cme- breathlessness rad

Radtthiga ChelvarajMBBS

Batch 11Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11

Dyspnoea• Definition: abnormal awareness of breathing

occuring at an inappropriately low level of physical exertion or at rest.

Tuesday, April 11, 2023 Acute breathlessness, Radtthiga Batch 11

Causes of breathlessness

Respiratory1.Airway diseases2.Parenchymal disease3.Pulmonary circulation4.Chest wall and pleura

Source : Clinical examination, A systematic guide to physical diagnosis, Talley & O’ Connor


Causes of breathlessness Cardiovascular

1.Left ventricular failure

2.Mitral valve disease

3.Cardiomyopathy4.Pericardial

effusion

Source : Clinical examination, A systematic guide to physical diagnosis, Tally & O’ Connor


Causes of breathlessness

Non-cardiorespiratory1.Metabolic acidosis

2.Psychogenic

Source : Clinical examination, A systematic guide to physical diagnosis, Talley & O’ Connor


Causes of dyspnoeaSystem Acute dyspnoea at restCardiovascular Acute pulmonary edema

Respiratory Acute severe asthmaAcute exacerbation of COPDPulmonary embolismTension pneumothorax

Others Metabolic acidosis


Causes of dyspnoeaSystem Chronic exertional dyspnoea

Cardiovascular Chronic heart failureAngina

Respiratory COPDChronic asthmaBronchial carcinomaInterstitial lung disease

Others Severe anemia


Important aspects -Dyspnoea

• Onset?• Severity? • Number of episodes?• *Association with cardiovascular symptoms ?• *Association with respiratory system?


Association with respiratory system?

• Are there good days or bad days?• Diurnal variation?• Aggravating factors?• Relieving factors?• American College of Physician (ACP) guideline for dx

and mx of COPD guideline:– history of >40 pack-years of smoking best single

predictor of airflow obstruction


Associated symptoms

• Productive cough or acute chest illness (Hx of chronic cough with sputum, worse in the morning)

• Breathlessness• Wheezing


Association with cardiovascular system

• Onset:?–Physical exertion or at rest?– Triggering factors? ( MI)• Distance walked before breathlessness

occur?• Chest pain? (site, radiation)• Aggravating factors? (exercise, exertional,

stress anxiety)


Association with cardiovascular system

• Relieving factors ? • Orthopnoea? ( beds used to sleep)• Paroxysmal Nocturnal Dyspnoea?


COPD AND ASTHMA

Definition

• preventable & treatable respiratory disorder

• smoking• progressive, partially

reversible airflow obstruction

• lung hyperinflation + extrapx (systemic) manifestations

• comorbid conditions

• chronic airway inflammation

• Increased airway hyperresponsiveness

• sx of wheeze, cough,chest tightness and dyspnoea.

• Reversible with treatment.

COPD ASTHMA


COPD vs Asthma• Onset? : Gradual• Severity? : Progressively getting worse (exertional dyspnoea dyspnoea at rest and

Overnight.• Number of episodes? : With disease progression,

intervals become shorter• SMOKING• Association with cardiovascular symptoms ? : nil*


COPD vs Asthma

• Onset• Atopy : triggering factors?• Diurnal variations?• Good days and bad days? ( Days per week off

work or school)• Family history?• Reversibility of symptoms?• Other atopic disease? ( eczema, allergy)


History and signsConditions History SignsAcute severe asthma

Previous episodesAtopyAsthma medication

-Tachycardia-Pulsus paradoxus-Cyanosis-Reduced peak flow-Rhonchi


History and signs

Conditions History SignsAcute exacerbation of COPD

Previous episodes, *admissionsSmoking

-Cyanosis-Raised JVP--LL Edema( Cor pulmonale)-Respiratory distress signs


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-Barrel chest-Pursed lip breathing-Tripod position-Cardiac apex not palpable-Reduced breath sound -Prolonged expiration-rhonchi

Systemic manifestations


Investigations• Chest X-ray signs ofhyperinflation• flattening of the

diaphragm• increased

retrosternal air space

• long, narrow heart

shadow.• hypovascularity of

lung parenchyma


Spirometry

• Objective demonstration of airflow obstruction.

Bronchodilator Reversibility Testing:• required to establish lung function at that

point of time. • significant if the change in FEV1 = 200 mL and

12% above the pre-bronchodilator .• If there is a marked response to

bronchodilators asthma .


Classification of COPD Severity Based on Spirometric Impairment

Severity Classification by postbronchodilatorspirometricvalues

Mild FEV1/FVC < 0.70FEV1 > 80% predicted

Moderate FEV1/FVC < 0.7050% ≤ FEV1 < 80% predicted

Severe <FEV1/FVC < 0.7030% ≤ FEV1 < 50% predicted

Very severe FEV1/FVC < 0.70FEV1 < 30% predicted orFEV1 < 50% predicted pluschronic respiratory failure


Conditions History Signs

Left ventricular failure

Chest painOrthopnoeaPNDPink, frothy sputum

-Raised JVP--Central cyanosis-Bibasal crackles -S3-Cardiomegaly-Cold extremities-LL edema


Conditions History Signs

Metabolic acidosis Evidence of Diabetes/ renal diseases

-Acetone breath-Hyperventilation- Kussmaul’s breathing -Dehydration


Investigations

Conditions Chest radiography

Arterial blood gas analysis

ECG


CardiomegalyAbsence of air bronchogramKerley B linePleural effusion

-Low Pa O₂- Low PaCO₂

-Sinus tachycardia-Signs of Myocardial Infarction-Arrhythmia

Acute severe asthma

Hyperinflated chest

-Low Pa O₂- Low PaCO₂

-Sinus tachycardia* Bradycardia with severe hypoxemia


Conditions Chest radiography

Arterial blood gas analysis

ECG

Acute exacerbation of COPD

Hyperinflation Emphysema-Low Pa O₂-Low PaCO₂Bronchitis-Low Pa O₂-High PaCO₂- high bicarbonate

-Nil or signs of right ventricular strain

Metabolic acidosis

Normal -Normal Pa O₂-Low PaCO₂- low pH

-


Acute exacerbations of COPD

• Characterised by:• Increases in symptoms• Deterioration of lung function• Development of respiratory failure


Management

1. Oxygen therapy: ( 24- 28%)2. Bronchodilators: short acting β₂ agonist +

anticholinergic3. Corticosteroids: Prednisolone4. Antibiotic therapy: aminopenicillin, macrolide5. If above measures fail, do non-invasive

ventilation6. Other measures


Discharge

• Once patient is stable

• Short term nebuliser


Acute exacerbation of asthma

• Characterised by:• Increased symptoms• Deterioration in PEFMay be precipitated by infections(viral)


Mild – moderate exacerbations

• ‘rescue’ oral corticosteroid (prednisolone 30-60mg daily)

• Indications for rescue course:• Worsening symptoms and PEF• Fall of PEF < 60%• Worsening sleep disturbance• Persistence morning sx• Diminished response to inhaled bronchodilator


Acute severe asthma

• Initial assessment : PR, RR, BP and SaO2• PEF 35-50%• Respiratory rate > 25 /min• Heart rate >110b/min• Inability to complete sentences in 1 breath


Treatment

• 1. Oxygen ( high concentration ), maintain O₂ saturation >90mmhg

• 2. Bronchodilators :• β₂ agonist – salbutamol via metered dose

inhaler + ipratropium bromide• 3. Corticosteroids: Prednisolone ( 30-60mg,

oral) or IV hydrocortisone(200 mg)


Subsequent management

• If patient deteriorates IV Mg • Monitoring of treatment:• Record PEF every 15 min-30 min then, 4-6

hourly• Pulse oximetry ( SaO2>90mmHg)


Indications for endotracheal intubation

• deterioration of arterial blood gas despite optimal therapy :

• PaO₂ < 60 mmHg• Pa CO₂> 45 mmHg• pH low


Discharge

• Counselling on medications



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cme- breathlessness rad

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