1. Dr. Ghulam Hussain Baloch Associate Professor of Medicine
Approach to Dyspnea
Dr. Ghulam Hussain Baloch
Associate Professor of Medicine
LUMHS, Jamshoro

2. Definition
Awareness of his own breath

3. Hyperventilation
Signing breath
In ability to take deep breath

4. Orthopnea dyspnea on recumbence

5. Dyspnea Definitions Dyspnea of exertion (DOE) Orthopnea
Exertion-induced SOB
Orthopnea
Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND)
Sudden SOB after recumbent

6. PND (Cardiac Asthma)
Sever breathness at night relieved when patient sits up

7. Case 1
73 y/o F presents to the ED with complaints of SOB for the last 2 days

8. Case 2
28 year male presented with high grade fever, cough on examination bronchial breathing
Diagnosis
Investigation & Mangement

9. Dyspnea Rapid Assessment
ABC’s
Mental status
Presence of cyanosis

10. Dyspnea Initial Interventions
IV assess
Pulse oximetry; supplemental O2
Cardiac monitor

11. What Are the Indications for Airway Management?
Secure & maintain patency
Protection
AMS or altered gag
C-spine
Oxygenation
Ventilation
Treatment – Suction, medications

12. Dyspnea History Prolonged questioning can be counterproductive
Yes/No questions if significantly dyspneic
Unlike pain, severity of dyspnea = severity of disease
What does patient mean by SOB?
How long has SOB been present?
Is it sudden or gradual
Does anything make it better or worse?

13. Dyspnea History Has there been similar episodes?
Are there associated symptoms?
What is the past medical Hx?
Smoking Hx?
Medications?

14. Cause Acute Bronchial asthma Pneumonia Pneumothorax
thromboembolic disease
Cardiac
Pulmonary oedema
Non cardiac pulmonary oedema
psychogenic

15. Chronic Pulmonary Cause 1. COPD Chronic Bronchial Asthma
Emphysema Chronic Bronchitis
2. Restrictive Lung Disease
Sarcoidosis
Rheumatoid lung
fibrosing alveolitis
Pneumoconosis

16. Dyspnea Etiologies

17. Dyspnea Etiologies: Pulmonary Causes

18. Dyspnea Common Pulmonary Causes
Obstructive lung disease
Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax

19. Dyspnea Common Pulmonary Causes
Obstructive lung disease
Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax

20. Dyspnea Etiologies: Nonpulmonary Causes

21. Dyspnea Common Cardiac Causes
Acute coronary syndromes
CHF
Dysrhythmias
Valvular heart disease

22. Dyspnea Common Cardiac Causes
Acute coronary syndromes
CHF
Dysrhythmias
Valvular heart disease

23. Dyspnea Common Miscellaneous Causes
Metabolic acidemias
Severe anemia
Pregnancy
Hyperventilation syndrome

24. Dyspnea Physical Examination: Vital SignsBP
 if dyspnea significant
 = life-threatening problem
Pulse
Usually 
Bradycardia - severe hypoxemia
Respiratory rate
Sensitive indicator of respiratory distress
DANGER = > bpm or < bpm

25. Dyspnea Physical Examination: Observation
Ability to speak
Patient position
Cyanosis
Central vs. peripheral (acrocyanosis)
Mental status
Altered MS - hypoxemia/hypercapnia

26. Dyspnea Physical Examination
Pulmonary
Use of accessory muscles
Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor
Cardiac
Check neck for presence of JVD
Signs of severe respiratory distress

27. Dyspnea Physical Examination: Pulmonary
Inspection
Use of accessory muscles
Splinting
Intercostal retractions
Percussion
Hyper-resonance vs. dullness
Unilateral vs. bilateral

28. Dyspnea Physical Examination: Pulmonary
Auscultation
Air entry
Stridor = upper airway obstruction
Breath sounds
Normal
Abnormal
Wheezing, rales, rhonchi, etc.
Unilateral vs. bilateral

29. Dyspnea Physical Examination: Cardiac
Neck
? JVD
Auscultation
Abnormal S2 splitting
Present of S3 and/or S4
Rubs
Murmurs

30. What does
clubbing suggest?
Chronic Hypoxemia

31. Pneumonia
1.Fever with chills 2.Pleuratic chest pain 3. purulent sputum 4. History of upper respiratory symptoms 5.signs of consolidation 6.x-ray chest 7. CBC 8. Blood culture 9. ABG acute bronchial asthma age startedat childhood

32. 2. Acute Bronchial Asthma
1.Age start in young age
2. Family History
3. H/O Allergic Rhinitis
4.Physical exam
5.barrel shape chest
6.X-ray chest
7. ABG

33. Pneumothorax
1.Suden chest pain 2. dyspnea,caugh 3. H/O asthma 4.COPD 5.Examination, trachea, shifted to opposite side absent breath sound 6 x-ray chest

34. 3. Acute Pulmonary edema Previous H/O Heart Disease Hyperthyroidism
Rheumatic Heart disease (ms)
Sign of LVF
Tachycardia
Pulses alternan
Basal criptation
ECG change
X-ray Chest ( cardiomegaly)
Echo

35. Pulmonary Embolism History of prolonged remobilization pelvic surgery
contraceptive pills
cyanosis
ECG
x-ray chest
ABG
ECHO
PIQ study

36. Case 1 History Symptoms started 2 days ago
Onset gradual and progressive
Exertion makes it worse
New onset
(+) chest pain, cough, DOE, PND
No past medical Hx
No medications or smoking Hx

37. Case 1 Physical Examination
Moderate respiratory distress, talks in partial sentences, prefers to sit in ED cart
BP = 190/110 mmHg; HR = 118 /min; RR = 36 bpm; afebrile; SpO2 = 85%
HEENT: no angioedema
Lungs: rales & wheezing bilaterally
Cardiac: (+) JVD; (+) S3
Skin: no rashes
Extremities: no edema

38. Case 1 What are likely etiologies for this patient’s dyspnea?
Heart failure
? ACS

39. Dyspnea Diagnostic Adjuncts
What study will most patient’s with dyspnea get?
CXR
Indicated in most cases of dyspnea, especially new-onset

40. Case 1

41. Dyspnea Diagnostic Adjuncts
What other non-laboratory study would you like?
ECG
Indicated if cardiac etiology suspected or cardiac history

42. Case 1

43. Dyspnea Diagnostic Adjuncts
What lab tests might be useful in dyspnea workup?
ABG
If any question about ventilatory or acid-base status
Beware of interpretation of (A–a)O2
Troponin
How would it be helpful in our patient?
B-type natriuretic protein (BNP)
Laboratory studies based on suspected etiology of dyspnea

44. Dyspnea Treatment Cornerstone of Rx
Assuring oxygenation/ventilation
Supplemental O2
PaO2 > 60 mm Hg; SpO2 > 90%
Specific Rx depends on working diagnosis

45. Dyspnea Special Considerations: Pediatrics
Common upper airway problems
Infection
Croup
Retropharyngeal abscess
Epiglottitis
Foreign body aspiration

46. Dyspnea Special Considerations: Pediatrics
Common lower airway problems
Anaphylaxis
Asthma
Bronchiolitis
Bronchopulmonary dysplasia
Cystic fibrosis
Foreign body aspiration
Pneumonia

47. Dyspnea Special Considerations: Pregnant Patient
Venous thrombosis/pulmonary embolism
3/1000 pregnancis
Risk continues to the postpartum period
Heparin outpatient treatment of choice
Asthma
Rule of 1/3
Rx same as non-pregnant patient
Pulmonary edema
Preeclampsia
Postpartum cardiomyopathy

48. Case Conclusion Diagnosis = CHF & subacute MI Treatment
IV nitroglycerin
IV furosemide
Reassessment – much improved