ACUTE DYSPNEA

TEAM 6
HOFILENA, MARIE CHIN
ILAGAN, JONATHAN
ISLA, FROELAN
KHADKA,UMESH
JATTURAWUTTICHAI,NUTTORN
LAOHASINNURAK,NONLAPHAN
MOHAMED, MOHAMED HUSSEIM
AMNUAYNGERNTRA,AMONTHEP

OUTLINE ACUTE DYSPNEA

I.

SYNOPSIS/ DEFINITION

II. EPIDEMIOLOGY
III. MECHANISM OF SHORTNESS OF BREATH
IV. DIFFERENTIAL DIAGNOSIS
V. RED FLAGS
VI. DIAGNOSTIC/LABORATORY
VII. DIFFENTIALS

OUTLINE ACUTE DYSPNEA

VIII. HX OF PRESENT ILLNESS
IX. PHYSICAL EXAMINATION
X. ALGORITHM
XI. HYPOTHETICAL CASE
XII. EVIDENCE BASED MEDICINE
XIII. REFERENCES

Acute Dyspnea
The American Thoracic Society
defines dyspnea as a "subjective
experience of breathing discomfort
that consists of qualitatively distinct
sensations that vary in intensity.
Harrisons Principle of Internal Medicine 18th edition

Epidemiology
Shortness of breath is the primary reason 3.5% of people
present to theemergency departmentin the United
States. Of these approximately 51% are admitted to
hospital and 13% are dead within a year.

Anatomy

Overview of Respiratory muscles

Google image

Anatomy of the Lungs

Google images

Mechanisms of shortness of Breath

Desciptor

Clinical example

Pathophysiology

Chest tightness or
constriction

Asthma, CHF

Bronchoconstriction,
Interstitial edema

Increase work or effort

of breathing

Asthma, neuromuscular
disease, chest wall
restriction

Airway obstruction,
neuromuscular disease

Air hunger need to

breath,urge to breathe

CHF, Pulmonary
embolism, asthma,
pulmonary fibrosis

Increase drive to
breathe

Inability to get a deep

breath, unsatisfying
breath

Moderate to severe
asthma,pulmonary
fibrosis, chest wall
disease

Hyperflation and
restricted tidal volume

Heavy breathing,rapid
breathing, breathing
more

Sedentary status in
Deconditioning
healthy individual or
patient with
cardiopulmonary disease
Harrisons Principles of Internal Medicine 19th edition

Differential Diagnosis
Respiratory :- Acute exacerbation of asthma, and
COPD, pnemothorax, pulmonary embolism, foreign
body, pleural effusion
Cardiovascular :- Coronary artery disease ( angina and
MI), congestive heart failure, arrhythmia, pericardial
disease, anemia , Pulmonary HPN
Psychogenic:- Panic attack, hyperventilation
Others :- severe pain, poisoning ( OP, CO ),

Asthma
Characterized by inflammatory hyperactivity of the
respiratory tree to various stimuli, resulting in reversible
airways obstruction.

symptoms :- wheeze, chest tightness, breathlessness and

cough.

Severe attack :- use of accessory muscle of respiration,

diminished breath sound, loud wheezing, hyperresonence,
intercostal retraction.

Asthma
reduction in FEV1
Diagnosis is supported by increase FEV1 of < 12% and
200 cc after 2-4 puffs of short acting bronchodilator.

Chronic Obstructive Pulmonary Disease ,COPD

Include chronic bronchitis and emphysema
Both are nonreversible obstruction of the airways ( unlike asthma )
Cigarette smoking represents the most significant risk factor for
COPD
Use of accessory respiratory muscle, hyperinflated barrel shaped
chest, cyanosis, Hyper resonance , reduced breath sound,
prolonged expiration
Clubbing is not a feature of COPD.
Decreased FEV1
Chronic bronchitis : Blue blotters
Emphysema : Pink puffer

Pleural effusion
dyspnea usually develop > 0.5-1L of fluid, pluritic chest
pain, medistinal shifting ,decreased expansion of
chest , stony dull , absent breath sound and vocal
resonance

Pneumothorax
medistinal shifting , hyperresonence , decreased breath
sound and vocal fremitus

Pulmonary embolism
tachycardia, hypotension, JVP, rightventricular gallop
rhythm, loud P2, severe cyanosis,

Pulmonary Hypertension
Elevation of the mean pulmonary arterial pressure
> 25 mm hg at rest ( normal mean 15 ( 25/8) mm hg.
dyspnea , syncope, edema, loud S2 ;esp P2 component, sign
of Rt. Heart failure( inc. JVP, hepatomegaly, pulsatile liver,
pedal edema etc.)

Red Flags
Altered mental status.
Stridor and breathing effort without air movement.
(suspect upper airway obstruction)
R/R > 40/min
cyanosis
Unilateral tracheal deviation.(suspect tension
pnemothorax)
Low 02 saturation.
Diaphoresis ( asthma )
Pulsus paradoxus

Diagnostics
chestx-ray
Electro cardiogram
Spirometry

http://www.mdguidelines.com/dyspnea

Diagnostics
a D-dimer test may be done to detect clot formation if
pulmonary embolism is suspected.
Bronchoscopy: may be done in severe cases or to rule out
airway obstruction
PFT (pulmonary function test)
echocardiogram for suspected cardiac temponade
CTscan

http://www.mdguidelines.com/dyspnea

laboratory
Laboratory tests may include:CBC
ABG
blood carbon monoxide levels, and renal function studies.
Blood oxygen saturation is measured using an infrared
light sensor device on the finger. (Pulse Oximeter)
Creatinine sodium potassium and glucose

http://www.mdguidelines.com/dyspnea

Risk Factors for dyspnea

Exposure to toxic irritants such as tobacco smoke
Industrial toxins
Obesity
Inhaling organic and inorganic dusts
Toxic fumes
Environmental pollutants
Irritant gases .

Acute Dyspnea Differentials

Acute asthma
COPD exacerbation
Pneumonia
Congestive heart failure
Pulmonary embolism
Pneumothorax

http://www.mdguidelines.com/dyspnea

Acute Dyspnea Differentials

Epiglottitis

Bronchiolitis

Hyperventilation

Foreign body aspiration

Congestive heart failure

http://www.mdguidelines.com/dyspnea

Comprehensive adult health history

7 component:
1.Identifying data and source of the history:
2.Chief complaint(s)
3.Present illness
4.Past history
5.Family history
6.Personal and social history
7.Review of systems

reliability

History Acute Dyspnea

1. Emphasize Coexisting caediac and pulmonary s/sx.
Determine onset, duration, and occurrence at rest or
exertion.
2. Chest pain during dyspnea may be caused by coronary
or pleural disease, depending on the quality and
description of the pain.
3. Sudden shortness of breath at rest is suggestive of
pulmonary embolism or pneumothorax.
.http://www.aafp.org/afp/2003/1101/p1803.html

History Acute Dyspnea

4. Chest pain is almost universal in spontaneous
pneumothorax, while dyspnea is the second most
common symptom.
5. Consider spontaneous pneumothorax in patients with
COPD, cystic fibrosis, or acquired immunodeficiency
syndrome.
6. Inquire about indigestion or dysphagia, which may
indicate gastroesophageal reflux or aspiration.

General
General

Weight
Weight loss
loss or
or gain
gain

Fatigue
Fatigue

Fever
Fever or
or chills
chills

Weakness
Weakness

Trouble
Trouble sleeping
sleeping

Skin
Rashes
Lumps
Itching
Dryness

Head
Headache
Head injury
Dizziness
lightheadedness
Respiratory
Respiratory

Cough
Cough

Sputum
Sputum

Coughing
Coughing up
up blood
blood

Shortness
Shortness of
of breath
breath

Wheezing
Wheezing

Painful
Painful breathing
breathing

EYES
Vision Loss/Changes
Glasses or contacts
Pain
Redness
Blurry or double vision
Flashing lights
Specks
Glaucoma
Cataracts
Last eye exam

Ears
Decreased hearing
Ringing in ears
Earache
Discharge
Vertigo
Nose
Stuffiness
Discharge
Itching
Hay fever
Nosebleeds
Sinus pain

Throat/Mouth/Pharynx
Bleeding
Dentures
Sore tongue
Dry mouth
Sore throat
Hoarseness
Thrush
Non-healing sores
Neck
Lumps
Swollen glands
Pain
Stiffness

Cardiovascular
Cardiovascular

Chest
Chest pain
pain or
or discomfort
discomfort

Tightness
Tightness

Palpitations
Palpitations

Shortness
Shortness of
of breath
breath with
with
activity
activity

Difficulty
Difficulty breathing
breathing lying
lying
down
down

Swelling
Swelling

Sudden
Sudden awakening
awakening from
from
sleep
sleep with
with shortness
shortness of
of
breath
breath

Gastrointestinal

Swallowing difficulties
Heartburn
Change in appetite
Nausea
Change in bowel habits
Rectal bleeding
Constipation
Diarrhea
Yellow eyes or skin

Urinary
Frequency
Urgency
Burning or pain
Blood in urine
Incontinence
Change in urinary
strength
Vascular
Calf pain with walking
Leg cramping
varicose veins
swelling w redness or
tenderness
change in fingertips or toes
during cold weather

PHYSICAL EXAMINATION
ACUTE DYSPNEA

PHYSICAL EXAMINATION ACUTE DYSPNEA

1. Begin during interview of the patient.
2. Inability to speak in full sentences before stopping to
get deep breath?
3. Evidence of increased work of breathing? indicative
of increased airway resistance or stiffness of the lungs
and the chest wall.
4. VS

PHYSICAL EXAMINATION ACUTE DYSPNEA

5. During general examination, signs of anemia ( pale
conjunctivae), cyanosis, and cirrhosis ( spider
angiomata, gynecomastia) should be sought.
6. Chest: symmetry of movement; percussion (dullness is
indicative of pleural effusion; hyperresonance is a sign
emphysema); and auscultation (wheezes, rhonchi,
prolonged expiratory phase, and diminished breath
sounds are clues to D/O of the airways; rale suggest
interstitial edema or fibrosis).

PHYSICAL EXAMINATION ACUTE DYSPNEA

7. Cardiac: focus on signs of elevated right heart
pressures, left ventricular dysfunction, and valvular
diseases.
8. Abdomen: patient in the supine position, physician
should note whether there is paradoxical movement of
the abdomen: inward motion during inspiration is a
sign of diaphragmatic weakness, and rounding of the
abdomen during exhalation is suggestive of pulmonary
edema.

PHYSICAL EXAMINATION ACUTE DYSPNEA

9. Clubbing of digits may be an indication of interstitial
pulmonary fibrosis, and joint swelling or deformation
as well as changes consistent with raynauds disease
may be indicative of a collagen-vascular process that
can be associated with pulmonary disease.

PHYSICAL EXAMINATION ACUTE DYSPNEA

10. Patients with exertional dyspnea should be asked to
walk under observation in order to reproduce the
symptoms.

Adapted from MA Gillette, RM Schwartzstein, in SH Ahmedzai, MF, Muer [eds].

Supportive Care in Respiratory Disease. Oxford, UK, Oxford University Press,
2005

Case

A 75-year-old man with presents with a 1-day history of

dyspnea, rightsided chest pain, and cough with rustcolored
sputum. Further history reveals subjective fever and chills.
His physical activity level has diminished over the last 2 days.
Physical examination reveals the patient to be mildly
tachypneic and afebrile but in no acute distress.
Cardiac examination is without significant findings. There are
crackles and a friction rub in the right anterior lung field.
Laboratory examination demonstrates a mild leukocytosis and
a Pao2 of 60 mm Hg.

Hypothetical Case
I. Chief Complaint- Difficulty of breathing.
II. Hx of Present Illness- While walking, the patient
presented with difficulty of breathing with right sided
chest pain. He also complain of coughing with rust colored
sputum, thus leading to consultation. His physical activity
level has diminished over the last 2 days
. III. Past Hx- (-) DM, No known HPN,

V. Family Medical Hx- Parents are both hypertensive, No

known cancer, DM, allergy, TB, thyroid problem or
genetically transmitted disease among family members

Hypothetical Case Continuation

VI. Personal/Social Hx-He is a engineer, smoker for 20 pack
years, Goes to catholic church every Sunday, drinks alcohol
(beer) occasionally, and once a week.
VII. Physical Exam Findings- Febrile, ambulatory with the ff :
Vitals Signs: BP: 90/60mmHg, RR: 32 T: 38 degree celsius
HR:126beats per minute
HEENT: Normal JVP, No cervical lymphadenopathy, No
thryromegaly, (-) anecteric sclera,(-) carotid bruits
Chest/Lungs: symmetrical, Increased tactile fremitus right,
(+) retractions, (-) lag, (-) spider angiomas, dullness on the
right side,(+) crackles, (-) wheezes

Continuation
VII. Physical Exam Findings:
Heart: adynamic precordium; apex beat at 4th to 5th ICS
LMCL, (-) thrills, normal S1 and S2, No murmurs
Abdomen: abdominal girth normal, flat, (-) caput
medsau; normoactive bowel sounds, soft, non tender
tymphanic, no organomegaly, normal bowel movements
Extremities: (-) deformities, (-) clubbing, (-) cyanosis,
with the ff pulses:
DP

PT

++

++

++

++

++

++

++

++

++

++

++

++

Continuation
Rectal: (-) anal tag, good sphincter tone, rectal vault
not collapse, (-) hemorrhoids nor mass noted; brownish
stool in tactating finger.
Neurologic Exam:
Cerebrum: conscious, oriented to 3 spheres
Cerebellum : (-) nystagmus ; can do heel to shin test ;
intact Rombergs test ; can do rapid alternating
movements ; can do finger to nose test

Cranial nerves :
I can smell coffee
II, III pupils equally reactive to light
III, IV, VI intact extraoccular muscles
V intact corneal reflex , bilateral ; intact masseter muscle
contraction
VII (-) facial asymmetry
VIII can hear, bilateral
IX, X intact gag reflex
XI can shrug shoulders , bilateral
XII - tongue midline on protrusion
(-) Babinski ;(-) nuchal rigidity( -) Brudzinski (-) Kernigs sign
Dermatomal test : equal and intact on all levels Motor Sensory

DTR

Hypothetical Case
II. Primary Working Impression: Community Acquired
Pneumonia, COPD
III. Laboratory Examinations:ECG, ABG, CBC, Creatinine,
Chest Xray

Laboratory Results
Sinus Tachycardia ECG
ABG:
pH increased
PCO2 decreased
HCO3 normal
Repiratory Alkalosis
CBC: increased neutrophil count
Creatinine: Normal
Chest Xray: Right upper lobe consolidation

Final Diagnosis:
Community Acquired Pneumonia Right Upper Lobe
Moderate Risk

Evidence-Based Medicine

We ask this question during our

meeting in group.

How would
apprehensiveness
affect the patient
suffering from dyspnea?

References:
www.pubmed.com
http://www.mdguidelines.com/dyspnea
http://www.aafp.org/afp/2003/1101/p1803.html
The Washington Manual of Medical Therapeutics 33rd
Edition, 2010
Kaplan Medical Book, 2010
Bates Guide to Physical Examination and History Taking
11th Edition

THANK YOU.