CME - Breathlessness Rad

Radtthiga Chelvaraj MBBS Batch 11
Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11
Dyspnoea
Definition: abnormal awareness of breathing occuring at an inappropriately low level of physical exertion or at rest.
Sunday, March 17, 2013
Acute breathlessness, Radtthiga Batch 11
Causes of breathlessness
Respiratory 1. Airway diseases 2. Parenchymal disease 3. Pulmonary circulation 4. Chest wall and pleura
Source : Clinical examination, A systematic guide to Acute breathlessness, Radtthiga Batch 11 physical diagnosis, Talley & O Connor
Cardiovascular 1. Left ventricular failure 2. Mitral valve disease 3. Cardiomyopathy 4. Pericardial effusion
Source : Clinical examination, A systematic guide to Acute breathlessness, Radtthiga Batch 11 physical diagnosis, Tally & O Connor
Non-cardiorespiratory 1. Metabolic acidosis 2. Psychogenic
Source : Clinical examination, A systematic guide to Acute breathlessness, Radtthiga Batch 11 physical diagnosis, Talley & O Connor
Causes of dyspnoea
System Cardiovascular Respiratory Acute dyspnoea at rest Acute pulmonary edema Acute severe asthma Acute exacerbation of COPD Pulmonary embolism Tension pneumothorax Metabolic acidosis
Others
Causes of dyspnoea
System Cardiovascular Chronic exertional dyspnoea Chronic heart failure Angina COPD Chronic asthma Bronchial carcinoma Interstitial lung disease Severe anemia
Respiratory
Others
Important aspects -Dyspnoea

Onset? Severity? Number of episodes? *Association with cardiovascular symptoms ? *Association with respiratory system?
Association with respiratory system?

Are there good days or bad days? Diurnal variation? Aggravating factors? Relieving factors? American College of Physician (ACP) guideline for dx and mx of COPD guideline:
history of >40 pack-years of smoking best single predictor of airflow obstruction
Associated symptoms
Productive cough or acute chest illness (Hx of chronic cough with sputum, worse in the morning) Breathlessness Wheezing
Association with cardiovascular system
Onset:? Physical exertion or at rest? Triggering factors? ( MI) Distance walked before breathlessness occur? Chest pain? (site, radiation) Aggravating factors? (exercise, exertional, stress anxiety)
Association with cardiovascular system

Relieving factors ? Orthopnoea? ( beds used to sleep) Paroxysmal Nocturnal Dyspnoea?
COPD AND ASTHMA
Definition
COPD ASTHMA
preventable & treatable respiratory disorder smoking progressive, partially reversible airflow obstruction lung hyperinflation + extrapx (systemic) manifestations comorbid conditions
chronic airway inflammation Increased airway hyperresponsiveness sx of wheeze, cough,chest tightness and dyspnoea. Reversible with treatment.
COPD vs Asthma
Onset? : Gradual Severity? : Progressively getting worse (exertional dyspnoea dyspnoea at rest and Overnight. Number of episodes? : With disease progression, intervals become shorter SMOKING Association with cardiovascular symptoms ? : nil*
COPD vs Asthma
Onset Atopy : triggering factors? Diurnal variations? Good days and bad days? ( Days per week off work or school) Family history? Reversibility of symptoms? Other atopic disease? ( eczema, allergy)
History and signs

Conditions History Signs
Acute severe asthma
Previous episodes Atopy Asthma medication
-Tachycardia -Pulsus paradoxus -Cyanosis -Reduced peak flow -Rhonchi
History and signs

Conditions Acute exacerbation of COPD History Previous episodes, *admissions Smoking Signs -Cyanosis -Raised JVP --LL Edema( Cor pulmonale) -Respiratory distress signs
-Barrel chest -Pursed lip breathing -Tripod position -Cardiac apex not palpable -Reduced breath sound -Prolonged expiration -rhonchi
Systemic manifestations
Investigations
Chest X-ray
signs of hyperinflation flattening of the diaphragm increased retrosternal air space long, narrow heart shadow. hypovascularity of lung parenchyma
Chest X-ray
Investigations
Investigations
Chest X-ray
Spirometry
Objective demonstration of airflow obstruction. Bronchodilator Reversibility Testing: required to establish lung function at that point of time. significant if the change in FEV1 = 200 mL and 12% above the pre-bronchodilator . If there is a marked response to bronchodilators asthma .
Classification of COPD Severity Based on Spirometric Impairment

Severity Classification by postbronchodilator spirometric values FEV1/FVC < 0.70 FEV1 > 80% predicted FEV1/FVC < 0.70 50% FEV1 < 80% predicted
Mild Moderate
Severe
<FEV1/FVC < 0.70 30% FEV1 < 50% predicted

FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
Very severe
Conditions
History
Signs
Left ventricular failure
Chest pain Orthopnoea PND Pink, frothy sputum
-Raised JVP --Central cyanosis -Bibasal crackles -S3 -Cardiomegaly -Cold extremities -LL edema
Conditions Metabolic acidosis
History
Signs
Evidence of Diabetes/ renal -Acetone breath diseases -Hyperventilation - Kussmauls breathing -Dehydration
Investigations
Conditions Left ventricular failure
Chest radiography Cardiomegaly Absence of air bronchogram Kerley B line Pleural effusion
Arterial blood ECG gas analysis -Low Pa O -Sinus - Low PaCO tachycardia -Signs of Myocardial Infarction -Arrhythmia
Acute severe asthma
Hyperinflated chest
-Low Pa O - Low PaCO
-Sinus tachycardia * Bradycardia with severe hypoxemia
Conditions Acute exacerbation of COPD
Chest Arterial blood radiography gas analysis Hyperinflation Emphysema -Low Pa O -Low PaCO Bronchitis -Low Pa O -High PaCO - high bicarbonate
ECG -Nil or signs of right ventricular strain
Metabolic acidosis
Normal
-Normal Pa O -Low PaCO - low pH
Acute exacerbations of COPD

Characterised by: Increases in symptoms Deterioration of lung function Development of respiratory failure
Management
1. Oxygen therapy: ( 24- 28%) 2. Bronchodilators: short acting agonist + anticholinergic 3. Corticosteroids: Prednisolone 4. Antibiotic therapy: aminopenicillin, macrolide 5. If above measures fail, do non-invasive ventilation 6. Other measures
Discharge
Once patient is stable Short term nebuliser
Acute exacerbation of asthma

Characterised by: Increased symptoms Deterioration in PEF May be precipitated by infections(viral)
Mild moderate exacerbations

rescue oral corticosteroid (prednisolone 3060mg daily) Indications for rescue course: Worsening symptoms and PEF Fall of PEF < 60% Worsening sleep disturbance Persistence morning sx Diminished response to inhaled bronchodilator
Acute severe asthma

Initial assessment : PR, RR, BP and SaO2 PEF 35-50% Respiratory rate > 25 /min Heart rate >110b/min Inability to complete sentences in 1 breath
Treatment
1. Oxygen ( high concentration ), maintain O saturation >90mmhg 2. Bronchodilators : agonist salbutamol via metered dose inhaler + ipratropium bromide 3. Corticosteroids: Prednisolone ( 30-60mg, oral) or IV hydrocortisone(200 mg)
Subsequent management
If patient deteriorates IV Mg Monitoring of treatment: Record PEF every 15 min-30 min then, 4-6 hourly Pulse oximetry ( SaO2>90mmHg)
Indications for endotracheal intubation

deterioration of arterial blood gas despite optimal therapy : PaO < 60 mmHg Pa CO> 45 mmHg pH low
Discharge
Counselling on medications
Left ventricular failure
THANK YOU

CME - Breathlessness Rad

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Radtthiga Chelvaraj MBBS Batch 11

Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Sunday, March 17, 2013

Non-cardiorespiratory 1. Metabolic acidosis 2. Psychogenic

Sunday, March 17, 2013

Important aspects -Dyspnoea

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Association with respiratory system?

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Association with cardiovascular system

Sunday, March 17, 2013

Association with cardiovascular system

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

COPD AND ASTHMA

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

History and signs

Acute severe asthma

Previous episodes Atopy Asthma medication

-Tachycardia -Pulsus paradoxus -Cyanosis -Reduced peak flow -Rhonchi

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

History and signs

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Classification of COPD Severity Based on Spirometric Impairment

<FEV1/FVC < 0.70 30% FEV1 < 50% predicted

Sunday, March 17, 2013

Left ventricular failure

Chest pain Orthopnoea PND Pink, frothy sputum

Sunday, March 17, 2013

Acute breathlessness, Radtthiga Batch 11

Conditions Metabolic acidosis

Sunday, March 17, 2013