what is dyspnea and what can be done about it? - cleveland clinic
TRANSCRIPT
![Page 1: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/1.jpg)
What is dyspnea and what can be
done about it?
Dan Culver DO
![Page 2: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/2.jpg)
Outline
• What is dyspnea?
• What tests do we use for it?
• Questions
![Page 3: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/3.jpg)
What is dyspnea?
![Page 4: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/4.jpg)
What is dyspnea?
“Difficulty in breathing or
in catching the breath”
Low oxygen
delivery
Acid build-up
Muscle weakness
Lung blood vessels
Restriction of
lung motion
Central Airways narrowing
![Page 5: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/5.jpg)
![Page 6: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/6.jpg)
The main role of the lungs is gas
exchange
![Page 7: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/7.jpg)
Subpleura
Interlobular septa
Bronchovascular area
![Page 8: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/8.jpg)
Sarcoidosis likes to involve the
airways too
“Pebbly mural” appearance
![Page 9: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/9.jpg)
Bronchoscopy results
LUL
LLL
RUL
Upper
division
lingula
![Page 10: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/10.jpg)
Pulmonary hypertension in
sarcoidosis
0
10
20
30
40
50
60
70
80
Per
cen
t w
ith
Pu
lmon
ary
Hyp
erte
nsi
on
Kyoto Detroit Milan New York Cincinnati Transplant
All patients Only Dyspneic Patients
![Page 11: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/11.jpg)
Muscle weakness in sarcoidosis
![Page 12: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/12.jpg)
Marcellis RG. ERJ 2011
Muscle weakness relates to other
variables affecting QOL
6MWD Hand grip Extensor Quadrice
ps PT
HPT Pimax
Men -0.25 -0.25 -0.29 -0.17 -0.36 0.24
Women -0.12 -0.21 -0.30 -0.04 -0.043 0.051
![Page 13: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/13.jpg)
Outline
• What is dyspnea?
• What tests do we use for it?
• Questions
![Page 14: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/14.jpg)
![Page 15: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/15.jpg)
Spirometry
Flow-volume loop
showing obstruction
![Page 16: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/16.jpg)
Data at the time of evaluation
![Page 17: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/17.jpg)
![Page 18: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/18.jpg)
The main role of the lungs is gas
exchange
![Page 19: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/19.jpg)
![Page 20: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/20.jpg)
![Page 21: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/21.jpg)
Stage I: 85-90% Stage II: 50-65%
Stage III: 20-30% Stage IV: 0%
Scadding X-ray stages
![Page 22: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/22.jpg)
Which patient has worse
pulmonary function tests?
69 year-old male 46 year-old male
![Page 23: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/23.jpg)
Some potential causes of
shortness of breath in sarcoidosis
• Involvement of the lung tissue
• Airways involvement (usually asthma-like)
• Deconditioning (out of shape)
• Anemia (low blood counts)
• Airways involvement with stenosis
• Poor heart function
• Muscle inflammation
• High blood pressures in the lungs
(pulmonary hypertension)
RARE
![Page 24: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/24.jpg)
Chest x-ray is not a very good
marker of disease activity
0
5
10
15
20
25
-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7
0 0 0 0 0 1 1
15
6 7
23
3 3 4
9
Judson MA. Respirology 2008
51%
n=36
ĸ=0.54
![Page 25: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/25.jpg)
What about chest CT scan?
![Page 26: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/26.jpg)
Does ACE help?
Rothkrantz-Kos S. Clin Chem 2003
Correlation with respiratory functional impairment in 144 non-smoking patients
![Page 27: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/27.jpg)
Correlation of biomarkers with
outcome
Acute sarcoidosis Chronic sarcoidosis
AUC 0.89 (0.79-1) sIL2R
AUC 0.72 (0.52-0.92) for ACE Rothkrantz-Kos S. Clin Chem 2003
![Page 28: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/28.jpg)
Sarcoidosis penumbra
Lazar CA. SRCCM 2010
![Page 29: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/29.jpg)
![Page 30: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/30.jpg)
Pulmonary sarcoid with
bulky adenopathy
![Page 31: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/31.jpg)
Overdosing steroids?
• 36 acute exacerbations
• Mean steroid dose
19 mg
• FVC improved from
68% to 82%
• Median assessment at
21 days
Goldstein DS. Thorax 1986 McKinzie BP. AM J Med Sci 2010
![Page 32: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/32.jpg)
Predictors of requirement for
therapy at 2 years in ACCESS
0
20
40
60
80
100
120
No early treatment Early treatment
Independent predictors
Initial treatment
O.R. 3.6 (1.8-7.2)
Dyspnea
O.R. 2-4
Baughman RP. QJM 2006
n=205
No.
of subje
cts
![Page 33: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/33.jpg)
![Page 34: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/34.jpg)
Data at the time of evaluation
![Page 35: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/35.jpg)
Making the diagnosis:
Bronchoscopy
Overall diagnostic yield 70-97%
Yield in non-chest diseases
Sensitivity
TBBx: 43-96%
EBBx: 40-75%
TBNA: 46-66%
Combination: 91%
“Pebbly mural” appearance
![Page 36: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/36.jpg)
Treatment
• Treat the disease
– Immunosuppressives
– TNF antagonists variably successful
• Cognitive behavioral therapy
• Aerobic and strength training
• Stimulants
Hoving JL. Scand J Rheumatol 2009
Chauffier K. Rheumatology 2011 Lower EE. Chest 2008 White PD Lancet 2011
![Page 37: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/37.jpg)
![Page 38: What is dyspnea and what can be done about it? - Cleveland Clinic](https://reader035.vdocuments.site/reader035/viewer/2022070222/613d0a0e736caf36b758974a/html5/thumbnails/38.jpg)
Endobronchial stenosis requiring
lung transplant