in cardiac output.
• Malignant pleural effusions, most often caused by
  lung or breast cancer, manifest with dyspnea as
  the presenting complaint in more than 50 of
  patients

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Acute Lung Injury (ARDS)

• The mortality rate is 60 to 70
• epithelial and endothelial damage, surfactant
  dysfunction, and microatelectasis.
• High protein exudate and inflammatory exudate
  containing plasma proteins, RBCs, platelets, and
  leukocytes fill the alveolar airspace resulting
  in severe right-to-left intrapulmonary shunts.
• There is a decrease in lung compliance because of
  alveolar and interstial edema

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Acute Lung Injury (ARDS)

• Tachypnea ? progressive dyspnea.
• Tachypnea may be the physicians only clue to
  impending lung injury
• Bilateral rales.
• Cxr reveal bilateral pulmonary edema without
  evidence of cardiomegaly.
• Abg hypoxemia despite high inspired
  concentrations of oxygen
• Most often associated with sepsis and gastric
  aspiration

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Acute Lung Injury (ARDS)

• Other insults including
• Head trauma (neurogenic pulmonary edema)
• Drug-induced noncardiogenic pulmonary edema
• thromboembolism
• Pancreatitis
• Near-drowning
• Multiple blood transfusions
• Smoke or toxic gas inhalation
• Amniotic fluid or air embolism
• High altitude pulmonary edema (HAPE)
• Cardiopulmonary bypass

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Acute Cardiogenic Pulmonary Edema

• Any condition that renders the heart an
  ineffective pump results in heart failure
• Dyspnea on exertion may be the first
  manifestation of cardiogenic pulmonary edema.
• As cardiac failure progresses, the patient may
  experience paroxysmal nocturnal dyspnea,
  orthopnea, and finally dyspnea at rest

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Acute Cardiogenic Pulmonary Edema

• Orthopnea, breathlessness that occurs in
  recumbency, is a type of dyspnea seen among
  patients with heart failure.
• The supine position enhances venous return to the
  heart, precipitating increases in diastolic
  cardiac pressure.
• The symptoms abate when the patient sits up and
  venous return decreases.

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Acute Cardiogenic Pulmonary Edema

• Paroxysmal nocturnal dyspnea (PND) is
  breathlessness that awakens the patient from
  sleep
• Recumbency? venous pressures in the legs
  decrease? interstitial edema fluid is reabsorbed
  into the circulation? plasma volume expansion?
  pulmonary congestion

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Acute Cardiogenic Pulmonary Edema

• In addition to symptoms of dyspnea, the patient
  with CHF may have chest pain, weakness, fatigue,
  palpitations, or cough.
• Physical examination may reveal hypertension,
  tachycardia, jugulovenous distension, S3 gallop,
  and rales.
• Pulmonary edema may lead to bronchospasm and
  so-called cardiac asthma, allowing the
  auscultation of wheezing on the lung examination

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Psychogenic Dyspnea (hyperventilation syndrome)

• Dyspnea 50 to 90
• The diagnosis may be suggested if the objective
  findings are inconsistent with the patients
  subjective complaints.
• Although stress may aggravate dyspnea of any
  cause, dyspnea clearly related to emotional
  stress suggests psychogenic dyspnea.
• Often unrelated to exertion
• More often in women than in men
• Generally presents in the second to fourth
  decades of life

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Psychogenic Dyspnea (hyperventilation syndrome

• This results in a decrease in PaCO2 with
  resultant decrease in cerebral blood flow.
• The patient may experience light-headedness,
  faintness, visual disturbances, or numbness of
  fingers or perioral areas.
• Because psychogenic dyspnea is a diagnosis of
  exclusion, diagnosis is made by excluding organic
  causes of dyspnea
• Treatment consists of reassurance and addressing
  the underlying anxiety

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Guillain-Barré Syndrome

• an acute, symmetrically progressive, ascending,
  inflammatory, demyelinating polyneuropathy
• It is the most common neuromuscular cause of
  acute respiratory failure.
• Nearly 50 of patients with Guillain-Barré
  syndrome develop respiratory complications.
• When respiratory musculature is involved,
  patients may have severe dyspnea.

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Guillain-Barré Syndrome

• Complications of this disorder include
  aspiration, pneumonia, atelectasis, and pulmonary
  embolus.
• Treatment consists of mechanical ventilation in
  patients with respiratory failure and supportive
  care.

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Myasthenia Gravis

• an autoimmune disorder of the neuromuscular
  junction caused by antibodies against the
  acetylcholine receptors.
• It is characterized by muscle weakness and easy
  fatigability.
• Symptoms resulting from respiratory muscle
  involvement depend on the severity of the disease
  and range from dyspnea on mild or moderate
  exertion to dyspnea at rest.

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• Patients may have severe respiratory muscle
  involvement even when peripheral muscle
  involvement is mild.
• Severe respiratory muscle weakness leads to
  diminished lung volume, development of patchy
  atelectasis, and consequently ventilation-perfusio
  n mismatch and hypoxemia.
• Patients may also experience impaired cough
  reflex and inability to clear airway secretions.

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History

• Dyspnea on exertion
• Cardiac or pulmonary disease, deconditioning
• Dyspnea during rest
• Severe cardiopulmonary disease or
  noncardiopulmonary disease (e.g., acidosis)
• Orthopnea, paroxysmal nocturnal dyspnea, edema
• Congestive heart failure, chronic obstructive
  pulmonary disease

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• Medications
• Beta blockers may exacerbate bronchospasm or
  limit exercise tolerance. Pulmonary fibrosis is a
  rare side effect of some medications
• Smoking
• Emphysema, chronic bronchitis, asthma
• Allergies, wheezing, family history of asthma
• Asthma
• Coronary artery disease
• Dyspnea as anginal equivalent

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• High blood pressure
• Left ventricular hypertrophy, congestive heart
  failure
• Anxiety
• Hyperventilation, panic attack
• Lightheadedness, tingling in fingers and perioral
  area
• Hyperventilation
• Recent trauma
• Pneumothorax, chest-wall pain limiting respiration

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• Occupational exposure to dust, asbestos or
  volatile chemicals
• Interstitial lung disease

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Physical examination

• Anxiety
• Anxiety disorder
• Nasal polyp, septal deviation
• Dyspnea due to nasal obstruction
• Postnasal discharge
• Allergies/asthma
• Jugular vein distention
• Congestive heart failure

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• Decreased pulse or bruits
• Peripheral vascular disease with concomitant
  coronary artery disease
• Increased anteroposterior chest diameter
• Emphysema
• Wheezing
• Asthma, pulmonary edema
• Rales
• Alveolar fluid (edema, infection, etc.)
• Tachycardia
• Anemia, hypoxia, heart failure, hyperthyroidism

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• S3
• Congestive heart failure
• Murmur
• Valvular dysfunction
• Hepatomegaly, hepatojugular reflux, edema
• Congestive heart failure
• Cyanosis, clubbing
• Chronic severe hypoxemia

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Diagnostic Examination

• The most useful methods of evaluating dyspnea
• ECG
• CXR
• Useful second-line tests include
• Spirometry
• pulse oximetry
• exercise treadmill testing.

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• Arterial Blood Gases
• altered pH,
• hypercapnia,
• Hypocapnia
• hypoxemia.
• Arterial blood gas measurement can be normal,
  however, in patients with clinically significant
  pulmonary disease.
• Normal arterial blood gas measurements do not
  exclude cardiac or pulmonary disease as a cause
  of dyspnea.

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Therapeutic Interventions

• The optimal therapy is to treat the cause. Often
  the cause is untreatable and in that situation
  the following have been tried
• Breathing techniques which may include pursed-lip
  or diaphragmatic breathing in COPD
• Exercise training The goal is not to alter the
  lung disease (usually untreatable) but rather to
  maximize the individual's exercise tolerance
• Nutritional manipulations with reduced CO2
  production

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• Psychologic interventions
• espiratory muscle training
• Sedative/Narcotic pharmacotherapy
• Supplemental Oxygen to reduce work of breathing

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• 1.  Exercise Training
• 2.  Pharmacologic Therapy
• 3.  Fans
• 4.  Altered Breathing Patterns
• 5.  Continuous Positive Airway Pressure (CPAP)
• 6.  Nutrition
• 7.  Positioning
• 8.  Steroids

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• 1.  Exercise Training Controlled studies have
  shown that dyspnea upon exertion decreases and
  exercise tolerance improves in response to
  exercise training, even in patients with advanced
  disease. It is now well established that for
  patients with COPD who remain breathless despite
  optimal drug therapy, exercise training can
  confer significant symptomatic benefits.

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• 2.  Pharmacologic Therapy Two types of
  medications have proven useful in alleviating
  dyspnea opiates and drugs that reduce anxiety. A
  number of studies have shown that opiates acutely
  relieve dyspnea and improve exercise performance
  in patients with COPD. The drugs to reduce
  anxiety have the potential to relieve
  ventilatory response related to the available
  amounts of oxygen in the blood, as well as by
  lowering the emotional response to dyspnea.

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• 3.  Fans The movement of cool air with a fan has
  been observed to reduce dyspnea in pulmonary
  patients. A decrease in the temperature of the
  facial skin alters feedback to the brain and
  modifies the perception of dyspnea. Cool air has
  been shown in normal volunteers to reduce dyspnea
  in response to excess carbon dioxide in the
  blood.

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• 4.  Altered Breathing Patterns Breathing
  retraining including diaphragmatic breathing and
  pursed lip breathing has been advocated to
  relieve dyspnea in COPD patients.  During a
  breathing retraining period, many patients adopt
  slower, deeper breathing techniques however,
  they often resort to spontaneous, fast, shallow
  breathing patterns when the training ends.

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• 5.  Continuous Positive Airway Pressure (CPAP)
  In various studies, CPAP has been shown to
  relieve dyspnea during asthma attacks, when
  patients are being weaned from ventilators, and
  during exercise sessions for patients with
  advanced COPD.

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• 6.  Nutrition Several investigators have shown
  improvement in respiratory muscle function in
  response to short-term use of nutritional
  repletion by an intravenous route.

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• 7.  Positioning Patients with COPD often change
  body position to improve dyspnea. They tend to
  lean forward to improve overall respiratory
  muscle strength and to reduce their symptoms.

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• 8.  Steroids Steroid use can be beneficial to
  pulmonary patients by reducing airway
  inflammation and by increasing vital capacity in
  chronic lung inflammation. 
• adverse effects including muscle wasting and
  weakness.
• These potential problems need to be balanced
  against possible gains in lung function
  associated with this drug. 

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• Cognitive-behavioral Approaches In patients with
  different pain syndromes, distraction,
  relaxation, and education about symptoms have
  modified the intensity of pain, increased
  tolerance, and decreased distress.
• Improvements in dyspnea and anxiety have been
  shown to follow distractions such as music during
  exercise, although long-term effects have been
  minimal.
• However, exercise in a monitored, supportive
  environment has been shown to be a powerful
  method of overcoming apprehension, anxiety,
  and/or fear associated with exertional dyspnea.