GROUP A4

Tay Qin Le Low Li Tatt

Amirul Asyraf

Farah Izzati Nadiah Umar

Chua Hui Shan Magdalen

..Breathlessness..

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CASE PRESENTATION“SHORTNESS OF BREATH”

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Biodata

• Mr M• 57 y/o• Malay• Gentleman• Security Guard• Married• Kajang• Admitted: 4 August 2010

Chief Complaint

Shortness of breath for half an hour

HOPI

Intermittent SOB ?(day/night, before/after meal)

Last for half an hour Occur at rest Relieving factor: No Exacerbating factor: cold weather, lying

down, 20 feet walking

Associated symptoms

• Orthopnoea• PND(wake up 3-4 times)• Cough: productive, yellowish sputum, large

volume, bubbles, no haemoptysis, ?viscosity

• Chest pain: pleuritic chest pain with prickling in nature, chest tightness, left anterior chest wall, localised

• Wheezing while dyspnoea• Can only climb one flight of stairs• LOA, LOW(5kg in 2 weeks)• No fever

Past Medical History

• Recurrent bronchitis for 20 years and being admitted to hospital-recently admitted to HKJ 2/8/2010 and discharged on the following day

• Inhaler for 20 years (Ventoline & Bricanyl)

• No asthma• No DM, HPT• No known allergy

Family History-No significant family history except daughter has asthma since childhood

Past surgical history-do not have any surgery before.

Drug history-daun pecah kaca(Strobilanthes crispus )

Social History

Job- security guard Living environment- terrace house with

clean environment Chronic smoker Pet-No Non-alcoholic

Systemic review

General – PND CVS – orthopnoea, chest pain, no

palpitation RS – SOB, wheezing, cough, headache AS – not significant except pain at

epigastric and right hypochondriac region

US – frequency CNS & PNS – not significant MS – not significant Endocrine – not significant

Physical Examination

• General Appearance: On nasal prong, cardiac monitoring for pulse oximetry, cannula insertion at right dorsum of hand, well-hydrated

• Vital signs: RR= 26/min, HR= 92/min• RS: no clubbing, no flapping tremor, no

muscle wasting, no trachea deviation, resonance on percussion, reduced chest expansion, bibasal crepitation, reduced breath sound bilaterally, increased in AP diameter(barrel chest)

CVS: raised JVP(5 cm), apex beat not palpable, no cardiac & liver dullness, bilateral pedal edema up to mid-shin, no pallor, no jaundice, drnm

AS: tenderness at right hypochondriac and epigastric region on deep palpation

No significant finding in CNS, PNS, US, MS and Endocrine

Provisional Diagnosis: AECOPD Differential Diagnosis: CCF

SHORTNESS OF BREATH / DYSPNOEA

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Definition

Breathlessness / Dyspnoea – Awareness that an abnormal amount of works is required for breathing

....often described as SOB,inabliltiy to get enough air,suffocation,chest tightness,activities limit by exercise & heavy breathing

Orthopnoea – dyspnoea that develop when a patient is supine

Paroxysmal Nocturnal Dyspnoea – severe dyspnoea that wakes patient up from sleep to gasp for breath

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ClassificationGraded from I to IV based on the New York

Heart Association classification:

Class I – disease present but no dyspnoea or dyspnoea only on heavy exertion

Class II – dyspnoea on moderate exertion Class III – dyspnoea on minimal exertion Class IV – dyspnoea at rest

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Causes of Dyspnoea

I. Decrease O2 supply from lung dysfunction

II. Decrease O2 delivery from CVS problems

III. Decrease O2 carrying capacity in the circulation

IV. Increased O2 demand

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I. Decrease O2 supply from lung dysfunction

O2 carrying capacity is dependent on adequate air exchange in lung & to transport O2 on Hb

For adequate gas exchange, the lung need;- adequate inspiratory and expiratory forces- alveolar spaces is able to permit adequate gas exchange- vascular flow to the lung must be unobstructed

Disruption in any of above, will result in mismatches of O2 delivery and demand

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Chest mechanical abnormalities- fractured ribs, severe kyphosis/scoliosis

Airway obstruction- Epiglottic/laryngeal obstruction – Viral infection (croup), epiglottitis (Haemophilus influenzae)- Bronchial inflammation/obstruction – chronic bronchitis, lung cancers, asthma- Alveolar obstruction – pneumonia, pulmonary edema

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II. Decrease O2 delivery from CVS problems

Left ventricular failureRise of pressure in the left atrium and pulmonary capillaries leading to interstitial and alveolar oedemaLung less compliant which increase respiratory effort necessary to breathe

Cardiac failure Cardiomyopathies

- Diabetic cardiomyopathy, hypertensive cardiomyopathy

Myocardial ishemia

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III. Decrease O2 carrying capacity in the circulation

Concentration of Hb & its ability to bind & release O2 are important factors in determining available O2 in tissues

Acquired anemia – blood loss, hemolysis, underproduction

Congenital abnormalities in Hb – Thalassemia, Sickle cell

Acquired dysfunction in Hb function – Carbon monoxide poisoning

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IV. Increased O2 demand

Hyperthyroidism

Drug that produce hypermetabolic state – cocaine/ amphetamines

Generalized anxiety disorder

Panic disorder

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Causes of orthopnea Cardiac failure Uncommon-massive ascites; pregnancy;

bilat. diaphraghmatic paralysis; large Pleural Effusion; severe Pneumonia

Causes of paroxysmal nocturnal dyspnoea Left ventricular failure

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HISTORY TAKING

Evaluate patient24

Information should be obtained in patient with dyspnoea

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Relieving factors Rest Medications (physician and self-prescribed)Predisposing factors Cigarette smoking Occupational and environmental exposuresAssociated medical diseases and symptoms Pulmonary Cardiac NeuromuscularFamily history

Occurrence Rest Exertion (quantify) Position  Orthopnea (dyspnea lying flat)  Trepopnea (dyspnea in lateral position)  Platypnea (dyspnea when upright)Other precipitating factors  Environment  Emotional stateChronology Duration Progression Diurnal and seasonal variations Constant or intermittent

Physical examination:

INSPECTIONLooks for signs of respiratory distressChest wall deformities

1. Respiratory rate >20 breaths per mins2. Pursed lips breathing3. Flaring of nasal alae4. Use of accessory muscle5. Subcostal & intercostal muscle retraction6. Cyanosis(severe cases)

PALPATEChest expansionbarrel chest, pigeon chest, funnel chest, kyphoscoliosisVocal fremitus

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PERCUSS Hyperresonant pneumothoraxDullFibrosis,pleural thickeningStony dullPleural effusion

AUSCULTATE

~breath sounds~added sounds-Rhonchi and

wheezing

Differential diagnosis

With wheezing?? Asthma COPD Heart failure Anaphylaxis

With crepitations?? Heart failure Pneumonia Bronchiectasis Fibrosis

Others?? Hyperresonance in

pneumothorax Stony dullness in pleural

effusion

With stridor?? Foreign body/tumor Acute epiglottitis Anaphylaxis Trauma

With chest clear?? Pulmonary embolism Hyperventilation Metabolic acidosis Anaemia Drugs eg salicylates Shock Pneumocystis pneumonia Central causes

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Investigation

Lab no use in detection of dyspnoea (great value in differential d(x) & quantify severity of underlying d/o

Pulse oxymetry measuring oxygen saturation- COPD ↓oxygen saturation

Pulmonary function test detect obstructive & restrictive of lung & chest wall; VC & (FEV1) correlate well with dyspnoea

Arterial blood gas(ABG) generally performed but limited usefulness in evaluate breathlessness; most useful for quantify severity of gas exchange abnormalities in patients with lung dysf(x

Blood test Anaemia CXRPneumothorax ECGcardiac abnormalities

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Management

Nonpharmacologic interventions-Relaxation techniques-Supportive therapy : Fans, air supply , supplementary O2

Pharmacology intervention Opiods-Morphine Anxiolytics

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DIFFERENTIAL DIAGNOSIS

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HEART FAILURE

Heart unable to maintain cardiac output to meet the demands of the body

Right heart failure – 2o to left HF, volume overload, outflow obstruction, compromised ventricular filling, etc

Left heart failure – myocardial dysfunction, vol. overload, outflow obstruction

Biventricular - myocardial dysfunction, compromised ventricular filling, arrhytmia

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SYMPTOMS

RHF Nausea, anorexia,

fatigue Dyspnoea (pl.

effusion) abdominal

distension Ankle swelling

LHF Exertional

dyspnea Orthopnea Paroxysmal

nocturnal dyspnoea

Nocturnal cough wheeze

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SIGNS

RHF JVP raised Pl. effusion Hepatomegaly Ascites Dependent pitting

oedema Fxnal tricuspid

regurgitation

LHF Resting

tachycardia Tachypnea Displaced apex

beat 3rd heart sound Basal lung

crackles Fxnal mitral

regurgitation

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INVESTIGATIONS

Blood – FBC (anemia), BUSE (poor renal fx), TFT (thyrotoxicosis)

CXR – cardiomegaly, prominent upper lobe vessel, bat’s wing, kerley B line, pl.effusion

ECG – arryhtmia, ischemia Echocardiogram – assess LV fx, valvular

abnormality, pericardial effusion

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MANAGEMENTS

Encourage bed rest during exacerbation Correction of aggravating factors –

arrythmia, anemia Low-level endurance exercise Avoid exacerbating factor e.g. NSAID (cause

fluid retention), verapamil (-ve inotrope) Stop smoking, eat less salt, maintain

optimal weight and nutrition Drug: diuretics, ACE inhibitor, β-blocker,

spironolactone, digoxin, vasodilator

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PULMONARY EMBOLISM

• Venous thrombi, usually from DVT pass into the pulmonary circulation and block blood flow to the lungs.

Risk Factors• Malignancy• Surgery• Prolonged bed rest, reduced mobility• Leg fracture• Previous thromboembolism and inherited

thrombophilia

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SYMPTOMS

• Acute breathlessness

• Pleuritic chest pain• Hemoptysis• Dizziness• Syncope

SIGN

Pyrexia Cyanosis Tachypnoea Tachycardia Hypotension Raised JVP Pleural rub Pleural effusion

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INVESTIGATION

CXR– dilated pulmonary artery, pleural effusion, wedge shape opacity or cavitation

ECG – N or tachycardia, right bundle branch block, right ventricular strain

Blood Test- the quantity plasma D-dimer level is elevated.

ABG – may show Pa O2 and PaCO2

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TREATMENT

Anticoagulant with Low Molecular Weight Heparin (LMWH).

Starting regime for warfarin 10mg on day 1 and day 2,then 5mg on the third day.

Stop heparin when INR>2 and continue warfarin for a minimum of 3 months.

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MANAGEMENT

Compression stockings to prevent further thrombsis

60% of O2 if hypoxemic Dissolution of thrombus consider for

massive embolism with hypotension – streptokinase

IV morphine - to relieve pain & anxiety IV heparin, oral warfarin or LMWH for

prevention

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PNEUMOTHORAX

Air in the pleural space. Spontaneous or as result of trauma to

the chest Spontaneous (esp. in young thin men) d/t

rupture of pleural bleb In pt. over 40 years of age usual cause is

underlying COPD Secondary pneumothorax occurs with

rupture of any pulmonary lesion situated closed to pleural surface.

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SYMPTOMS Sudden onset of dyspnea Pleuritic chest pain Pt. with asthma or COPD may present with a

sudden deterioration

SIGNS Reduced expansion Hyperresonance to percussion Diminish breath sound on the affected side. Trachea deviated away from the affected side.

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TREATMENT AND MANAGEMENT

Depend whether it is primary or secondary (underlying lung disease) pneumothorax, size and symptoms.

Pneumothorax due to trauma requires a chest drain.

Aspiration of pneumothorax - identify the 2nd intercostal space midclavicular line or 4-6th intercostal space in the midaxillary line & filtrate with 1% lidocaine down to the pleura.

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ASTHMA

• Recurrent episodes of dyspnoea, cough, and wheeze caused by reversible airway obstruction

• 3 factors contribute to airway narrowing bronchial muscle contraction mucosal swelling/ inflammation increased mucus production

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SYMPTOM intermittent dyspnoea, wheeze, cough (often

nocturnal) and sputumask about:- precipitants: cold air, exercise, allergens,

infection, drugs- Exercise: quantify the exercise tolerance- Disturbed sleep: quantify as nights per

week(sn of serious asthma)- Atopic disease: eczema, hay fever, allergy,or

family history?- The home: pets?carpet?feather pillows?- Occupation?

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SIGN tachypnoea, audible wheeze, hyper-

inflated chest, hyper-resonant percussion note, diminished air entry.

severe attack: inability to complete sentences, pulse>110bpm, RR>25/min, PEF 33-50% predicted

life-threatening attack: silent chest, cyanosis, bradycardia, exhaustion, PEF<33% of predicted, confusion

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INVESTIGATIONS

Chronic asthma -PEF monitoring -spirometry- obstructive defect ( FEV1/FVC) -CXR- hyper-inflation -skin prick test-help to identify allergens

Acute attack -PEF -sputum culture - FBC- ↑ eosinophil count -ABG analysis – N/slightly low PO2 & PCO2 -radioallergosorbent test(RAST)-↑ serum level

of total or allergen-specific IgE

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MANAGEMENT

Behaviour-stop smoking,avoid precipitants

Drugs- β2-adrenoreceptor agonists, Corticosteroids, Aminophylline, Anticholinergics

Pt. and family education about asthma

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

A term used to describe pt’s with chronic bronchitis & emphysema

Chronic bronchitisproductive cough with sputum on most days for at least 3 months for 2 consecutive years

EmphysemaDilation and destruction of alveolar septum distal to terminal bronchioles

Common progressive disorder of airway obstruction (↓FEV1 <80%, ↓FEV1/FVC <70%)

Age onset > 35 years old Smoking related

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SYMPTOMS : cough, sputum, dyspnoea, wheeze

SIGNS: Inspection:Tachypnoea; prolong

expiration; hyperinflated chest Palpation : chest expansion Percussion: Resonant @ hyperresonant Auscultation: Quiet breath sound

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GENERAL EXAMINATION

Oedema Sn(s) of CO2 retention

Warm peripheries Bounding/collapsing pulse Asterixis/Flapping tremor Papilledema Confusion(severe cases)

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• Ix: -FBC- Hb & PCV↑ Polycythaemia -CXR- hyperinflation -ECG- R atrial and ventricular hypertrophy (cor pulmonale) -Lung function test (↓FEV1 <80%, ↓FEV1/FVC <70%)

• Management : Gen.management Persuade pt to stop smoking

Specific managementControlled O2 therapy(start with 24-28%,according to ABG)Nebulizer (eg:Salbutamol ;Ipratropium Bromide)Antibiotic ( eg:Amoxicillin /Ampicillin)

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PULMONARY EDEMA

Definition : -elavation of left atrial pressure

pulmonary capillary pressure transudation of fluid into lungs (cardiogenic pulm. edema )

Etiology :

Cardiogenic Non-cardiogenic

-LVF ( eg : IHD , MI )-mitral & aortic regurgitation-arrhythmias -malignant HTN

-ARDS d/t trauma , malaria , drugs -fluid overload-neurogenic ( eg : head injury )

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Clinical Features :

Complications :

-respiratory distress respiratory arrest

Investigations :

-chest X ray –distension of upper lobe veins, bat’s wing , Kerley B lines, small pleural effusions

-ECG-evidence of MI

Symptoms Signs

-breathlessness & orthopnea-wheezing -pink frothy sputu5m

Inspection :-cyanosis-tacyhpneaPalpation :-tachycardia ;low volume pulse-pulsus alternans ( indicates LVF)Auscultations :-gallop rhythm -rhonchi &crepitations

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-Blood -ABG- evidence of hypoxemia , initially low PaCO2 then high PaCO2 d/t impaired gas exchange

-cardiac enzymes

Management :General :- Sit patient up- 60% Oxygen via facemask

Pharmacological Rx:-IV frusemide -IV dimorphine -IV antiemetic

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PLUERAL EFFUSION

Definition : Excess accumulation of fluid in pleural space .

Etiology :Tansudate ( < 30 g/l) Exudate ( > 30 g/l)

-CCF-Chronic liver disease ( cirrhosis )-nephrotic syndrome

-Infections ( bac. Pneumonia, empyema, TB )- neoplasia : bronchial carcinoma, mesothelioma-Pulmonary infarction -Sarcoidosis -Post MI syndrome -Pancreatitis -Connective tissue disease

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Other types of pleural effusion : empyema, hemothorax, chylothorax

Clinical Features :Symptoms Signs

-pleuritic chest pain -dyspnea

Inspection :-Ipsilateral reduced chest movementPalpation:-ipsilateral reduced chest expansion -reduced vocal fremitusPercussion :-stony dull to percussionAuscultation :-reduced /absent breath sound-bronchial breath sound above effusion-whispering pectoriloquy

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Investigations :1 ) imaging : CXR ( can detect radiologically if > 300ml) - loss of costophrenic angle - dense shadow over lung field with concave upper

limit2) Pleural aspiration :- protein estimation - bacteriological examination( gram stain, Ziehl Nielson stain

and culture)-cytology ( for malignant cells )- Others ( amylase, Rheumatoid factor ,glucose)

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MANAGEMENTS:

-to treat underlying cause

Symptomatic Rx :

1) Pleural aspiration – for large effusions

2) Pleurodesis

-to induce adhesions between visceral and parietal pleural.

- 2 types : chemical -eg : with talc, tetracycline, bleomycin surgical - decortication ( abrasion of pleura to

induce adhesions )

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References

Oxford Clinical Handbook 7th edition Clinical Examination by Nicholas J Talley and

Simon O’Connor http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?

book=cm&part=A1140 http://www.supportiveoncology.net/journal/

articles/0101023.pdf http://ajrccm.atsjournals.org/cgi/content/full/159/

1/321#SEC4 Davidson’s Principles & Practice of Medicine,

20th edition. Kumar & Clark, Clinical Medicine, sixth edition.

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Ventolin62

Beta-agonist – prevent bronchospasm Used in: treat or prevent airway spasms,

as well as to prevent exercise-induced asthma attacks

Used as inhaler Side effect: throat irritation, coughing,

and respiratory infections

Bricanyl63

Beta-agonist Used in: reliever medication for

asthmatic symtoms, prevention against acute exercise induced asthma attacks

Used as inhaler/injection Side effect: Tremor, palpitations,

nervousness and restlessness, headache