بسم الله الرحمن الرحیم dr asadian amoli 1391-24 bahman

بسم الله الرحمن الرحیم

dr asadian amoli 1391-24 bahman

سالم به همکاران عزیز


DYSPNEA


by Dr Asadollah Asadian

Dyspnea - common complaint/symptom

• “shortness of breath” or “breathlessness”

Defined as abnormal/uncomfortable breathing

Multiple etiologies -

• 2/3 of cases - cardiac or pulmonary etiology


HOW TO DESCRIBE THESE SENSATIONS

Cannot get enough air

Air does not go all the way down

Smothering feeling in the chest

Tightness in the chest

Fatigue in the chest


Normal person may experience the physiologic dyspnea during heavy exercise


DIFFERENTIAL DIAGNOSIS

Composed of four general categories

• Cardiac• Pulmonary• Mixed cardiac or pulmonary• non-cardiac or non-pulmonary


PULMONARY ETIOLOGY

COPD

Asthma

Restrictive Lung Disorders

Hereditary Lung Disorders

Pneumonia

Pneumothorax


CARDIAC ETIOLOGYCHF

CAD

MI (recent or past history)

Cardiomyopathy

Valvular dysfunction

Left ventricular hypertrophy

Pericarditis

Arrhythmias


MIXED CARDIAC/PULMONARY ETIOLOGY

COPD with pulmonary HTN and/or cor pulmonale

Chronic pulmonary emboli

Pleural effusion


NONCARDIAC OR NONPULMONARY ETIOLOGY

Metabolic conditions (e.g. acidosis)

Pain

Trauma

Neuromuscular disorders

Functional (anxiety,panic disorders, hyperventilation)

Chemical exposure


TOXIC DYSPNEA

In the metabolic acidosis (uremiaand

diabetic acidosis, the acid metabolites stimulate the respiratory center, causing deep and regular respiration (Kussmanul) with snoring.


ACUTE DYSPNEA

PTE

Pneumonia

Asthma

Anxiety

MI


There is no one specific cause of dyspnea and no single specific treatment

Treatment varies according to patient’s condition

• chief complaint• history• exam• laboratory & study results


نا رسایی تنفسی


انواع نارسایی تنفس

تیپ ( )1هیپوکسمیک

تیپ ( )2هیپرکاپنیک


نا رسایی حاد تنفسی= هیپوکسمیک تنفسی po2<60mmgh w نارسایی

FIO2=>50

تنفسی نارسایی PCO2.>45mmgh+acidosis=هیپرکاپنیک


علل هیپوکسی

FIO2 کاهش

دردیفیوژن اختالل

شنت

هیپوونتیالسیون

V/Q mismatch


علت ترین شایعشنت نارساییدر ICUاست تنفسی


علل شنت

intracardiac • any cause of a right to left shunt eg Fallot's

tetralogy, Eisenmenger's syndrome pulmonary

• pneumonia • pulmonary oedema • atelectasis • collapse • pulmonary haemorrhage • pulmonary contusion


تهویه بدون پرفیوژن

) علت به گیرد نمی صورت گاز تبادل ولی شود می واردریه هوا ( هوایی راه همانند الوئولها نتیجه در پرفیوژن فقدان

(physiological dead space ) میکنند )عمل

) low cardiac output( -قلبی نارسایی علل

( مکانیکی ( تهویه الوئولی فشارداخل افزایش


CAUSES OF HYPOVENTILATION

Brainstem

• brainstem injury due to trauma, haemorrhage, infarction, hypoxia, infection etc • metabolic encephalopathy • depressant drugs

Spinal cord

• trauma, tumour, transverse myelitis Nerve root injury

Nerve

• trauma • neuropathy eg Guillain Barre • motor neuron disease

Neuromuscular junction

• myasthenia gravis • neuromuscular blockers

Respiratory muscles

• fatigue • disuse atrophy • myopathy • malnutrition

Respiratory system

• airway obstruction (upper or lower) • decreased lung, pleural or chest wall com


NERO-PSYCHOGENIC DYSPNEA

Patient suffer from hysteria will be seen

repetitive deep, signing respiration with

numbness of extremities or lips, spasm.


HAEMATOLOGICL DYSPNEAThe decrease of oxygen-carrying capacity and oxygen content develop abnormal respiration and increase heart rate, such as severe anemia, carbon monoxide.

Hypotension can stimulate respiration when patient suffer from shock.


ACCOMPANYING SYMPTOMS

Paroxysmal dyspnea with wheezing, It is present in bronchial asthma and cardiac asthma. Paroxysmal severe dyspnea is often seen in acute larynx edema(spontaneous pneumothoraxmassive pulmonary embolism.



Dyspnea with chest pain. It is frequently observed in lobar pneumoniapulmonary infarction(), spontaneous pneumothorax, acute exudative pleurisy), acute myocardial infarctionand bronchial carcinoma```````````````````````



Dyspnea with fever. It is commonly noted in pneumonia, lung abscesspulmonary tuberculosispleurisy, acute pericarditisand nervous system diseases.



Dyspnea with cough and purulent sputum. It is often present in chronic bronchitis, obstructive pulmonary emphysema with infection, purulent pneumonia, and lung abscess; Dyspnea with large amount of foamy sputum is often seen in acute left ventricular heart failure and organophosphorus poisoning



Dyspnea with coma. It suggests cerebral hemorrhage(pneumonia with shock, uremia, diabetic ketoacidosis, and acute poisoning.


COMMON CAUSES OF TYPE I (HYPOXEMIC) RESPIRATORY FAILURE

Chronic bronchitis and emphysema (COPD) Pneumonia Pulmonary edema Pulmonary fibrosis Asthma Pneumothorax Pulmonary embolism Pulmonary arterial hypertension Pneumoconiosis Granulomatous lung diseases Cyanotic congenital heart disease Bronchiectasis Adult respiratory distress syndrome Fat embolism syndrome Kyphoscoliosis Obesity


COMMON CAUSES OF TYPE II (HYPERCAPNIC) RESPIRATORY FAILURE

Chronic bronchitis and emphysema (COPD) Severe asthma Drug overdose Poisonings Myasthenia gravis Polyneuropathy Poliomyelitis Primary muscle disorders Porphyria Cervical cordotomy Head and cervical cord injury Primary alveolar hypoventilation Obesity hypoventilation syndrome Pulmonary edema Adult respiratory distress syndrome Myxedema Tetanus


EASILY PERFORMED DIAGNOSTIC TESTS

Chest radiographs

Electrocardiograph

Screening spirometry


Commonly used to evaluate acute dyspnea

can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia

normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea

• Remember- ABGs may be normal even in cases of acute dyspnea

ABGS


Bilateral airspace infiltrates on chest radiograph film secondary to acute respiratory distress syndrome that resulted in

respiratory failure


A 44-year-old woman developed acute respiratory failure and diffuse bilateral infiltrates. She met the clinical criteria for the diagnosis of acute respiratory distress syndrome. In this case, the likely cause was urosepsis


با تشکر از توجه شما


QUESTIONS?


بسم الله الرحمن الرحیم dr asadian amoli 1391-24 bahman

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