Download Free Medical Diagnosis of Dyspnea PowerPoint Presentation

Diagnosis of Dyspnea PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical presentation on Diastolic Heart Failure, which is titled "Diagnosis of Dyspnea", to know about dyspnea, an unpleasant, subjective sensation of abnormal respiration.

Tags : Diastolic Heart Failure, Diagnosis, Dyspnea

Published on : Jul 01, 2021 | Views : 3304 | Downloads : 4

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

DyspneaDyspnea 1 Dyspnea Diagnosis of Dyspnea Vicken Y. Totten MD MS, FACEP FAAFP Associate Professor Emergency Medicine University Hospitals Case Medical Center
Slide 2-

DyspneaDyspnea 2 Dyspnea – from Latin ‘dyspnoea’ Dyspnea (also SOB, air hunger) subjective symptom of breathlessness. normal in heavy exertion pathological if it occurs in unexpected situations.
Slide 3-

DyspneaDyspnea 3 April, 99 2 Definition Dyspnea: unpleasant, subjective sensation of abnormal respiration. Labored breathing - physical presentation of respiratory distress/ dyspnea Many causes
Slide 4-

DyspneaDyspnea 4 Descriptors of Dyspnea Dyspnea on Exertion (DoE) Dyspnea after Eating (PPD) Nocturnal Dyspnea Paroxysmal nocturnal dyspnea Dyspnea in Pregnancy (hormonal, mechanical)
Slide 5-

DyspneaDyspnea 5 What is respiratory distress? Vague term meaning “not breathing well”. A constellation of signs including: using accessory muscles of respiration tachypnea Gasping Panting restlessness Sometimes, also confusion (hypoxemia) Somnolence (hypercarbia)
Slide 6-

DyspneaDyspnea 6 Respiratory Definitions Eupnea - normal breathing Bradypnea - decreased breathing rate Tachypnea – breathing very fast. Pt not always aware of it. Apnea – not breathing at all Hyperpnea - faster and/or deeper breathing Hyperventilation - rapid breathing with hypocarbia
Slide 7-

DyspneaDyspnea 7 April, 99 Goals of this presentation Discuss dyspnea & its differential diagnosis Discuss pathophysiology Discuss diagnostic tests for dyspnea
Slide 8-

DyspneaDyspnea 8 My Philosophy of teaching: Me: make it as simple as you can. No simpler. You: Interact, ask questions. You will stay awake ;). No question is dumb, and the answer will be just in front of you.
Slide 9-

DyspneaDyspnea 9 Principles of Emergency Medicine “Air goes in and out.” “Blood goes round and round.” “All bleeding stops eventually.” “All else is details.” But…the devil is in the details.
Slide 10-

DyspneaDyspnea 10 What is NOT Dyspnea? Not the O2 saturation of Hemoglobin Not the total amount of O2 attached to Hemoglobin Not the amount of O2 in solution in the blood (the PaO2) Not the respiratory rate, (not all tachypnea is dyspnea) But: a subjective sensation of air hunger.
Slide 11-

DyspneaDyspnea 11 Case 1 47 y/o man c/o dyspnea. SOB, worse on exertion Also admits to mild left sided CP, maybe respirophasic. Onset 5-7 days ago. Getting slightly worse What else do you want to know? What’s your current differential? Admit or Discharge?
Slide 12-

DyspneaDyspnea 12 Case 1 – additional history PMHx: none. No asthma SHx: Tobacco Smoker. Social drinker. Occasional MJ. Married. No Children. Likes to jog, last 5 mi run yest. Works at a desk. ROS: needs to see a dentist. No palpitations. No edema. No PND, nor orthopnea. Otherwise negative. What else do you want to know?
Slide 13-

DyspneaDyspnea 13 Case 1 V/S: T=36.9; P=85; RR=20; BP 128/79 HEENT: nl CHEST: WD, nl excursion, lungs hard to hear, but no rales, ronchi, wheezes. Cor: RRR w/o RMG. Abd: soft & NT, well muscled. Extr/MS/Neuro/Skin: all wnl. How will you approach this?
Slide 14-

DyspneaDyspnea 14 Approach to the patient with shortness of breath, or respiratory distress: the emergency approach.
Slide 15-

DyspneaDyspnea 15 1: Degree of urgency Is the patient going to live long enough to give you a history? If not, intervene. If yes, try to make a diagnosis.
Slide 16-

DyspneaDyspnea 16 2. Assess patient. Is the patient actively trying to breath?  look for mechanical obstruction. Correct it. Is patient hypoxic? If yes,  increase FiO2 Is the patient not able to breathe adequately? If no,  supplement respiratory efforts.
Slide 17-

DyspneaDyspnea 17 3. Locate the problem Causes of air hunger: mechanical, metabolic, cerebral, Psychological
Slide 18-

DyspneaDyspnea 18 4. Correct it Topic for another lecture After the (correct) diagnosis is made, treatment is (relatively) simple
Slide 19-

DyspneaDyspnea 19 Suspicion You don’t have to know all the diagnoses, but you do have to evaluate threat to life Know when & how to intervene. Understand your tools. Understand your available interventions. Know when to get help
Slide 20-

DyspneaDyspnea 20 Ask (yourself) questions. Can the chest wall support breathing? Are there barriers preventing the air getting through the airway to the blood? Are there metabolic reasons to increase respiratory rate? Is enough blood, of good quality, going round and round?  if not, assist circulation
Slide 21-

DyspneaDyspnea 21 What is the purpose of respiration: Gas exchange To assist in balancing blood (body) pH Lesser extent: temperature regulation / cooling the body Cellular respiration vs Organism respiration
Slide 22-

DyspneaDyspnea 22 Abnormal atmosphere CO: even small amounts of CO can bind with hemoglobin in place of O2 and prevent O2 binding (competitive inhibition) 300 times more tightly than O2 Methemoglobinemia occasionally causes dyspnea; usually just tachypnea Heliox: helium instead of nitrogen as the inert gas. Helium molecules are smaller than nitrogen, slicker, less turbulent flow.
Slide 23-

DyspneaDyspnea 23 Other substances can injure the airways directly Noxious / toxic gases – work in many different ways and levels. Allergens – immune system modulated Particulates – “smothering” Irritants – cause bronchospasm
Slide 24-

DyspneaDyspnea 24 Mechanical Airway Obstruction External: gagging, strangulation, smothering Internal: food bolus, other mechanical airway obstructions: peanuts, beads, Internal growths: tumors, infections, abscesses Encroachment on the airway Internal substances: pus, blood, mucus, transudates
Slide 25-

DyspneaDyspnea 25 Muscular / Chest Wall system Diaphragm Chest wall muscles Accessory muscles such as supraclaviculars, neck muscles. Myesthenia, paralysis other muscular causes Increased muscle tension.
Slide 26-

DyspneaDyspnea 26 Air to blood interface: Mechanical filling of alveoli Lack of surfactant: alveoli collapse with exhalation Abnormalities (thickening) of alveolar membranes, Interstitium (tissues between the alveolus and the capillary endothelium) Capillary endothelium Blood: enough of it, flowing well enough
Slide 27-

DyspneaDyspnea 27 Causes of dyspnea Psychogenic Hypoxic Metabolic Pulmonary Cardiogenic Hematologic Any others?
Slide 28-

DyspneaDyspnea 28 April, 99 Tools to evaluate dyspnea Suspicion / Clinical knowledge. “If you don’t think of it, you will never find it.” History PE including Vital Signs, pulse ox, PEF Formal Studies
Slide 29-

DyspneaDyspnea 29 What other tools? PEF ABG Other blood tests CXR EKG CT UltraSound
Slide 30-

DyspneaDyspnea 30 Additional items of history Cough Vomiting Temporal relationship  What does that mean? Circadian variations
Slide 31-

DyspneaDyspnea 31 Cough What good is a cough? What bad is a cough? Central & peripheral triggers Air travels in excess of 150 kilometers per second during a cough can denude respiratory epithelium exposed basement membranes stimulate future antigenic response
Slide 32-

DyspneaDyspnea 32 Aphorism Coughing till you vomit is bronchospasm till proven otherwise. Consider cardiac. Vomiting AND THEN coughing -> think aspiration
Slide 33-

DyspneaDyspnea 33 Vital Signs What are the VS? Normal vs Stable How do they change over time? What does this tell you?
Slide 34-

DyspneaDyspnea 34 Vital Signs The meaning of each value depends on its context. A slowing respiratory rate in a bad asthmatic may mean he is about to die. A slowing respiratory rate in an anxious bystander may mean he is getting better.
Slide 35-

DyspneaDyspnea 35 Vital Signs: Respiratory rate: Do it yourself! Temp. Don’t trust the Triage Temps. HR, BP. What do they tell you about the RR?
Slide 36-

DyspneaDyspnea 36 Pulse Ox What is a dangerous level? Why? When is the pulse ox normal and the patient about to die? Why? When is the pulse ox bad and the patient is fine? Why?
Slide 37-

DyspneaDyspnea 37 VS - Combinations: High RR, HR, BP Discussion Low RR, HR, BP Discussion High RR, HR, low BP Discussion
Slide 38-

DyspneaDyspnea 38 Focused exam Accessory muscles Facial expression, color. Chest wall, lungs, heart, abd & extr. (Discussion)
Slide 39-

DyspneaDyspnea 39 Physical Exam Observation Auscultation – with and without a stethoscope. Where? Palpation – what & where & why? Scratch test The REST of the exam – habitus, edema, muscle wasting, lots more.
Slide 40-

DyspneaDyspnea 40 April, 99 Scratch Test Place stethoscope on mediastinum, gently scratch the anterior chest wall alternate sides, equidistant from the stethoscope. One side may not transmit sounds as well as the other. What would the scratch test tell you?
Slide 41-

DyspneaDyspnea 41 Pathophysiology chemoreceptors, mechanoreceptors, lung receptors 3 components that contribute to dyspnea: afferent signals, efferent signals, and central information processing. brain compares the afferent and efferent signals, and a "mismatch" results in the sensation of dyspnea.
Slide 42-

DyspneaDyspnea 42 Afferent neurons chemoreceptors carotid bodies, Various brain organs, juxtacapillary (J) receptors, chest wall and its musclesMuscle spindles sense stretch Lung parenchymal tissues,
Slide 43-

DyspneaDyspnea 43 Efferent signals motor neurons of respiratory muscles. Diaphragm, intercostal, abdominal muscles, accessory muscles.
Slide 44-

DyspneaDyspnea 44 Central Processing Objective data Subjective data Psychiatric is a diagnosis of exclusion
Slide 45-

DyspneaDyspnea 45 April, 99 MRC Breathlessness Scale Grade 0 1 2 3 4 Degree of dyspnea no dyspnea except with strenuous exercise Only when walking up incline or hurryingl Slow on level, or stops after 15 minutes stops few minutes of walking on the level minimal activity such as getting dressed, too dyspneic to leave the house The Modified Borg Scale
Slide 46-

DyspneaDyspnea 46 Causes of dyspnea 4 general categories: cardiac, pulmonary, mixed cardiac or pulmonary, Non-cardiac, non-pulmonary
Slide 47-

DyspneaDyspnea 47 Common specific disease entities Asthma Pneumonia Pleural effusion Pneumothorax Interstitial Lung disease COPD Psychogenic Pericardial effusion Cardiac ischemia CHF Dysrhythmia Mechanical obstruction Anemia
Slide 48-

DyspneaDyspnea 48 Blood tests ABG Vidas d-Dimer BNP Basic Metabolic Panel Cardiac Enzymes What else, and why?
Slide 49-

DyspneaDyspnea 49 April, 99 Chest radiography (CXR) Insufficient by itself Do your own read: the radiologist may not know what you are looking for and may overlook the most important clue. Look for pneumothorax, aortic dissection, pneumonia, pleural effusions, sub-segmental atelectasis, pulmonary infiltrates or an elevated hemi-diaphragm
Slide 50-

DyspneaDyspnea 50 CXR 1
Slide 51-

DyspneaDyspnea 51 CXR 2
Slide 52-

DyspneaDyspnea 52 CXR 3
Slide 53-

DyspneaDyspnea 53 April, 99 ECG Lots of clues as to cause of dyspnea Look for pericarditis (S1Q3T3, right axis deviation), myocardial infarction, ST segment elevation new onset atrial fibrillation or right heart strain
Slide 54-

DyspneaDyspnea 54 EKGs (TB Inserted)
Slide 55-

DyspneaDyspnea 55 April, 99 Arterial Blood Gases (ABG) Must be interpreted in context. “Complete” ABG includes lactate VBG sometimes very useful. When? Why?
Slide 56-

DyspneaDyspnea 56 ABG and Acid base balance. (This could easily be a few hours’ lecture.) 3 important components pH, CO2 and O2 pH changes because of both metabolic and respiratory causes. Each tries to compensate for abnormalities in the other.
Slide 57-

DyspneaDyspnea 57 pH pH should be 7.4. If lower  acidotic. If higher  basic.
Slide 58-

DyspneaDyspnea 58 PaCO2 should be 40, +/- If lower, breathing too much. If higher, not breathing enough. CO2 / HCO3 is the end product of oxidative metabolism
Slide 59-

DyspneaDyspnea 59 PaO2 O2 % (Pulse Ox) = saturation. Should be 85 -100. If lower  hypoxic. If higher than 100  getting more than 21% or over-breathing seriously. PaO2 is a measure of oxygen carriage. Oxygen carrying capacity is a function of amount of carrier, and carrier saturation.
Slide 60-

DyspneaDyspnea 60 Respiratory Acidosis and Alkalosis Low pH = acidosis Lo pH, high CO2  respiratory acidosis Lo ph, low CO2  metabolic alkalosis High pH = alkalosis Hi pH, low CO2  respiratory alkalosis Hi pH, high CO2  metabolic alkalosis
Slide 61-

DyspneaDyspnea 61 April, 99 Ventilation / Perfusion Scanning (V/Q Scan) combined with clinical suspicion sensitivity is 85 - 90% positive predictive value depends on clinical suspicion More radiation than a CT-PE study.
Slide 62-

DyspneaDyspnea 62 April, 99 CT Scan of the Chest 2 kinds: rapid helical without contrast. Usual speed, with contrast. CT more rapid, safer, detects other potential causes of dyspnea with better accuracy than VQ helical CT scanning – no contrast needed Regular PE protocol requires normal Cr or GFR. Why? Always consider Metformin. Why?
Slide 63-

DyspneaDyspnea 63 April, 99 Ultrasonography & Echocardiography Next lecture TEE = transesophagyl echocardiogram (TEE) is > 90% sensitive for large clots, very specific. This, we can’t do yet. TTE = TransThoracic echocardiogram: aortic dissection, cardiac tamponade, acute valvular lesion. This, we can do.
Slide 64-

DyspneaDyspnea 64 Specific entities: Asthma Pneumonia Acute Pulmonary Edema Pulmonary Embolism Emphysema Pneumo / hemothorax Carbon Monoxide (CO) Cyanide poisoning
Slide 65-

DyspneaDyspnea 65 Asthma: Reversible bronchoconstrictuion Air blocked between the large airways to the alveoli. Alveoli may collapse. Treatment: open the airways, prevent stacking (time enough for exhalation). Keep O2 high enough to keep patient’s brain alive. Consider steroids, permissive hypercarbia.
Slide 66-

DyspneaDyspnea 66 Pulmonary edema: Basic problem: Heart stretches so far it can’t contract well. (Falls off Frank Starling Curve) Cardiac oxygen demand exceeds availability. Air can’t cross the air-blood interface. Fluid seeps from the blood into the alveoli. Surfactant gets diluted. Caused by cardiac and vascular derangements. Vicious cycle.
Slide 67-

DyspneaDyspnea 67 Pulmonary edema: Symptoms: Sudden onset; respiratory distress, Rales, ronchi. Foamy sputum. Sometimes blood tinged. Blood pressure high (vasoconstriction) usually 240/120. If onset between 4 pm and 8 pm, likely to be associated with acute MI.
Slide 68-

DyspneaDyspnea 68 Pulmonary edema Treatment: increase airway pressure, to force fluids back into the vascular system, (BVM with patient effort, CPAP or intubation) increase FiO2, dilate blood vessels and reduce systemic blood pressure (which reduces the work of the heart and reduces oxygen demand). Get excess fluid off via kidneys (if working), via bleeding (bloodletting) or sequester fluid (tourniquets).
Slide 69-

DyspneaDyspnea 69 Diabetic KetoAcidosis DKA Tachypnea often without Air hunger metabolic derangement: blood is too acid. Respiratory system tries to compensate, gets overwhelmed.
Slide 70-

DyspneaDyspnea 70 Pneumo / hemo thorax. Stuff gets between the inside of the chest wall and the lung. Air can’t get in well, and blood can’t go round and round well enough. Treatment: mechanically remove the stuff that keeps the lung collapsed. Needle, needle with flutter valve, or chest tube. Intubation or BVM may make things worse, if there is a flap.
Slide 71-

DyspneaDyspnea 71 Pneumonia Infection in the lower airway. Consolidation (fluid in alveoli) often only one part of a lung. Generally SICK. Upper, middle and lower airways clogged by mucus, often tenacious. Fever increases metabolic demand for O2. Treatment: Antibiotics if bacterial (Abx) thin the mucus mechanical ventilation if needed.
Slide 72-

DyspneaDyspnea 72 Pulmonary Embolism A blood clot in the pulmonary circulation (often from the systemic venous circulation) blocks. Blood can’t go round and round, so there is lack of oxygen in the circulating blood. Diagnosis: hypoxemia, tachycardia, tachypnea, sometimes chest pain. Treatment: anticoagulation and o2 supplementation. CO2 usually normal. Why is CO2 normal?
Slide 73-

DyspneaDyspnea 73 Emphysema Not enough lung tissue. That is, a paucity of the blood/air interface. Optimize all functioning tissue. Treatment: new lungs.
Slide 74-

DyspneaDyspnea 74 CO poisoning: competitive inhibition of O2 binding at hemoglobin site. Treatment: overwhelm the CO with 100% O2. If not good enough, use hyperbaric O2.
Slide 75-

DyspneaDyspnea 75 Cyanide poisoning: Mechanism: inhibition of O2 utilization at the cellular level. There can be plenty of O2 in the air, and in the blood, but the cells can’t use it. Treatment: inactivate the cyanide using “BAL” British Anti-Lewisite. Time is of the essence
Slide 76-

DyspneaDyspnea 76 Summary: Dyspnea is a subjective Think systematically Multiple causes / multiple tools to diagnose the problem “When you can’t breathe, not much else matters.”
Slide 77-

DyspneaDyspnea 77 REFERENCES Saracino A (October 2007). "Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?". Emerg Med Australas 19 (5): 394–404. Stenton C (2008). "The MRC breathless scale.". Occup Med 58 (3): 226–7. doi:10.1093/occmed/kqm162. PMID 18441368. Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990. Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed. Baltimore: Williams & Wilkins, 1986. Tobin MJ. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med 1990;150:1604-13. Silvestri GA, Mahler DA. Evaluation of dyspnea in the elderly patient. Clin Chest Med 1993;14:393-404. Cockcroft A, Adams L, Guz A. Assessment of breathlessness. Q J Med 1989;72:669-76. Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med 1993;8:383-92. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997. Fauci AS, ed. Harrison's Principles of internal medicine. 14th ed. New York: McGraw-Hill, 1997. Enright PL, Hyatt RE, eds. Office spirometry: a practical guide to the selection and use of spirometers. Philadelphia: Lea & Febiger, 1987:253. Baum GL, Wolinsky E, eds. Textbook of pulmonary diseases. 4th ed. Boston: Little, Brown, 1989: 1595-2102. Rubenstein E, Federman DD, eds. Respiratory medicine. In: Scientific American medicine. New York: Scientific American, 1995.