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DYSPNEA
Dyspnea
A persons uncomfortable sensation associated with
breathing
Air hunger
Increased effort of breathing
*Breathing controlled by central and peripheral
mechanisms that adjust ventilation appropriate to
increased metabolic demands during physical activity
and increase ventilation in excess of metabolic demands
in conditions such as anxiety or fear
Perception by the individual
Entirely subjective (severity varies widely among patients
*What may be severe in one patient may be just mild to
another patient thus you cannot really rely on what the
patient is saying
*Tests that quantify and can be objective about
patients symptoms of dyspnea
i. New York Heart Association Classification
ii. Analog Scale: ask patient on scale from 1-10,
10 being the most severe and 1 being the
mildest

New York Heart Association Classification
Overview: The New York heart Association developed a functional
classification for patients with heart disease.

Patients: heart Disease must be present

Parameters:
1.Limitations on physical activity
2.Symptoms with ordinary physical activity
3.Status at rest

A. Class I
Patients with no limitation of activities; they suffer no symptoms
from ordinary activities: are asymtpomatic

B. Class II
Patients with slight, mild limitation of activity; they are comfortable
with rest or with mild exertion: are asymptomatic

C. Class III
Patients with marked limitation of activity; they are comfortable
only at rest

D. Class IV
Patients who should be at complete rest, confined to a bed or chair;
any physical activity brings on discomfort and symptoms occur at
rest

FUNCTIONAL DYSPNEA SCALE
0 Not troubled with breathlessness except with strenuous
exercise

1 Troubled by shortness of breath when hurrying on the level or
walking up a slight hill
2 Walks slower than people of the same age on the level
because of breathlessness or has to stop breath when walking
about 100 meters or after a few minutes on the level
3 Stops for breath after walking about 100 meters or after a
few minutes on the level
4 Too breathless to leave the house or breathless when
dressing or undressing


Physiologic Dyspnea
May occur normally in states of strenuous activities
Not a consequence of cardiopulmonary or metabolic
disorder

Pathologic Dyspnea
A sensation of uncomfortable breathing which may occur
at rest
Advanced cardiac or pulmonary disorder is usually present

Mechanisms of Dyspnea
Primarily involves the following:
Heart
Lungs
Neuromuscular abnormalities

*Cardiovascular dyspnea
-Inadequate delivery of oxygen to the tissues
*Pulmonary dyspnea
-Heightened respiratory drive
-Altered pulmonary mechanisms
-Gas exchange abnormalities

Patient history
Dyspnea at rest
-Severe cardiopulmonary disease
-Anxiety
Dyspnea with exercise
-Cardiac problem
-Pulmonary problem
-Metabolic disorders
-Deconditioning

Key Questions to ask in History

Cardiac questions
-Presence or absence of the following:
Chest pain
Orthopnea
Paroxysmal nocturnal Dyspnea
Edema
Weight gain
-Inquire about any cardiac medications
-Cardiac diagnosis

Pulmonary Questions
-Presence or absence of wheezing
Wheezing
Chest tightness
Cough
Sputum production
Pleuritic pain
Sleep patterns
History of tobacco smoking

Other history of:
-Cirrhosis
-Renal insufficiency
-Endocrine abnormalities

Cardiac Examination

Inspection
-Precordium is observed for any abnormal pulsations
-Assymertical enlargement of the left chest
may refect chronic heart enlargement of any cause
-Observe for:
jugular venous distension
ascites
pedal edema
Palpation
-Thrills (vibratory sensations detected by the palm of the hand
* Associated with both systolic and diastolic murmurs
(severe valvular heart disease or cardiac shunts)
-Parasternal lifts
*Indicate significant enlargement of the right ventricle
*Possible underlying pulmonary hypertension

2

DYSPNEA
Auscultation
-Recognition of normal heart sounds, physiologic sounds and
pathologic findings

Percussion
-Often not necessary
-Used mainly to detect cardiomegaly to or pericardial effusion


OTHER CAUSES OF DYSPNEA

Mechanism
-Decreased oxygen delivery
-Increased utilization of oxygen
-In the absence of pathology:
Deconditioning
Anxiety

Key components in the history for other causes of Dyspnea

* Presence of systemic disease
-Anemia
-Neoplastic disease
-Metabolic disorders
*Dyspnea of anxiety
-Present at rest
-Usually improves with exercise and activity
-Patient will often sigh
-Not being able to get enough air into my lungs
-May be accompanied by:
Sharp,stabbing pain (usually non-exertional)
inframammary chest pain
Hyperventilation
Circumoral and extremity paresthesias


EVALUATION OF DYSPNEA
Temporal Profile Primary Considerations
sudden onset of dyspnea pulmonary embolism
Pneumothorax
Acute MI
Acute cardiac tamponade
Acute exacerbation of asthma
subacute dyspnea Pleurisy
Pneumonia
Asthma
Anxiety
CHF
Chronic dyspnea COPD
Interstitial lung disease
Deconditioning
Anxiety
Asthma
Sleep disorders
Mitral valve disease
Nocturnal onset dyspnea CHF
COPD
Asthma
Sleep disorders
Mitral valve stenosis

*Associated Signs and
symptoms
Primary considerations
wheezing asthma
CHF
COPD
cough Pneumonia
Asthma
CHF
COPD
Interstitial lung disease
chest pain
Pleuritic



Angina

Relieved with exertion

Pulmonary embolism
Pneumonia
Pneumothorax

Myocardial ischemia

anxiety
Syncope/pre-syncope Pulmonary Hypertension
Pulmonary embolism
Idiopathic hypertrophic
subaortic stenosis
Aortic stenosis
dysrythmia

Specific Physical Findings Primary Considerations
Obesity

Clubbing



Pallor

Edema/ascites
Deconditioning

Bronchiectasis
Neoplasms
congenital heart disease

Anemia

CHF
Liver disease


Cardiovascular PE Primary Considerations
Elevated JVP or (+)
hepatojugular reflex



Parasternal lift

Diffuse apical impulse

Increased S1

Increased S2

S3 gallop

S4 gallop

Diastolic murmur

Pulsus alternans

Pulsus paradoxus
CHF
Pericardial disease
Cor pulmonale


Pulmonary hypertension

LV enlargement

mitral stenosis

Pulmonary hypertension

CHF/systolic dysfunction

diastolic dysfunction

valvular heart disease

LV dysfunction

cardiac tamponade
Clinical Pearls in Evaluation of dyspnea

The cause of dyspnea can be determined in many patients
by a careful history and physical examination
In acute dyspnea, consider AMI, airflow
obstruction,pulmonary embolism or pneumothorax as
underlying causes
New onset wheezing in men> 40 years old suggests cardiac
dyspnea
Dyspnea is the most common symptom of pulmonary
embolism.
Dyspnea from anxiety improves with exercise
Think cost/benefit when ordering tests for dyspnea.