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CME - Breathlessness Rad
CME - Breathlessness Rad
Dyspnoea
Definition: abnormal awareness of breathing occuring at an inappropriately low level of physical exertion or at rest.
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
Causes of breathlessness
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
Causes of breathlessness
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
Acute breathlessness, Radtthiga Batch 11
Others
Sunday, March 17, 2013
Causes of dyspnoea
System Cardiovascular Chronic exertional dyspnoea Chronic heart failure Angina COPD Chronic asthma Bronchial carcinoma Interstitial lung disease Severe anemia
Acute breathlessness, Radtthiga Batch 11
Respiratory
Others
Sunday, March 17, 2013
Associated symptoms
Productive cough or acute chest illness (Hx of chronic cough with sputum, worse in the morning) Breathlessness Wheezing
Onset:? Physical exertion or at rest? Triggering factors? ( MI) Distance walked before breathlessness occur? Chest pain? (site, radiation) Aggravating factors? (exercise, exertional, stress anxiety)
Acute breathlessness, Radtthiga Batch 11
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)
Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11
-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
signs of hyperinflation flattening of the diaphragm increased retrosternal air space long, narrow heart shadow. hypovascularity of lung parenchyma
Investigations
Investigations
Chest X-ray
signs of hyperinflation flattening of the diaphragm increased retrosternal air space long, narrow heart shadow. hypovascularity of lung parenchyma
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 .
Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11
Mild Moderate
Severe
Very severe
Conditions
History
Signs
-Raised JVP --Central cyanosis -Bibasal crackles -S3 -Cardiomegaly -Cold extremities -LL edema
History
Signs
Evidence of Diabetes/ renal -Acetone breath diseases -Hyperventilation - Kussmauls breathing -Dehydration
Investigations
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
Hyperinflated chest
Chest Arterial blood radiography gas analysis Hyperinflation Emphysema -Low Pa O -Low PaCO Bronchitis -Low Pa O -High PaCO - high bicarbonate
Metabolic acidosis
Normal
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
Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11
Discharge
Once patient is stable Short term nebuliser
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)
Discharge
Counselling on medications
THANK YOU
Sunday, March 17, 2013 Acute breathlessness, Radtthiga Batch 11