1. Cardinal Manifestations of Disease: DYSPNEA Dr. Meg-angela Christi Amores

2. Dyspnea a "subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses." -American Thoracic Society

3. Mechanisms of Dyspnea Motor efferents – Disorders of the ventilatory pump, muscles are weak or fatigued, greater effort is required Sensory afferents – Chemoreceptors in the carotid bodies and medulla are activated by hypoxemia, acute hypercapnia, and acidemia – air hunger – Mechanoreceptors in the lungs, when stimulated by bronchospasm, lead to a sensation of chest tightness

4. Mechanisms of Dyspnea Integration: Efferent – Reafferent Mismatch – discrepancy or mismatch between the feed-forward message to the ventilatory muscles and the feedback from receptors that monitor the response of the ventilatory pump increases the intensity of dyspnea – Asthma and COPD Anxiety – altering the interpretation of sensory data or by leading to patterns of breathing that heighten physiologic abnormalities in the respiratory system

5. Differential Diagnoses Dyspnea is the consequence of deviations from normal function in the cardiopulmonary systems Respi: 3 categories: Controller Ventilatory pump Gas exhanger Cardiovas: 3 categories Low Nomal High Cardiac output

7. Respiratory System Dyspnea Controller: Stimulation of pulmonary receptors, as occurs in acute bronchospasm, interstitial edema, and pulmonary embolism = air hunger High altitude, high progesterone states such as pregnancy, and drugs such as aspirin Ventilatory pump Disorders of the airways – inc resistance stiffen the chest wall, such as kyphoscoliosis Gas Exchanger Pneumonia, pulmonary edema, and aspiration all interfere with gas exchange Pulmonary vascular and interstitial lung disease

8. Cardiovascular System Dyspnea High Cardiac Output Mild to moderate anemia is associated with breathing discomfort during exercise Left to right cardiac shunts Normal Cardiovascular deconditioning Diastolic dysfunction (hypertension, aortic stenosis, or hypertrophic cardiomyopathy) Low Diseases of the myocardium resulting from coronary artery disease

9. Approach to patient Let patient describe in his/her words Ask for orthopnea, nocturnal dyspnea Onset, persistence Risk factors for certain diseases Platypnea – dyspnea in the upright position, relieved in the supine

11. Respiratory vs. CV system a cardiopulmonary exercise test should be carried out to determine which system is responsible for the exercise limitation At peak exercise, max ventilation reached, O2 sat below 90%, develops bronchospasm = Respiratory If HR >85% of predicted max, anaerobic threshold occurs early, BP high or drops, ischemic changes in ECG = Cardiovascular

12. Treatment Correct underlying problem Supplemental Oxygen if sO2 is <90% In COPD: pulmo rehab

13. For the next meeting, read on Cardinal Manifestations of Disease : EDEMA Harrison’s Principles of Internal Medicine 17 th edition