Diagnosis of Dyspnea

Vicken Y. Totten MD MS, FACEP

FAAFP

Associate Professor
Emergency Medicine
University Hospitals
Case Medical Center

2010-11
Dyspnea
DyspneaDyspnea

Dyspnea from Latin dyspnoea

Dyspnea (also SOB, air hunger)

subjective symptom of
breathlessness.
normal in heavy exertion
pathological if it occurs in
unexpected situations.

DyspneaDyspnea

Definition

Dyspnea: unpleasant, subjective

sensation of abnormal
respiration.
Labored breathing - physical
presentation of respiratory
distress/ dyspnea
Many causes

April, 99

2
DyspneaDyspnea

Descriptors of Dyspnea

Dyspnea on Exertion (DoE)

Dyspnea after Eating (PPD)
Nocturnal Dyspnea
Paroxysmal nocturnal dyspnea
Dyspnea in Pregnancy
(hormonal, mechanical)

DyspneaDyspnea

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)
DyspneaDyspnea

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
DyspneaDyspnea

Goals of this presentation

Discuss dyspnea &

its differential
diagnosis
Discuss
pathophysiology
Discuss diagnostic
tests for dyspnea
April, 99
DyspneaDyspnea

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.

DyspneaDyspnea

Principles of Emergency Medicine

Air goes in and out.

Blood goes round
and round.
All bleeding stops
eventually.
All else is details.
Butthe devil is in
the details.
DyspneaDyspnea

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.
DyspneaDyspnea

10

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?
Whats your current differential?
Admit or Discharge?
DyspneaDyspnea

11

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?
DyspneaDyspnea

12

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?

DyspneaDyspnea

13

Approach to the patient with

shortness of breath, or
respiratory distress: the
emergency approach.

DyspneaDyspnea

14

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.

DyspneaDyspnea

15

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.
DyspneaDyspnea

16

3. Locate the problem

Causes of air hunger:

mechanical,
metabolic,
cerebral,
Psychological

DyspneaDyspnea

17

4. Correct it

Topic for another lecture

After the (correct) diagnosis is made,
treatment is (relatively) simple

DyspneaDyspnea

18

Suspicion

You dont 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
DyspneaDyspnea

19

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
DyspneaDyspnea

20

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

DyspneaDyspnea

21

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.
DyspneaDyspnea

22

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
DyspneaDyspnea

23

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
DyspneaDyspnea

24

Muscular / Chest Wall system

Diaphragm
Chest wall muscles
Accessory muscles such as
supraclaviculars, neck muscles.
Myesthenia, paralysis other muscular
causes
Increased muscle tension.
DyspneaDyspnea

25

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
DyspneaDyspnea

26

Causes of dyspnea

Psychogenic
Hypoxic
Metabolic
Pulmonary
Cardiogenic
Hematologic
Any others?
DyspneaDyspnea

27

Tools to evaluate dyspnea

Suspicion / Clinical knowledge.

If you dont think of it, you will
never find it.
History
PE including

Vital Signs, pulse ox, PEF

Formal Studies
April, 99
DyspneaDyspnea

28

What other tools?

PEF
ABG
Other blood tests
CXR
EKG
CT
UltraSound
DyspneaDyspnea

29

Additional items of history

Cough
Vomiting
Temporal relationship What does
that mean?
Circadian variations

DyspneaDyspnea

30

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
DyspneaDyspnea

31

Aphorism

Coughing till you vomit is

bronchospasm till proven otherwise.
Consider cardiac.
Vomiting AND THEN coughing ->
think aspiration

DyspneaDyspnea

32

Vital Signs

What are the VS?

Normal vs Stable
How do they change over time?
What does this tell you?

DyspneaDyspnea

33

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.
DyspneaDyspnea

34

Vital Signs:

Respiratory rate: Do it yourself!

Temp. Dont trust the Triage Temps.
HR, BP. What do they tell you about
the RR?

DyspneaDyspnea

35

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?

DyspneaDyspnea

36

VS - Combinations:

High RR, HR, BP

Discussion
Low RR, HR, BP
Discussion
High RR, HR, low BP
Discussion

DyspneaDyspnea

37

Focused exam

Accessory muscles
Facial expression, color.
Chest wall, lungs, heart, abd & extr.
(Discussion)

DyspneaDyspnea

38

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.
DyspneaDyspnea

39

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?
April, 99
DyspneaDyspnea

40

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.
DyspneaDyspnea

41

Afferent neurons

chemoreceptors
carotid bodies, Various brain organs,
juxtacapillary (J) receptors,
chest wall and its musclesMuscle
spindles sense stretch
Lung parenchymal tissues,

DyspneaDyspnea

42

Efferent signals

motor neurons of respiratory

muscles.
Diaphragm, intercostal, abdominal
muscles, accessory muscles.

DyspneaDyspnea

43

Central Processing

Objective data
Subjective data
Psychiatric is a diagnosis of exclusion

DyspneaDyspnea

44

MRC Breathlessness Scale

Grade

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

April, 99
DyspneaDyspnea

45

Causes of dyspnea

4 general categories:
cardiac,
pulmonary,
mixed cardiac or pulmonary,
Non-cardiac, non-pulmonary

DyspneaDyspnea

46

Common specific disease entities

Asthma
Pneumonia
Pleural effusion
Pneumothorax
Interstitial Lung
disease
COPD
Psychogenic

Pericardial effusion
Cardiac ischemia
CHF
Dysrhythmia
Mechanical
obstruction
Anemia

DyspneaDyspnea

47

Blood tests

ABG
Vidas d-Dimer
BNP
Basic Metabolic Panel
Cardiac Enzymes
What else, and why?

DyspneaDyspnea

48

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
April, 99
DyspneaDyspnea

49

CXR 1

DyspneaDyspnea

50

CXR 2

DyspneaDyspnea

51

CXR 3

DyspneaDyspnea

52

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
April, 99
DyspneaDyspnea

53

EKGs (TB Inserted)

DyspneaDyspnea

54

Arterial Blood Gases (ABG)

Must be interpreted in context.

Complete ABG includes lactate
VBG sometimes very useful.
When? Why?

April, 99
DyspneaDyspnea

55

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.
DyspneaDyspnea

56

pH

pH should be 7.4.
If lower acidotic.
If higher basic.

DyspneaDyspnea

57

PaCO2

should be 40, +/If lower, breathing too much.

If higher, not breathing enough.
CO2 / HCO3 is the end product of
oxidative metabolism

DyspneaDyspnea

58

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.
DyspneaDyspnea

59

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

DyspneaDyspnea

60

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.

April, 99
DyspneaDyspnea

61

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?
April, 99
DyspneaDyspnea

62

Ultrasonography &
Echocardiography

Next lecture
TEE = transesophagyl
echocardiogram (TEE) is > 90%
sensitive for large clots, very
specific. This, we cant do yet.
TTE = TransThoracic echocardiogram:
aortic dissection, cardiac tamponade,
acute valvular lesion. This, we can do.
April, 99
DyspneaDyspnea

63

Specific entities:

Asthma
Pneumonia
Acute Pulmonary Edema
Pulmonary Embolism
Emphysema
Pneumo / hemothorax
Carbon Monoxide (CO)
Cyanide poisoning
DyspneaDyspnea

64

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 patients
brain alive.
Consider steroids, permissive
hypercarbia.
DyspneaDyspnea

65

Pulmonary edema:

Basic problem: Heart stretches so far it cant

contract well. (Falls off Frank Starling Curve)
Cardiac oxygen demand exceeds availability.
Air cant cross the air-blood interface.
Fluid seeps from the blood into the alveoli.
Surfactant gets diluted.
Caused by cardiac and vascular
derangements.
Vicious cycle.
DyspneaDyspnea

66

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.
DyspneaDyspnea

67

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).
DyspneaDyspnea

68

Diabetic KetoAcidosis DKA

Tachypnea often without Air hunger

metabolic derangement: blood is too
acid.
Respiratory system tries to
compensate, gets overwhelmed.

DyspneaDyspnea

69

Pneumo / hemo thorax.

Stuff gets between the inside of the chest

wall and the lung. Air cant get in well,
and blood cant 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.
DyspneaDyspnea

70

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.
DyspneaDyspnea

71

Pulmonary Embolism

A blood clot in the pulmonary circulation

(often from the systemic venous circulation)
blocks.
Blood cant 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?
DyspneaDyspnea

72

Emphysema

Not enough lung tissue. That is, a

paucity of the blood/air interface.
Optimize all functioning tissue.
Treatment: new lungs.

DyspneaDyspnea

73

CO poisoning:

competitive inhibition of O2 binding

at hemoglobin site.
Treatment: overwhelm the CO with
100% O2.
If not good enough, use hyperbaric
O2.

DyspneaDyspnea

74

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 cant use it.
Treatment: inactivate the cyanide
using BAL British Anti-Lewisite.
Time is of the essence

DyspneaDyspnea

75

Summary:

Dyspnea is a subjective
Think systematically
Multiple causes / multiple tools to
diagnose the problem
When you cant breathe, not much
else matters.

DyspneaDyspnea

76

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): 394404.
Stenton C (2008). "The MRC breathless scale.". Occup Med 58 (3): 2267. doi:
doi:
10.1093/occmed/kqm162.
10.1093/occmed/kqm162. PMID
PMID18441368.
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;14:393404.
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.

DyspneaDyspnea

77