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GROUP A4
Tay Qin Le  Low Li Tatt Amirul Asyraf


..Breathlessness..
Farah Izzati Nadiah Umar Chua Hui Shan  Magdalen

  

CASE PRESENTATION SHORTNESS OF BREATH

Biodata

Mr M 57 y/o Malay Gentleman Security Guard Married Kajang Admitted: 4 August 2010

Chief Complaint
Shortness of breath for half an hour

HOPI
Intermittent SOB ?(day/night, before/after meal) Last for half an hour Occur at rest Relieving factor: No Exacerbating factor: cold weather, lying down, 20 feet walking

Associated symptoms

Orthopnoea PND(wake up 3-4 times) Cough: productive, yellowish sputum, large volume, bubbles, no haemoptysis, ?viscosity Chest pain: pleuritic chest pain with prickling in nature, chest tightness, left anterior chest wall, localised Wheezing while dyspnoea Can only climb one flight of stairs LOA, LOW(5kg in 2 weeks) No fever

Past Medical History

Recurrent bronchitis for 20 years and being admitted to hospital-recently admitted to HKJ 2/8/2010 and discharged on the following day Inhaler for 20 years (Ventoline & Bricanyl) No asthma No DM, HPT No known allergy

Family History -No significant family history except daughter has asthma since childhood Past surgical history -do not have any surgery before. Drug history -daun pecah kaca(Strobilanthes crispus )

Social History
Job- security guard Living environment- terrace house with clean environment Chronic smoker Pet-No Non-alcoholic

Systemic review
General PND CVS orthopnoea, chest pain, no palpitation RS SOB, wheezing, cough, headache AS not significant except pain at epigastric and right hypochondriac region US frequency CNS & PNS not significant MS not significant Endocrine not significant

Physical Examination

General Appearance: On nasal prong, cardiac monitoring for pulse oximetry, cannula insertion at right dorsum of hand, well-hydrated Vital signs: RR= 26/min, HR= 92/min RS: no clubbing, no flapping tremor, no muscle wasting, no trachea deviation, resonance on percussion, reduced chest expansion, bibasal crepitation, reduced breath sound bilaterally, increased in AP diameter(barrel chest)

CVS: raised JVP(5 cm), apex beat not palpable, no cardiac & liver dullness, bilateral pedal edema up to mid-shin, no pallor, no jaundice, drnm AS: tenderness at right hypochondriac and epigastric region on deep palpation No significant finding in CNS, PNS, US, MS and Endocrine

Provisional Diagnosis: AECOPD Differential Diagnosis: CCF

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SHORTNESS OF BREATH / DYSPNOEA

Definition
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Breathlessness / Dyspnoea Awareness that an abnormal amount of works is required for breathing
....often described as SOB,inabliltiy to get enough air,suffocation,chest tightness,activities limit by exercise & heavy breathing

Orthopnoea dyspnoea that develop when a patient is supine Paroxysmal Nocturnal Dyspnoea severe dyspnoea that wakes patient up from sleep to gasp for breath

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Classification
Graded from I to IV based on the New York Heart Association classification: Class I disease present but no dyspnoea or dyspnoea only on heavy exertion Class II dyspnoea on moderate exertion Class III dyspnoea on minimal exertion Class IV dyspnoea at rest

Causes of Dyspnoea
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I. II. III. IV.

Decrease O2 supply from lung dysfunction Decrease O2 delivery from CVS problems Decrease O2 carrying capacity in the circulation Increased O2 demand

I. Decrease O2 supply from lung dysfunction


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O2 carrying capacity is dependent on adequate air exchange in lung & to transport O2 on Hb For adequate gas exchange, the lung need; - adequate inspiratory and expiratory forces - alveolar spaces is able to permit adequate gas exchange - vascular flow to the lung must be unobstructed Disruption in any of above, will result in mismatches of O2 delivery and demand

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Chest mechanical abnormalities - fractured ribs, severe kyphosis/scoliosis Airway obstruction - Epiglottic/laryngeal obstruction Viral infection (croup), epiglottitis (Haemophilus influenzae) - Bronchial inflammation/obstruction chronic bronchitis, lung cancers, asthma - Alveolar obstruction pneumonia, pulmonary edema

II. Decrease O2 delivery from CVS problems


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Left ventricular failure Rise of pressure in the left atrium and pulmonary capillaries leading to interstitial and alveolar oedema Lung less compliant which increase respiratory effort necessary to breathe Cardiac failure Cardiomyopathies - Diabetic cardiomyopathy, hypertensive cardiomyopathy Myocardial ishemia

III. Decrease O2 carrying capacity in the circulation


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Concentration of Hb & its ability to bind & release O2 are important factors in determining available O2 in tissues Acquired anemia blood loss, hemolysis, underproduction Congenital abnormalities in Hb Thalassemia, Sickle cell Acquired dysfunction in Hb function Carbon monoxide poisoning

IV. Increased O2 demand


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Hyperthyroidism Drug that produce hypermetabolic state cocaine/ amphetamines Generalized anxiety disorder Panic disorder

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Causes of orthopnea Cardiac failure Uncommon-massive ascites; pregnancy; bilat. diaphraghmatic paralysis; large Pleural Effusion; severe Pneumonia Causes of paroxysmal nocturnal dyspnoea Left ventricular failure

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Evaluate patient
HISTORY TAKING

Information should be obtained in patient with dyspnoea

Occurrence Rest Exertion (quantify) Position Orthopnea (dyspnea lying flat) Trepopnea (dyspnea in lateral position) Platypnea (dyspnea when upright) Other precipitating factors Environment Emotional state Chronology Duration Progression Diurnal and seasonal variations Constant or intermittent
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Relieving factors Rest Medications (physician and selfprescribed) Predisposing factors Cigarette smoking Occupational and environmental exposures Associated medical diseases and symptoms Pulmonary Cardiac Neuromuscular Family history

Physical examination:
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INSPECTION
Looks for signs of respiratory distress Chest wall deformities
1. 2. 3. 4. 5. 6.

Respiratory rate >20 breaths per mins Pursed lips breathing Flaring of nasal alae Use of accessory muscle Subcostal & intercostal muscle retraction Cyanosis(severe cases)

PALPATE Chest expansion barrel chest, pigeon chest, funnel chest, kyphoscoliosis Vocal fremitus

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PERCUSS Hyperresonant pneumothorax Dull Fibrosis,pleural thickening Stony dull Pleural effusion AUSCULTATE ~breath sounds ~added sounds-Rhonchi and wheezing

Differential diagnosis
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With wheezing??

With stridor??

Asthma COPD Heart failure Anaphylaxis

Foreign body/tumor Acute epiglottitis Anaphylaxis Trauma

With crepitations??

With chest clear??


Heart failure Pneumonia Bronchiectasis Fibrosis

Others??

Hyperresonance in pneumothorax Stony dullness in pleural effusion

Pulmonary embolism Hyperventilation Metabolic acidosis Anaemia Drugs eg salicylates Shock Pneumocystis pneumonia Central causes

Investigation
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Lab no use in detection of dyspnoea (great value in differential d(x) & quantify severity of underlying d/o Pulse oxymetry measuring oxygen saturation- COPD oxygen saturation Pulmonary function test detect obstructive & restrictive of lung & chest wall; VC & (FEV1) correlate well with dyspnoea Arterial blood gas(ABG) generally performed but limited usefulness in evaluate breathlessness; most useful for quantify severity of gas exchange abnormalities in patients with lung dysf(x Blood test Anaemia CXR Pneumothorax ECG cardiac abnormalities

Management
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Nonpharmacologic interventions -Relaxation techniques -Supportive therapy : Fans, air supply , supplementary O2 Pharmacology intervention
Opiods-Morphine Anxiolytics

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DIFFERENTIAL DIAGNOSIS

HEART FAILURE
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Heart unable to maintain cardiac output to meet the demands of the body Right heart failure 2o to left HF, volume overload, outflow obstruction, compromised ventricular filling, etc Left heart failure myocardial dysfunction, vol. overload, outflow obstruction Biventricular - myocardial dysfunction, compromised ventricular filling, arrhytmia

SYMPTOMS
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RHF Nausea, anorexia, fatigue Dyspnoea (pl. effusion) abdominal distension Ankle swelling

LHF Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnoea Nocturnal cough wheeze

SIGNS
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RHF JVP raised Pl. effusion Hepatomegaly Ascites Dependent pitting oedema Fxnal tricuspid regurgitation

LHF Resting tachycardia Tachypnea Displaced apex beat 3rd heart sound Basal lung crackles Fxnal mitral regurgitation

INVESTIGATIONS
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Blood FBC (anemia), BUSE (poor renal fx), TFT (thyrotoxicosis) CXR cardiomegaly, prominent upper lobe vessel, bats wing, kerley B line, pl.effusion ECG arryhtmia, ischemia Echocardiogram assess LV fx, valvular abnormality, pericardial effusion

MANAGEMENTS
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Encourage bed rest during exacerbation Correction of aggravating factors arrythmia, anemia Low-level endurance exercise Avoid exacerbating factor e.g. NSAID (cause fluid retention), verapamil (-ve inotrope) Stop smoking, eat less salt, maintain optimal weight and nutrition Drug: diuretics, ACE inhibitor, -blocker, spironolactone, digoxin, vasodilator

PULMONARY EMBOLISM
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Venous thrombi, usually from DVT pass into the pulmonary circulation and block blood flow to the lungs.

Risk Factors Malignancy


Surgery Prolonged bed rest, reduced mobility Leg fracture Previous thromboembolism and inherited thrombophilia

SYMPTOMS
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SIGN Pyrexia Cyanosis Tachypnoea Tachycardia Hypotension Raised JVP Pleural rub Pleural effusion

Acute breathlessness Pleuritic chest pain Hemoptysis Dizziness Syncope

INVESTIGATION
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CXR dilated pulmonary artery, pleural effusion, wedge shape opacity or cavitation ECG N or tachycardia, right bundle branch block, right ventricular strain Blood Test- the quantity plasma D-dimer level is elevated. ABG may show  Pa O2 and PaCO2

TREATMENT
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Anticoagulant with Low Molecular Weight Heparin (LMWH). Starting regime for warfarin 10mg on day 1 and day 2,then 5mg on the third day. Stop heparin when INR>2 and continue warfarin for a minimum of 3 months.

MANAGEMENT
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Compression stockings to prevent further thrombsis 60% of O2 if hypoxemic Dissolution of thrombus consider for massive embolism with hypotension streptokinase IV morphine - to relieve pain & anxiety IV heparin, oral warfarin or LMWH for prevention

PNEUMOTHORAX
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Air in the pleural space. Spontaneous or as result of trauma to the chest Spontaneous (esp. in young thin men) d/t rupture of pleural bleb In pt. over 40 years of age usual cause is underlying COPD Secondary pneumothorax occurs with rupture of any pulmonary lesion situated closed to pleural surface.

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SYMPTOMS Sudden onset of dyspnea Pleuritic chest pain Pt. with asthma or COPD may present with a sudden deterioration SIGNS Reduced expansion Hyperresonance to percussion Diminish breath sound on the affected side. Trachea deviated away from the affected side.

TREATMENT AND MANAGEMENT


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Depend whether it is primary or secondary (underlying lung disease) pneumothorax, size and symptoms. Pneumothorax due to trauma requires a chest drain. Aspiration of pneumothorax - identify the 2nd intercostal space midclavicular line or 4-6th intercostal space in the midaxillary line & filtrate with 1% lidocaine down to the pleura.

ASTHMA
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Recurrent episodes of dyspnoea, cough, and wheeze caused by reversible airway obstruction 3 factors contribute to airway narrowing bronchial muscle contraction mucosal swelling/ inflammation increased mucus production

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SYMPTOM intermittent dyspnoea, wheeze, cough (often nocturnal) and sputum ask about: - precipitants: cold air, exercise, allergens, infection, drugs - Exercise: quantify the exercise tolerance - Disturbed sleep: quantify as nights per week(sn of serious asthma) - Atopic disease: eczema, hay fever, allergy,or family history? - The home: pets?carpet?feather pillows? - Occupation?

SIGN
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tachypnoea, audible wheeze, hyper-inflated chest, hyper-resonant percussion note, diminished air entry. severe attack: inability to complete sentences, pulse>110bpm, RR>25/min, PEF 33-50% predicted life-threatening attack: silent chest, cyanosis, bradycardia, exhaustion, PEF<33% of predicted, confusion

INVESTIGATIONS
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Chronic asthma -PEF monitoring -spirometry- obstructive defect ( FEV1/FVC) -CXR- hyper-inflation -skin prick test-help to identify allergens Acute attack -PEF -sputum culture - FBC- eosinophil count -ABG analysis N/slightly low PO2 &  PCO2 -radioallergosorbent test(RAST)- serum level of total or allergen-specific IgE

MANAGEMENT
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Behaviour-stop smoking,avoid precipitants Drugs- 2-adrenoreceptor agonists, Corticosteroids, Aminophylline, Anticholinergics Pt. and family education about asthma

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)


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A term used to describe pts with chronic bronchitis & emphysema Chronic bronchitis productive cough with sputum on most days for at least 3 months for 2 consecutive years Emphysema Dilation and destruction of alveolar septum distal to terminal bronchioles Common progressive disorder of airway obstruction ( FEV1 <80%, FEV1/FVC <70%) Age onset > 35 years old Smoking related

SYMPTOMS : cough, sputum, dyspnoea, wheeze


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SIGNS: Inspection:Tachypnoea; prolong expiration; hyperinflated chest Palpation :  chest expansion Percussion: Resonant @ hyperresonant Auscultation: Quiet breath sound

GENERAL EXAMINATION
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Oedema Sn(s) of CO2 retention


Warm

peripheries Bounding/collapsing pulse Asterixis/Flapping tremor Papilledema Confusion(severe cases)

Ix: -FBC- Hb & PCV Polycythaemia -CXR- hyperinflation -ECG- R atrial and ventricular hypertrophy (cor pulmonale) -Lung function test ( FEV1 <80%, FEV1/FVC <70%) Management : Gen.management Persuade pt to stop smoking
Specific management Controlled O2 therapy(start with 24-28%,according to ABG) Nebulizer (eg:Salbutamol ;Ipratropium Bromide) Antibiotic ( eg:Amoxicillin /Ampicillin)

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PULMONARY EDEMA
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Definition : -elavation of left atrial pressure pulmonary capillary pressure transudation of fluid into lungs (cardiogenic pulm. edema ) Etiology :
Cardiogenic -LVF ( eg : IHD , MI ) -mitral & aortic regurgitation -arrhythmias -malignant HTN Non-cardiogenic -ARDS d/t trauma , malaria , drugs -fluid overload -neurogenic ( eg : head injury )

Clinical Features :
Symptoms
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Signs Inspection : -cyanosis -tacyhpnea Palpation : -tachycardia ;low volume pulse -pulsus alternans ( indicates LVF) Auscultations : -gallop rhythm -rhonchi &crepitations

-breathlessness & orthopnea -wheezing -pink frothy sputu5m

Complications : -respiratory distress respiratory arrest Investigations : -chest X ray distension of upper lobe veins, bats wing , Kerley B lines, small pleural effusions -ECG-evidence of MI

-Blood -ABG- evidence of hypoxemia , initially low PaCO2 then high PaCO2 d/t impaired gas exchange -cardiac enzymes Management : General : - Sit patient up - 60% Oxygen via facemask Pharmacological Rx: -IV frusemide -IV dimorphine -IV antiemetic
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PLUERAL EFFUSION
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Definition : Excess accumulation of fluid in pleural space . Etiology :


Tansudate ( < 30 g/l) -CCF -Chronic liver disease ( cirrhosis ) -nephrotic syndrome Exudate ( > 30 g/l) -Infections ( bac. Pneumonia, empyema, TB ) - neoplasia : bronchial carcinoma, mesothelioma -Pulmonary infarction -Sarcoidosis -Post MI syndrome -Pancreatitis -Connective tissue disease

Other types of pleural effusion : empyema, hemothorax, chylothorax


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Clinical Features :
Symptoms -pleuritic chest pain -dyspnea Signs Inspection : -Ipsilateral reduced chest movement Palpation: -ipsilateral reduced chest expansion -reduced vocal fremitus Percussion : -stony dull to percussion Auscultation : -reduced /absent breath sound -bronchial breath sound above effusion -whispering pectoriloquy

Investigations : 1 ) imaging : CXR ( can detect radiologically if > 300ml) - loss of costophrenic angle - dense shadow over lung field with concave upper limit 2) Pleural aspiration : - protein estimation - bacteriological examination( gram stain, Ziehl Nielson stain and culture) -cytology ( for malignant cells ) - Others ( amylase, Rheumatoid factor ,glucose)

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MANAGEMENTS: -to treat underlying cause Symptomatic Rx : 1) Pleural aspiration for large effusions 2) Pleurodesis -to induce adhesions between visceral and parietal pleural. 2 types : chemical -eg : with talc, tetracycline, bleomycin surgical - decortication ( abrasion of pleura to induce adhesions )

References
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Oxford Clinical Handbook 7th edition Clinical Examination by Nicholas J Talley and Simon OConnor http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&p art=A1140 http://www.supportiveoncology.net/journal/articles/01010 23.pdf http://ajrccm.atsjournals.org/cgi/content/full/159/1/321# SEC4 Davidsons Principles & Practice of Medicine, 20th edition. Kumar & Clark, Clinical Medicine, sixth edition.

Ventolin
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Beta-agonist prevent bronchospasm Used in: treat or prevent airway spasms, as well as to prevent exercise-induced asthma attacks Used as inhaler Side effect: throat irritation, coughing, and respiratory infections

Bricanyl
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Beta-agonist Used in: reliever medication for asthmatic symtoms, prevention against acute exercise induced asthma attacks Used as inhaler/injection Side effect: Tremor, palpitations, nervousness and restlessness, headache