Noble Approach to Patients with Dyspnea

bad breeze (Latin)

Breathlessness

Shortness of breath
Difficulty of breathing Disordered /inadequate breathing Uncomfortable awareness of breathing Air hunger

Dyspnea
One of the most common distressing symptoms of a patient.
Correlates with increased prevalence of cardiac and pulmonary diseases Predictor of hospitalization in pxs with chronic lung dse; more closely related with survival than FEV1 More closely associated with cardiac mortality than angina Sensation or perception? Acute or chronic?

Population Cancer (mixed) AIDS

Prevalence of Dyspnea (%) 10-70 11-62

References Solano 2006 Solano 2006

Lung cancer (primary or metastatic) Heart Disease COPD Renal Disease Stroke
ALS Dementia

62-95
60-88 90-95 11-62 37 47-50 70

Currow 2010
Solano 2006 Solano 2006 Solano 2006 Addington-Hall 1995 Obrien 1992, Hicks 1993 Lloyd Williams 1996

No cardiorespiratory disease

45-81

Currow 2010

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT Acute vs Chronic 5. RESEARCH PRIORITIES

a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. derives from interactions from multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioral responses.

dyspnea per se can only be perceived by the person experiencing it.

ATS Statement Mechanisms, Assessment, and Management of Dyspnea : 1999 and 2011 update

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT Acute vs Chronic 5. RESEARCH PRIORITIES

Dyspnea --Uncomfortable in work of breathing Tachypnea -- RR > normal Hyperpnea (Tidal volume x RR) > normal; pH = normal Hyperventilation (Tidal volume x RR) > demands; pH =

Dyspnea of exertion (DOE) -- Exertion-induced SOB

Orthopnea -- Recumbent-induced SOB

Paroxysmal nocturnal dyspnea (PND) -- Sudden SOB after recumbent

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1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

DOMAINS OF DYSPNEA MEASUREMENT

Sensory-perceptual experience: what breathing feels like; single item ratings of intensity eg Borg, VAS Affective distress: how distressing breathing feels; multi item scales of emotional responses such as anxiety Symptom impact or burden: how dyspnea affects functional ability, QOL; MRC, multidimensional scales of QOL

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

Visual Analog Scale

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

QUESTIONNAIRES

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1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

Modified Medical Research Council (MRC) Scale 0. I only get breathless with strenuous exercise 1. I get short of breath when hurrying on the level or walking up a slight hill 2. I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level 3. I stop for breath after walking about 100 yards or after a few minutes on the level 4. I am too breathless to leave the house or I am breathless when dressing

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

Evaluation still depends on a thorough HISTORY AND PE Priority of treatment is to focus on IDENTIFYING and RELIEVING the pathologic process leading to the symptom

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

CLUES from HISTORY AND PE Restricted thoracic motion : air hunger Bronchoconstriction: chest tightness

COPD: increased effort to breathe

Heart failure: air hunger; suffocation

Cardiovascular deconditioning: heavy breathing

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

EVALUATION OF ACUTE DYSPNEA

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

Run thru the checklist!

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

TWO MAJOR CATEGORIES Acute: new onset of breathing discomfort for whom the underlying cause of dyspnea has not yet been determined

Chronic: those with known cardiovascular, respiratory, or neuromuscular diseases who are experiencing worsening dyspnea

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

EVALUATION OF ACUTE DYSPNEA

CARDIOVASCULAR SYSTEM Acute myocardial ischemia Heart Failure Cardiac Tamponade

RESPIRATORY SYSTEM Bronchospasm Pulmonary Embolism Pneumothorax Pulmonary infection Upper Airway Obstruction Aspiration Anaphylaxis

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

LAB WORK-UPS FOR ACUTE DYSPNEA CXR, ABG, ECG SOB Panel D Dimer high negative predictive value NT ProBNP

Myoglobin
Troponin

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

301 patients in the ER with DOB Increased sensitivity by 5% Specificity not significantly improved.
Acad Emer Med 2009

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

LAB WORK-UPS FOR ACUTE DYSPNEA

Plasma BNP With chronic and advanced HF, ventricular cells are recruited to secrete ANP and BNP in response to high ventricular filling pressures plasma concentrations of both hormones increased in patients with symptomatic or asymptomatic LV dysfunction Meta analysis: BNP testing at ED in patients with dyspnea can reduce length of stay in the hospital Lam et.al, Ann of Int Med 2010

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

LAB WORK-UPS FOR ACUTE DYSPNEA

Plasma BNP

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

EVALUATION OF CHRONIC DYSPNEA LAB TESTING CBC, glucose, BUN, creatinine, electrolytes, Ca, P, TSH PFT spirometry, bronchoprovocation testing, lung volumes, lung diffusion, maximal inspiratory pressure, MVV IMAGING CXR, CT Others Echocardiography, Cardiopulmonary Exercise Testing, EMGNCV

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1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATiON AND TREATMENT 5. RESEARCH PRIORITIES

TREATMENT primary focus to optimize treatment of underlying disease

Oxygen advanced heart or lung disease; related to changes in chemoreceptor stimulation Heliox helium with decreased density mixed with gas decreased resistance to airflow, decreased WOB, decreased severity of hyperinflation, inc exercise capacity, dec dyspnea; ?long term studies

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATiON AND TREATMENT 5. RESEARCH PRIORITIES

Pharmacologic therapy OPIOIDS can reduce breathlessness in advanced COPD, ILD, CA, chronic HF Nebulized opioids not superior to oral/parenteral NEBULIZED FUROSEMIDE dec breathlessness induced in healthy volunteers, vagal afferent
Possible benefit in COPD, but no benefit in CA patients
Still with insufficient data

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATiON AND TREATMENT 5. RESEARCH PRIORITIES

Other agents: Anxiolytics, Antidepressants, Phenothiazines, NaHCO3, inhaled topical anesthetics lack data PULMONARY REHABILITATION esp in patients with chronic lung disease reduction in exertional dyspnea during exercise and improved exercise tolerance. Other nonpharmacologic approaches: chest wall vibration, cool air, noninvasive ventilation Alternative/complementary medicine: acupuncture, yoga training

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATiON AND TREATMENT 5. RESEARCH PRIORITIES

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUAITON AND TREATMENT 5. RESEARCH PRIORITIES

New treatments and larger clinical trials treatment of dyspnea per se?

Standardized instruments for measuring dyspnea

Neuromodulation, neuroimaging and central processing of dyspneic sensations and associated unpleasantness. Interdisciplinary approaches to research in dyspnea

DYSPNEA
1. DEFINITION 2. MECHANISMS UNDERLYING DYSPNEA 3. DYSPNEA MEASUREMENT 4. EVALUATION AND TREATMENT 5. RESEARCH PRIORITIES

Patient Education

Summary and Recommendations

When developing a differential diagnosis, use a construct that distinguishes respiratory ssystem dyspnea fro cardiovascular dyspnea. Also take into account chronic conditions contributing to dyspnea. Inquire about the quality of patients breathing discomfort, use assessment tools. Plasma BNP may be helpful in establishing or excluding the dx of heart failure as cause of dyspnea.

Summary and Recommendations

History and PE lead to accurate diagnoses of patients in 2/3 of cases. CXR and spirometry to screen. CT for ILD, occult emphysema, chronic thromboembolic disease. CPET is a useful study in patients in whom the cause of their breathing discomfort remains elusive after standard testing, in patients whom deconditioning is a serious consideration, and in patients who appear to have breathing discomfort out of proportion to their physiologic derangements.