Abraham Chiu En Loong Group 1 6th Year Therapy

2012

Difficulty in breathing or dyspnoea is described as the increased awareness of ones laborious breathing. Difficulty in breathing is one of the commonest complaints a patient will present with, next to fever and upper respiratory tract infection. It may be a symptom in a varied range of pathological entities and in a similar range of varied body systems. This is sometimes confused with asthma, where there is a component of difficulty breathing, but is associated with an expiratory wheeze. So with regards to the pathophysiology, symptoms, and management we will discuss on the similarities and the dissimilarities of bronchial asthma and cardiac asthma.

Bronchial asthma (BA) is a respiratory tract condition, where there is an element of chronic inflammatory process, with reversible narrowing of the airways and an associated airway hyper responsiveness. This is usually caused by immune mediated mechanisms and/or direct contact with minute particles. There are oedematous cells with, mucus plugs, secretion of mucus and thickened basement membranes. Here on examination of the lungs the patient will have bilateral wheezing sounds/ rhonchi. The management of this condition is done through using oxygen and bronchodilators like beta agonists, with long term usage of corticosteroids to retard the chronic inflammatory process. If not properly managed there can be sudden death following life threatening asthma attacks or respiratory failure.

Cardiac asthma (CA) is a condition where there is either an acute left ventricular failure (left heart failure) or congestive (left and right) cardiac failure. In this condition, the hearts left side has become damaged leading to reduced capacity to pump the blood out of the heart. Thus, blood backtracks into the pulmonary veins, and the capillary baskets around the alveoli of the lungs. The hydrostatic pressure finally gives way to the transudation of fluids into the alveoli reducing the effective surface are for the diffusion of gases. This will lead to a feeling of drowning, where the patient complains of dyspnoea. Here on examination of the lungs, there will be bilateral basal fine crepitations. The management will be based on oxygenation and reducing the fluids in the lungs with morphine, and reducing the overall load to the heart with the use of a loop diuretic like Furosemide, and controlling the blood pressure. Unless this is properly managed with the underlying condition, there is a risk of death due to repeated episodes or chronic heart failure.

The pattern of shortness of breath helps doctors determine which type of asthma you have people with bronchial asthma tend to experience shortness of breath early in the morning, whereas people with heart failure and cardiac asthma often find they wake up breathless a few hours after going to bed, and have to sit upright to catch their breath. This is because in people with heart failure, lying down for prolonged periods will cause fluid to accumulate in the lungs leading to shortness of breath. Both bronchial and cardiac asthma can make people short of breath when they exert themselves. In bronchial asthma, symptoms are usually brought on by vigorous exercise and tend to be worse after the exercise than during it. On the other hand, cardiac asthma tends to happen during less vigorous exertion someone with heart failure can find themselves short of breath while climbing stairs, or in severe cases, while getting dressed.

Evidence Previous illnesses

Bronchial Asthma

Cardiac asthma attack

Chronic bronchopulmonary Rheumatic heart disease, GB, disease, vasomotor rhinitis, CHD, chronic glomerulonephritis allergic disease

The reason for Acute inflammation in the The physical and mental stress, the attack respiratory tract, the contact with acute MI the allergen, psychogenic factors, meteorological factors The nature of the Expiratory dyspnea attack The nature cyanosis Auscultation of Central Ispiratory dyspnea Expressed acrocyanosis

Abundant scattering dry whistling Rales are mainly in the lower and buzzing mainly expiratory lung wheezing Rapid, weak filling, the rhythm is Often arrhythmic correct Increased Often there

Pulse

Percussion heart Reduced size Edema Sputum No

Thick, viscous, separated with Liquid, frothy, sometimes pink, it difficulty in small quantities separates Not changed Of bronchodilators Often increased Of morphine, drainage, cardiac glycosides, diuretics

Size of the liver Therapeutic effect

Diagnostic aid Heart failure ECG changes

Bronchial asthma About the rightventricular type Signs of right ventricular systolic overload

Cardiac asthma On the left-ventricular type Signs of left ventricular systolic overload and myocardial ischemia

Character of sputum

Thick, viscous, Large, liquid, separated with sometimes foaming difficulty in small with blood quantities
Expiratory Inspiratory, then mixed

The nature of breathlessness Orthopnea

Auscultation Chest X-ray

No
Dry rales Emphysematous, depletion of lung pattern

There is
Bubbling rale Signs of congestion