Dispne 2021
Dispne 2021
Dispne 2021
One year ago he was able to walk up the stairs to his apartment
without difficulty, but now he has difficulty walking one block.
– Acute: hours to days due to immune problems ya da astma COPD, kalp yetmezliği
– Chronic dyspnea: at least 4 weeks
Acute dyspnea
life-threatening!!
• Pulmonary embolism
• Pump failure
– myocardial infarction
– acute heart valve insufficiency
– cardiac tamponade
• Pneumothorax
• Pulmonary broncial constriction
– anaphylaxis
• Possible foreign body aspiration
• Pneumonia
COVID-19
• Patients with (COVID-19) often
have clinical characteristics, such
as chest tightness and dyspnea.
• The primary target organ of SARS-
CoV-2 in the human body is the
lung.
• Sudden or exacerbated dyspnea in
the clinic often indicates an
increase in lung lesions and Ground-glass opacity
Buzlu cam opaklığı
further aggravation of the disease.
History Taking
occurs ar rest or with exertion
ortopnea
• Listen to the patient’s PND
description of dyspnea
timing, setting, exacerbating and alleviating
factors
associated signs and symptoms.
the effect of dyspnea on activities of daily living
• Ask about risk factors for conditions causing
dyspnea from the past medical, social, and
family histories.
History
• A thorough social history should include home and
occupational environments.
• Personal tobacco use, exposure to tobacco smoke, and
other irritant substances–both at home and at work–
should be questioned.
• Irritants include chemical fumes, molds, allergens, and
other substances that may cause or aggravate the
patient’s dyspnea.
• A full review of the patient’s current medications,
including supplements and herbal preparations, should
be conducted.
Physical exam
• A comprehensive physical exam should be performed
• Vital signs with height, weight and pulse oximetry at rest
should be measured.
Normal pulse oximetry will not rule out a pulmonary
cause
• The general appearance of the patient and any presence
of distress should be noted.
• Evaluate mental status
• Skin color should be evaluated for pallor or cyanosis, and
nails should be assessed for clubbing
• Skin should also be assessed for eczema
Physical exam
• A through exam of the eyes, ears, nose, throat, and
sinuses to evaluate for allergies, postnasal drip, and
chronic sinusitis should be performed
• The neck should be evaluated for the presence of
thyromegaly, and jugular vein distension should be
estimated
• The thorax should be evaluated for the presence of
spinal, rib cage, or sternal deformities that could cause
restriction of the chest cavity, and therefore, chronic
shortness of breath.
Physical exam
• The ease of respirations, use of accessory muscles,
symmetry of chest excursion
• The respiratory rate and depth
should be noted while at rest
• The lungs should be percussed for areas of dullness
(consolidation or atelectasis) or diffuse hyperresonance
(air-trapping).
• Diminished breath sounds or the presence of crackles or
wheezes should be noted.
Physical exam
• Cardiac rate, rhythm, location of the point of maximal
impulse (apical impulse), and presence of extra heart
sounds and murmurs should be documented.
normalden anormale
Berliner et al. Dtsch Arztebl Int 2016; 113: 834–45
• Patients who complain of air hunger may have heart failure
(HF)
• Troponins for MI
(the positive predictive value of repeated troponin
measurement for acute myocardial ischemia is 75% to 80%)
LAB
• D-dimers
– they are found in higher concentrations after
thrombotic events
– for the diagnosis and treatment of pulmonary
embolism that the use of age-adjusted threshold
values (age × 10 µg/L for patients over age 50)
markedly improves the specificity of the D-dimer
test, while keeping its sensitivity above 97% .
The five most common causes of
chronic dyspnea
●Asthma
●Chronic obstructive pulmonary disease (COPD)
●Interstitial lung disease
●Myocardial dysfunction
●Obesity/deconditioning
Chronic Dyspnea
Diagnosis
• Most common causes:
– Cardiovascular
– Respiratory disorders
One year ago he was able to walk up the stairs to his apartment
without difficulty, but now he has difficulty walking one block.
• Asthma
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Pneumonia
Dyspnea and COPD
• COPD:
– Cough and dyspne
– Productive cough
– Smokers
– Second-hand smokers
– Exposure of pollution, and other respiratory
irritants
COPD
• Productive cough for greater than 3 months
• Impressive smoking history;
both have high likelihood ratios for chronic obstructive
pulmonary disease (COPD).
• However, congestive heart failure and COPD frequently
occur together; thus a diagnosis of one does not
exclude the other.
• Further evaluation for cardiac causes should be
pursued because the patient has several coronary
artery disease risk factors
(smoking, male sex, and age over 60) and CHF may be
contributing to the patient's dyspnea.
COPD? Asthma?
The classic symptoms of asthma are
dyspnea, wheezing, and cough, which
overlap with those of COPD, making diagnostic
distinction difficult.
In this case, the patient's older age of onset
makes asthma less likely.
Pneumonia is unlikely based on the chronicity of
symptoms and lack of systemic symptoms or
signs of infection.
Dyspnea and Asthma
• Patients with asthma may complain of chest tightness
and shortness of breath with or without wheezing or
with cough only
• Wheezing and/or cough are not specific to respiratory
conditions and may also be present in the patient with
HF or other conditions.
• Patients with asthma may be able to identify a trigger,
such as weather changes or a particular respiratory
irritant that precipitates the symptoms.
• Patients with asthma often have worsening of
symptoms at night and symptoms that interfere with
sleep.
Less Common Respiratory Causes Of
Chronic Dyspnea
• Postnasal drainage
• Chronic pneumonia
• Chronic pulmonary embolism
BNP
• Brain-type natriuretic peptide (BNP) should be drawn.
Elevations of BNP greater than 100 pg/mL are suggestive of
HF.