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Approach to the patient with Approach to the patient with dyspnea in primary caredyspnea in primary care

Yrd. Doç. Dr. Özlem TanrıöverYrd. Doç. Dr. Özlem TanrıöverYeditepe University Medical Yeditepe University Medical Faculty, Department of Family Faculty, Department of Family MedicineMedicine

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DyspneaDyspnea

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IntroductionIntroduction

DYSPNEA is a word which is DYSPNEA is a word which is composed of 2 greek words:composed of 2 greek words:

DYS: DYS: painfull, difficult, sickpainfull, difficult, sick PNOIA:PNOIA: breathing breathing

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IntroductionIntroduction

DyspneaDyspnea is the perception of is the perception of uncomfortable, distressful, or uncomfortable, distressful, or labored breathing. labored breathing.

Most common complaint of Most common complaint of patients with cardiopulmonary patients with cardiopulmonary diseases.diseases.

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NORMAL RESPIRATORY NORMAL RESPIRATORY RATERATE

12-16 per minute for adults12-16 per minute for adults 15-30 per minute for children15-30 per minute for children Patients usually define their Patients usually define their

dyspnea as difficulty in breathing, dyspnea as difficulty in breathing, shortness of breath, painfull shortness of breath, painfull breathing or inability in breathing.breathing or inability in breathing.

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IntroductionIntroduction Tachypnea: Tachypnea: is increased respiratory rate is increased respiratory rate

(20/min)(20/min) Bradypnea: Bradypnea: is decreased respiratory rate is decreased respiratory rate

(10/min)(10/min) Hyperpnea: Hyperpnea: is increased respiratory is increased respiratory

amplitude (deep respiration)amplitude (deep respiration) Hypopnea: Hypopnea: is decreased respiratory is decreased respiratory

amplitude (shallow respiration)amplitude (shallow respiration) Apnea: Apnea: No respirationNo respiration

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DYSPNEADYSPNEA Sometimes the patient is not conscious of Sometimes the patient is not conscious of

being dyspneic, and the first clue being dyspneic, and the first clue encountered by the examiner is that the encountered by the examiner is that the patient pauses for breath patient pauses for breath in the middle of in the middle of an avarage sentence. an avarage sentence.

It is useful to distinguish several degrees, It is useful to distinguish several degrees, ranging from ranging from exertional dyspneaexertional dyspnea to to dyspnea at restdyspnea at rest and and orthopneaorthopnea..

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OrthopneaOrthopnea

This is the most severe form of dyspneaThis is the most severe form of dyspnea; ; the patient is prompted to assume a the patient is prompted to assume a position at rest that elevates the head and position at rest that elevates the head and thorax toward the vertical.thorax toward the vertical.

Many will have learned to do so because Many will have learned to do so because of suddenly awakening at night due to a of suddenly awakening at night due to a severely shortness of breath in the severely shortness of breath in the supine position (supine position (paroxysmal nocturnal paroxysmal nocturnal dyspneadyspnea).).

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The differential diagnosis is The differential diagnosis is composed of four general composed of four general categoriescategories

CardiacCardiac PulmonaryPulmonary Mixed cardiac or pulmonaryMixed cardiac or pulmonary Noncardiac or nonpulmonaryNoncardiac or nonpulmonary

**Although other causes may contribute, the Although other causes may contribute, the cardiac and pulmonary organ systems are cardiac and pulmonary organ systems are most frequently involved in the etiology of most frequently involved in the etiology of dyspnea.dyspnea.

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Cardiac causes includeCardiac causes include

Congestive heart failure (right, left or Congestive heart failure (right, left or biventricular)biventricular)

Angina pectorisAngina pectoris Myocardial infarction(recent or past)Myocardial infarction(recent or past) Valvular dysfunctionValvular dysfunction PericarditisPericarditis ArrythmiasArrythmias CardiomyopathyCardiomyopathy OthersOthers

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Pulmonary causesPulmonary causes

COPDCOPD AsthmaAsthma PneumothoraxPneumothorax Restrictive lung disorders (extrapulmonary Restrictive lung disorders (extrapulmonary

such as spine or chest deformities, obesity such as spine or chest deformities, obesity and intrinsic pulmonary pathology such as and intrinsic pulmonary pathology such as interstitial fibrosis, pneumoconiosis, interstitial fibrosis, pneumoconiosis, collagen vascular disease)collagen vascular disease)

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Mixed cardiac or Mixed cardiac or pulmonarypulmonary

COPD with pulmonary COPD with pulmonary hypertension and cor pulmonalehypertension and cor pulmonale

Pulmonary embolismPulmonary embolism TraumaTrauma

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Noncardiac or Noncardiac or nonpulmonarynonpulmonary

Metabolic conditions such as anemia, dabetic Metabolic conditions such as anemia, dabetic ketoacidosisketoacidosis

Pain in the chest wallPain in the chest wall Obstructive rhinolaryngeal problems (such as Obstructive rhinolaryngeal problems (such as

nasal obstruction due to polyps or septal nasal obstruction due to polyps or septal deviation, enlarged tonsils)deviation, enlarged tonsils)

Neuromuscular disordersNeuromuscular disorders Somatic manifestation of psychiatric disorders, Somatic manifestation of psychiatric disorders,

such as an anxiety disorders, with resultant such as an anxiety disorders, with resultant hyperventilation.hyperventilation.

History and Physical Examination Clues to History and Physical Examination Clues to Conditions That Cause DyspneaConditions That Cause Dyspnea

FFiinnddiinnggss

ConditionCondition

HHiissttoorryy

DDyyssppnneeaa oonn eexxeerrttiioonn

Cardiac or pulmonary disease, deconditioningCardiac or pulmonary disease, deconditioning

DDyyssppnneeaa dduurriinngg rreesstt

Severe cardiopulmonary disease or Severe cardiopulmonary disease or noncardiopulmonary disease (e.g., acidosis)noncardiopulmonary disease (e.g., acidosis)

OOrrtthhooppnneeaa,, ppaarrooxxyyssmmaall nnooccttuurrnnaall ddyyssppnneeaa,, eeddeemmaa

Congestive heart failure, chronic obstructive Congestive heart failure, chronic obstructive pulmonary diseasepulmonary disease

MMeeddiiccaattiioonnss

Beta blockers may exacerbate bronchospasm or limit Beta blockers may exacerbate bronchospasm or limit exercise tolerance. Pulmonary fibrosis is a rare side exercise tolerance. Pulmonary fibrosis is a rare side effect of some medicationseffect of some medications

SSmmookkiinngg

Emphysema, chronic bronchitis, asthmaEmphysema, chronic bronchitis, asthma

AAlllleerrggiieess,, wwhheeeezziinngg,, ffaammiillyy hhiissttoorryy ooff aasstthhmmaa

AsthmaAsthma

CCoorroonnaarryy aarrtteerryy ddiisseeaassee

Dyspnea as anginal equivalentDyspnea as anginal equivalent

HHiigghh bblloooodd pprreessssuurree

Left ventricular hypertrophy, congestive heart failureLeft ventricular hypertrophy, congestive heart failure

AAnnxxiieettyy

Hyperventilation, panic attackHyperventilation, panic attack

LLiigghhtthheeaaddeeddnneessss,, ttiinngglliinngg iinn ffiinnggeerrss aanndd ppeerriioorraall aarreeaa

HyperventilationHyperventilation

RReecceenntt ttrraauummaa

Pneumothorax, chest-wall pain limiting respirationPneumothorax, chest-wall pain limiting respiration

OOccccuuppaattiioonnaall eexxppoossuurree ttoo dduusstt,, aassbbeessttooss oorr vvoollaattiillee cchheemmiiccaallss

Interstitial lung diseaseInterstitial lung disease

PPhhyyssiiccaall eexxaammiinnaattiioonn

AAnnxxiieettyy

Anxiety disorderAnxiety disorder

NNaassaall ppoollyypp,, sseeppttaall ddeevviiaattiioonn

Dyspnea due to nasal obstructionDyspnea due to nasal obstruction

PPoossttnnaassaall ddiisscchhaarrggee

Allergies/asthmaAllergies/asthma

JJuugguullaarr vveeiinn ddiisstteennttiioonn

Congestive heart failureCongestive heart failure

DDeeccrreeaasseedd ppuullssee oorr bbrruuiittss

Peripheral vascular disease with concomitant Peripheral vascular disease with concomitant coronary artery diseasecoronary artery disease

IInnccrreeaasseedd aanntteerrooppoosstteerriioorr cchheesstt ddiiaammeetteerr

EmphysemaEmphysema

WWhheeeezziinngg

Asthma, pulmonary edemaAsthma, pulmonary edema

RRaalleess

Alveolar fluid (edema, infection, etc.)Alveolar fluid (edema, infection, etc.)

TTaacchhyyccaarrddiiaa

Anemia, hypoxia, heart failure, hyperthyroidism Anemia, hypoxia, heart failure, hyperthyroidism

SS33

Congestive heart failureCongestive heart failure

MMuurrmmuurr

Valvular dysfunctionValvular dysfunction

HHeeppaattoommeeggaallyy,, hheeppaattoojjuugguullaarr rreefflluuxx,, eeddeemmaa

Congestive heart failureCongestive heart failure

CCyyaannoossiiss,, cclluubbbbiinngg

Chronic severe hypoxemiaChronic severe hypoxemia

SS33=third heart sound.=third heart sound.

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Hyperventilation Hyperventilation SyndromeSyndrome

Response to stress, anxietyResponse to stress, anxiety Patient exhales COPatient exhales CO2 2 faster than faster than

metabolism produces itmetabolism produces it Blood vessels in brain constrictBlood vessels in brain constrict Anxiety, dizziness, lightheadednessAnxiety, dizziness, lightheadedness Seizures, unconsciousnessSeizures, unconsciousness

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Upper AirwayUpper Airway

Foreign Body ObstructionForeign Body Obstruction Pharyngeal EdemaPharyngeal Edema CroupCroup EpiglottitisEpiglottitis

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Foreign Body Foreign Body ObstructionObstruction

Partial or completePartial or complete Most common cause of pediatric Most common cause of pediatric

airway obstructionairway obstruction

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Foreign Body Foreign Body ObstructionObstruction

Suspect in any child with Suspect in any child with • Sudden onset of dyspneaSudden onset of dyspnea

Suspect in any adult who develops dyspnea Suspect in any adult who develops dyspnea or loses consciousness while eatingor loses consciousness while eating

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Pharyngeal EdemaPharyngeal Edema

Swelling of soft tissues of throatSwelling of soft tissues of throat Allergic reactions, upper airway burnsAllergic reactions, upper airway burns Hoarseness, stridor, droolingHoarseness, stridor, drooling

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Pharyngeal EdemaPharyngeal Edema

ManagementManagement• Position of comfortPosition of comfort• OxygenOxygen• Assist breathing as neededAssist breathing as needed• Consider AConsider Advanced dvanced LLife ife SSupport upport for for

invasive airway managementinvasive airway management

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EpiglottitisEpiglottitis

Bacterial infection Bacterial infection Causes edema of epiglottisCauses edema of epiglottis Children age 4-7 years Children age 4-7 years Increasingly common in adultsIncreasingly common in adults Rapid onset, high fever, stridor, Rapid onset, high fever, stridor, sore sore

throatthroat, , droolingdrooling

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CroupCroup

LaryngotracheobronchitisLaryngotracheobronchitis Viral infectionViral infection Causes edema of larynx/tracheaCauses edema of larynx/trachea Children ages 6 months to 4 yearsChildren ages 6 months to 4 years

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CroupCroup

Slow onset, hoarseness, brassy cough, Slow onset, hoarseness, brassy cough, nightime stridor, dyspneanightime stridor, dyspnea

When in doubt, manage as epiglottitisWhen in doubt, manage as epiglottitis

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Croup/Epiglottitis Croup/Epiglottitis

ManagementManagement• OxygenOxygen

• Assist ventilations as neededAssist ventilations as needed

• Do Do notnot excite patient excite patient

• Do Do notnot look in throat look in throat

• Consider ALSConsider ALS

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Lower AirwayLower Airway

AsthmaAsthma Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

• Chronic bronchitisChronic bronchitis• EmphysemaEmphysema

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AsthmaAsthma

Reversible obstructive pulmonary Reversible obstructive pulmonary diseasedisease

Younger person’s disease (80% have Younger person’s disease (80% have first episode before age 30)first episode before age 30)

Lower airway hypersensitive to Lower airway hypersensitive to allergens, emotional stress, irritants, allergens, emotional stress, irritants, infectioninfection

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AsthmaAsthma

BronchospasmBronchospasm Bronchial edemaBronchial edema Increased mucus production, pluggingIncreased mucus production, plugging

Resistance to airflow, work of breathing increase

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AsthmaAsthma

Airway narrowing interferes with Airway narrowing interferes with exhalationexhalation

Air trapped in chest interferes with gas Air trapped in chest interferes with gas exchangeexchange

Wheezing, coughing, respiratory Wheezing, coughing, respiratory distressdistress

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AsthmaAsthma

All that wheezes is All that wheezes is notnot asthma asthma Other possibilitiesOther possibilities

• Pulmonary edemaPulmonary edema• Pulmonary embolismPulmonary embolism• Anaphalaxis (severe allergic reaction)Anaphalaxis (severe allergic reaction)• Foreign body aspirationForeign body aspiration• PneumoniaPneumonia

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AsthmaAsthma

TreatmentTreatment• High concentration OHigh concentration O22, humidified, humidified

• Position of comfortPosition of comfort

• Assist ventilation as neededAssist ventilation as needed

• Bronchodilators via small volume Bronchodilators via small volume nebulizernebulizer

• Calm patient, reassureCalm patient, reassure

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Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease

Chronic BronchitisChronic Bronchitis EmphysemaEmphysema

• Most patients exhibit a mixture of Most patients exhibit a mixture of symptoms and signssymptoms and signs

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COPD - Physical COPD - Physical FindingsFindings

TachypneaTachypnea Accessory respiratory muscle useAccessory respiratory muscle use Pursed lip exhalationPursed lip exhalation Weight loss due to poor dietary Weight loss due to poor dietary

intake and excessive caloric intake and excessive caloric expenditure for work of breathingexpenditure for work of breathing

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Chronic BronchitisChronic Bronchitis

Chronic lower airway inflammationChronic lower airway inflammation

• Increased bronchial mucus Increased bronchial mucus productionproduction

• Productive coughProductive cough Urban male smokers > 30 years oldUrban male smokers > 30 years old

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Chronic BronchitisChronic Bronchitis

Mucus, swelling interfere with ventilationMucus, swelling interfere with ventilation Increased COIncreased CO22, decreased 0, decreased 022

CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema

Blue Bloater

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EmphysemaEmphysema

Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers > 40-50 years oldUrban male smokers > 40-50 years old

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EmphysemaEmphysema

Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22, maintain near normal O, maintain near normal O22

CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin, wastedThin, wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips

Pink Puffer

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COPDCOPD

Prone to periods of “decompensation”Prone to periods of “decompensation” Triggered by respiratory infections, chest Triggered by respiratory infections, chest

traumatrauma Signs/SymptomsSigns/Symptoms

• Respiratory distressRespiratory distress• TachypneaTachypnea• Cough productive of green, yellow sputumCough productive of green, yellow sputum

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COPD ManagementCOPD Management

OxygenOxygen• Monitor carefullyMonitor carefully

• Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen

Assist ventilations as neededAssist ventilations as needed

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COPD ManagementCOPD Management

If wheezing present, nebulized If wheezing present, nebulized bronchodilatorsbronchodilators

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PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIA

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6th leading cause of death in the 6th leading cause of death in the USUS

Respiratory viruses & mycoplasma Respiratory viruses & mycoplasma responsible for greater than 1/3 of responsible for greater than 1/3 of casescases

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Common types of respiratory Common types of respiratory infectionsinfections

TracheobronchitisTracheobronchitis PneumoniaPneumonia EffusionsEffusions EmpyemaEmpyema AbscessAbscess Cavitary lesionsCavitary lesions post-obstructivepost-obstructive

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Common Respiratory Common Respiratory VirusesViruses

Influenza A & BInfluenza A & B Parainfluenza 1& 3Parainfluenza 1& 3 Respiratory Syncytial VirusRespiratory Syncytial Virus AdenovirusAdenovirus CytomegalovirusCytomegalovirus Herpes Simplex & Zoster/varicellaHerpes Simplex & Zoster/varicella Hanta Virus InfectionHanta Virus Infection

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Classic Pneumonia Classic Pneumonia SymptomsSymptoms

Dyspnea, chillsDyspnea, chills high fever, cough/sputumhigh fever, cough/sputum pleuritic chest painpleuritic chest pain

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Viral Pneumonia - Viral Pneumonia - symptomssymptoms

Chest PainChest Pain FeverFever DyspneaDyspnea Prodrome - malaise, upper Prodrome - malaise, upper

respiratory symptoms, and other GI respiratory symptoms, and other GI symptomssymptoms

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Viral pneumonia - Viral pneumonia - Clinical FindingsClinical Findings

Minimal/variableMinimal/variable Chest exam - may reveal wheezingChest exam - may reveal wheezing Fine rales if heard can signify Fine rales if heard can signify

interstitial involvementinterstitial involvement Chest x-ray - patchy densities or Chest x-ray - patchy densities or

interstitial involvementinterstitial involvement

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Viral pneumoniaViral pneumoniaManagement Management /Prophylaxis/Prophylaxis

Supportive treatment - decrease severity of Supportive treatment - decrease severity of symptomssymptoms

bed restbed rest analgesicsanalgesics Patients w/Patients w/

• airway obstruction - treat w/bronchodilatorsairway obstruction - treat w/bronchodilators

• secondary bacterial infection -secondary bacterial infection - antibiotics antibiotics

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Atypical PneumoniaAtypical Pneumonia Accounts for 25% of community acquired Accounts for 25% of community acquired

pneumoniaspneumonias Mycoplasma/chlamyda/legionellaMycoplasma/chlamyda/legionella can case extrapulmonary manifestations -can case extrapulmonary manifestations -

• meningitis, encephalitis, pericarditis, hepatitis, meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemiahemolytic anemia

• typically bilateral infiltrates on chest x-raytypically bilateral infiltrates on chest x-ray

• primarily effects younger peopleprimarily effects younger people

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Atypical PneumoniaAtypical PneumoniaTreatmentTreatment

AntibioticsAntibiotics MacrolidesMacrolides fluroquinolonesfluroquinolones doxycyclinedoxycycline

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Bacterial pneumonia Bacterial pneumonia presentationpresentation

acute shaking - chillsacute shaking - chills tachypneatachypnea tachycardiatachycardia malaisemalaise anorexiaanorexia myalgias myalgias flank or back painflank or back pain vomitingvomiting

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