APPROACH TO A CASE OF DYSPNEA
by Prof. Arvind Mishra M.D.
Dept. of Medicine
DEFINITION
A subjective experience of breathing discomfort
that consists of qualitatively distinct sensations
that vary in intensity
(By American Thoracic Society)
CAUSES OF DYSPNEA
1)Respiratory causes
2)Cardiovascular causes
3)Dyspnea with normal cardiorespiratory function
RESPIRATORY CAUSES
1. Diseases of the airway
2. Diseases of the pleura and lung parenchyma
3. Diseases of the chest wall
1)Diseases of the airway
e.g. Asthma and COPD
Characterised by expiratory airflow obstruction
Hyperinflation of lung and chest wall
Increased resistive and elastic load on the
ventilatory muscles and increased work of
breathing
Hypoxia
2)Diseases of the pleura and lung
parenchyma
• Pleural effusion
• Infective diseases of parenchyma
- Pneumonia
-Pneumonia occuring over existing parenchymal
infective diseases-Bronchiectasis,lung abscess
• Interstitial lung disease – caused by
-occupational exposures
- autoimmune disorders
3)Diseases of the chest wall
a)Diseases that stiffens the chest wall
-kyphoscoliosis
b)Diseases that weakens the chest wall
-myasthenia gravis and guillain - barre
syndrome
CARDIOVASCULAR CAUSES
• Diseases of left heart
• Diseases of pulmonary vasculature
• Diseases of pericardium
Diseases of left heart
e.g. Coronary heart diseases
Valvular heart diseases
Dilated cardiomyopathy
Greater end diastolic volume and incresed LV
end diastolic and pulmonary capillary pressure
Interstitial edema and stimulation of pulmonary
receptors leading to dyspnea
Diseases of pulmonary vasculature
• Pulmonary thromboembolic diseases
• Primary pulmonary hypertension
• Pulmonary vasculitis
Increased pulmonary artery pressure and
stimulation of pulmonary receptors leading to
dyspnea
Diseases of pericardium
• Constrictive pericarditis
• Cardiac tamponade
Dyspnea caused by
-incresased pulmonary vascular pressure
-decreased cardiac output
stimulation of metaboreceptors and
chemoreceptors
Dyspnea with normal cardiorespiratory
function
ANEMIA- stimulation of metaboreceptors
OBESITY-impaired ventilatory pump function
and high cardiac output
EVALUATION OF A PATIENT WITH DYSPNEA
A)History
B)Physical examination
C)Investigations
HISTORY
1)Effect of position
a)Orthopnea-CHF, Obesity, asthma triggered
by oesophageal reflux
b)Platypnea-left atrial myxoma
2)Timing
Nocturnal- CHF , Asthma
3)Duration
a)Acute- Myocardial ischemia
Pulmonary embolism
b)Chronic- a)COPD
b)Interstitial lung disease
c)Chronic thromboembolic disease
4)RISK FACTORS – related to
a)Occupational lung disease
b)Coronary artery disease
PHYSICAL EXAMINATION
A)General appearance
- Evidence of increased work of breathing
a)supraclavicular retractions
b)use of accessory muscles
c)tripod position
Increased airway resistance or stiff lungs
and chest wall
-Vital signs
a)RR
b)pulsus paradoxus: COPD , Asthma
-General examination
a)anemia
b)cyanosis-central/peripheral
c)clubbing-cyanotic heart disease
Bronchiectasis
lung abscess
Empyema thoracis
Interstitial pulmonary fibrosis etc.
d)pedal edema-cor pulmonale
e)Joint swelling or deformity-Collagen Vascular Ds
CHEST EXAMINATION
a)Symmetry of movements
b)Percussion:
dullness-pleural effusion
hyperresonance-emphysema
tympanitic-pneumothorax
c)Auscultation:
Rales/ rhonchi/ diminished breath sounds/prolonged
expiratory phase
Disorders of airway/ interstitial edema/fibrosis
CVS EXAMINATION
A)Elevated right heart pressure
-raised JVP
-edema
-ascitis
-tender hepatomegaly
B)Left ventricular dysfunction
-Gallop rhythm(S3 and S4 gallop)
C)Valvular disese
-murmurs
INVESTIGATIONS POINTING NEUROLOGICAL,
MUSCULAR AND SKELETAL DISORDERS
• Neurological disease-NCV testing
• Muscular disease- Creatine phosphokinase
enzyme estimation(CPK)
• Skeletal deformities-X-ray of affected area of
spine(AP/Lateral view)
ABDOMINAL EXAMINATION
A)Paradoxical movement of abdomendiaphragmatic weakness
B)Tender hepatomegaly-Right heart failure
C) Tense Ascitis- Chonic liver disese ,Chonic heart
failure
If diagnosis not evident yet? What next….
CXR
-assess for cardiac size , evidence of CHF
-Assess for hyperinflation
-Assess for pneumonia, ILD and Pleural effusion
Chest X ray
a)Prominent pulmonary vasculature in upper zone:
pulmonary venous hypertension
b)Enlarged central pulmonary arteries:
pulmonary artery hypertension
c)Enlarged cardiac silhouette-Dilated
cardiomyopathy, valvular disease
d)Pleural effusion- CHF ,TB, Pneumonia, Pulmonary
embolism
CT –Chest: for further evaluation
(in ILD ,Pulmonary embolism)
CARDIOPULMONARY EXERCISE TEST
-To distinguish cardiovascular from respiratory
dyspnea
-If at peak exercise:
a) patient achieves predicted maximum
ventilation, increase in dead space/hypoxemia or
develops bronchospasm- Respiratory system is
involved
b)HR is>85% of predicted maximum, BP becomes
excessive high/decrease during exercise, O2 pulse
falls(O2 consumption/HR,an indicator of stroke
volume) ischemic changes on ECGCardiovascular system is involved
TREATMENTA)correct the underlying problem
B)If A) is not possible, try to lessen the severity
of symptoms
-supplemental oxygen
-pulmonary rehabilitation programs
MCQs
1)A 40 year old man ,chronic smoker and a known
diabetic presented with sudden onset
brethlessness since 1 day. O/E peripheral
extremities are cool, B/L crepts in the chest and
neck veins are engorgerd .MOST LIKELY
DIAGNOSIS
a)Spontaneous pneumothorax
b)Pulmonary embolism
c)Cardiac tamponade
d)Myocardial infarction
2)A young patient presented with high grade fever
,left sided chest pain in the evening hours and
developed marked breathlessness by next
morning.X-ray chest revealed areas of
parenchymal necrosis, air filled cystic spaces and
pleural effusion on left. Possibility will be
a)Fried landers pneumonia
b)Staphylococcal pneumonia
c)Pneumonia by H.influenzae
d)Nosocomial pneumoniae
3)A 40 year old women developed sudden sharpshooting chest pain on the right side which
followed immediately by marked breathlessness
.Very rapidly patient developed shock,BP was not
recordable.On general examination ,patient
revealed cyanosis.Most likely etiology would be
a)Tension pneumothorax
b)Status asthmaticus
c)Cardiac tamponade
d)Cardiogenic shock
4)A 30 year old male came with H/O severe epigastric
pain with radiation to back and recurrent vomitings
for past 3 days and breathlessness for past one day.
No H/O .jaundice or abdominal pain in past. O/E: BP104/68, RS-decreased BS in Left hemithorax,
Abdomen –decreased bowel sounds. Biochemical
investigation reveals hypocalcemia,hyperglycemia
and hypertriglyceridemia. Most likely diagnosis
a)Acute pancreatitis
b)Perforation peritonitis
c)GERD
d)Left side pneumonitis
5) A 28 year old man, a known diabetic came with
h/o gastroenteritis 1 week back –cause could not
be evaluated. Patient has developed symmetrical
weakness of B/L lower limb followed by trunk and
B/L upper limb without BBI for past 3 days. Since
morning patient has developed breathlessness.
Diagnosis
a)Lead poisoning
b)Myasthenia Gravis
c)Guillain Barre Syndrome
d)Diabetic neuropathy