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Pulmonary
Perspective
Section of Pulmonary and
Critical Care
DYSPNEA:
Breathing
Life into a
Complex
Symptom
Maria Piedad Rosales – Natividad, MD and Patrick Gerard L, Moral, MD
Section of Pulmonary and Critical Care Medicine
Department of Medicine, UST Faculty of Medicine and Surgery
Definition
• “a person’s uncomfortable sensation
associated with breathing”
• a perception by the individual and is entirely
subjective
• not a clinical observation, nor does it relate
directly to any physiological or laboratory test
• the patient’s interpretation of a reduction in
pleasant breathing.
Hingal
sumisikip ang
dibidib
Kapos ng
hininga
Nasasakal
Hinahapo
Are all episodes of dyspnea
pathologic?
yes no
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Normal Dyspnea
• Dyspnea may occur normally in states of
intense exercise, such as running,
mountain climbing, lifting, rowing, and
swimming, where the stress of breathing
is a direct result of intense physical effort
and not a consequence of
cardiopulmonary or metabolic disorder.
Key Questions
• Quality (description, progression)
• Location / Radiation
• Severity (bearable, intolerable)
• Timing /Duration (acute, chronic)
• Setting
• Precipitating (body positions, exposures)
Palliating (body positions, medications)
• Associated symptoms (chest pain, cough)
Quality
• I feel that I am •My breathing requires
suffocating effort
• My chest feels tight •I cannot get enough air
• My breathing is heavy
•I feel a hunger for air
•My breathing is shallow
• I feel that I am
smothering •I feel out of breath
• My breath does not go in •My chest is constricted
all the way •My breathing requires
• My breath does not go
work
out all the way
• I feel that I am breathing
more
CHEST 2000; 118:679–690
Severity
• The usual technique is to determine the amount
of effort required to bring on dyspnea.
– How far can the patient walk, at a normal pace (in meters)
before stopping due to shortness of breath?
– Can the patient walk uphill?
– How many flights of stairs can the patient climb?
– In conversation, can the patient finish a sentence (or word)
without taking a breath?
– During telephone conversations, does the patient notice
shortness of breath?
• These questions should be asked at each visit
to assess symptom progression or
improvement.
Visual Analogue Scale
No shortness of breath
100 mm line
Manning HL, Schwartzstein, RM. Mechanisms of disease: Pathophysiology of dyspnea. New Engl J Med. 1995;
Ventilatory Control
Neurogenic Voluntary Control Chemical
anxiety / hysteria
Factors Stimuli
cortex
Pulmonary receptors Respiratory Center
sensitive to stretch and stimulated by increase
Chest wall PaCO2 and H+
bronchial irritation (stimulated receptors
in asthma, pulmonary embolism and
pneumonia)
Carotid and
Juxta capillary (J) receptors Aortic Bodies
stimulated by pulmonary congestion (heart stimulated by
failure)
increase PaO2 <
Muscle and joint 8kPa
receptors stimulated
by exercise
Dyspnea
respiratory cardiopulmonary
respiratory
drives system response
drives
cardiopulmonary
system response
• The work of breathing must be appropriate to
the task and in the context of the resultant
cardiovascular and respiratory responses.
Pulmonary Sources
Respiratory work
major components:
obstructive
1. resistive load
– the resistance of moving
restrictive
air through the airways
2. elastic load
– the load imposed by
elasticity and recoil of the
lungs, thorax, and
respiratory musculature
vascular
Restrictive
Obstructive
Vascular
• Ventilation
• No perfusion Migration
Embolus
Thrombus
Gas Diffusion
• Thickness of membrane
• Surface area of
membrane O2
• Diffusion coefficient of
gas
O2
• CO driving pressure O2
• RBC volume
• Rate of reaction of Hgb
and CO
Patient presents
with dyspnea Initial hypotheses
General Data
Chief Complaint
History
Social/ Family/ Past
Medical/Occupational
Review of Systems
Dyspnea
General Data:
•42, male – cardiac, pulmonary
•asian – if pulmonary, not cystic fibrosis or
alpha-1 antitrypsin deficiency
•politician – cardiac
•Pampanga – volcanic dust exposure?
History:
•progressive – cardiac, pulmonary (COPD)?
•worsened with dust and heat – asthma / COPD
•relieved by salbutamol– asthma, / COPD
•episodic/ at rest– asthma/ COPD/ cardiac/ embolism
Dyspnea
Additional history:
•smoker – cardiac, pulmonary (STOP!)
•obesity – cardiac, restrictive lung,
embolism
•hypertension– cardiac; medication
exacerbates asthma
•Pain reliever– drug allergy (ask about dyspnea
occurring with drug intake)
•Family hx – (+) asthma; PTB less likely
•Politician – no other occupational risks
Dyspnea
Review of Systems:
•Weight gain – hypothyroid; familial;
anxiety
•Morning headaches– sleep apnea
•Daytime somnolence– sleep apnea;
work related
•Cold intolerance – hypothyroidism
•Morning nasal stuffiness – rhinitis
•Epigastric pain – peptic ulcer; reflux; NSAID
•Knee pains – osteorathritis
•Edema – cardiac, obesity; DVT; cor pulmonale
Differential Diagnosis
•Cardiac – Coronary Artery Disease
–Dyspnea – congestive heart failure
•Bronchial asthma or COPD
–Dyspnea – obstructive lung disease
•Obesity ( familial or due to hypothyroidism)
–Dyspnea - restricitive
•Deep venous thromboses > embolism
–Dyspnea - vascular
•Anxiety
–Dyspnea - psychogenic
Anxiety symptoms may
imply psychogenic causes
of dyspnea, but organic
etiologies always should
be considered first.
Patient presents
with dyspnea Initial hypotheses
Inspection
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Palpation
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Percussion
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Percussion
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Physical Examination
Pneumonia Effusion Pneumothorax Atelectasis
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Try Again!
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TRY AGAIN