Approach to dyspnoea

“I CANNOT BREATH VERY
WELL”
DR.RISHIKESAN K.V
SPECIALIST PHYSICIAN
VENNIYIL MEDICAL CENTRE,
SHARJAH

AIMS AND LEARNING OBJECTIVE
DEFINITION OF DYSPNOEA AND
DISCUSSION OF PATHOPHYSIOLOGY
AETIOLOGY,
DIFFERENTIAL DIAGNOSIS,
EVALUATION OF BREATHLESS PATIENTS
APPROACH TO THE PATIENTS WITH
DYSPNOEA
CASE STUDY
UNDERSTANDING THE INTERPRETATION OF
PULSE OXIMETRY, AND SPIROMETRY.

DEFINITION
DYSPNEA,
ALSO KNOWN AS SHORTNESS OF BREATH OR
BREATHLESSNESS,
IS A SUBJECTIVE SENSATION OF BREATHING DISCOMFORT.
IT IS AN UN IGNORABLE FEELING OF NEEDING OXYGEN
THE SENSATIONS ARE SIMILAR TO THAT OF THIRST OR HUNGER
ACTIVATION OF SEVERAL PATHWAYS CAN LEAD TO
THE SENSATION OF BREATHLESSNESS.

DEFINITION BY MY PROFESSOR
DYSPNOEA IS DEFINED AS
UNDUE AWARENESS OF UNPLEASANT BREATHING

PATHOPHYSIOLOGY
THE PATHOPHYSIOLOGY OF DYSPNOEA IS COMPLEX.
IT INVOLVES THE ACTIVATION OF SEVERAL PATHWAYS AS WELL AS,
STIMULATION OF THE RECEPTORS OF THE UPPER OR LOWER AIRWAY,
LUNG PARENCHYMA, CHEST WALL, CENTRAL AND PERIPHERAL
CHEMORECEPTORS.
ACTIVATION OF THESE PATHWAYS IS RELAYED TO THE CNS VIA
RESPIRATORY MUSCLE AND VAGAL AFFERENTS, WHICH ARE
CONSEQUENTLY INTERPRETED BY THE INDIVIDUAL IN THE CONTEXT OF
THE AFFECTIVE STATE, ATTENTION, AND PRIOR EXPERIENCE, RESULTING IN
THE AWARENESS OF BREATHING.
The pathophysiology, aetiology, clinical presentation and management of dyspnoea are reviewed. S Afr Med J
2016;106(1):32-36. DOI:10.7196/SAMJ.2016.v106i1.10324

AETIOLOGY
CAREFUL HISTORY-TAKING IS THE MOST USEFUL FIRST
STEP IN ELUCIDATING THE ETIOLOGY OF DYSPNEA.
THE ETIOLOGY OF DYSPNEA COVERS A BROAD
RANGE OF PATHOLOGIES FROM MILD,
SELF-LIMITED PROCESSES TO LIFE-THREATENING
CONDITIONS.
THE MOST COMMON ETIOLOGIES ARE DISEASES OF
CARDIOVASCULAR,
PULMONARY, AND
NEUROMUSCULAR SYSTEMS

DYSPNOEA
SEVERAL FACTORS NEED TO BE ADDRESSED IN
THE CLINICAL HISTORY WHEN CONSTRUCTING
THE INITIAL DIFFERENTIAL DIAGNOSIS
THE EVALUATION AND MANAGEMENT OF DYSPNOEA IS DIRECTED BY
 THE CLINICAL PRESENTATION,
 FINDINGS FROM THE HISTORY AND PHYSICAL EXAM,
 THE PRELIMINARY INVESTIGATION RESULTS.

USEFUL APPROACH IN THE DIAGNOSIS….
IS TO ENVISION THE ETIOLOGIES AND DIAGNOSTIC WORK-UP AS A CHECK
LIST OF THE PHYSIOLOGIC PROCESS THAT MOVE OXYGEN FROM THE
ATMOSPHERE INTO THE MITOCHONDRIA.
RESPIRATORY CAUSES OF DYSPNOEA MAY AFFECT ANY LEVEL OF THE
RESPIRATORY TRACT FROM THE NARES AND MOUTH TO THE PULMONARY
ALVEOLI
WE HAVE THE RESPIRATORY PUMP (1.NEURO MUSCULO SKELETAL
DISEASES) TO GENERATE NEGATIVE PLEURAL PRESSURE (2.PLEURAL
DISEASES) SO AS TO EXPAND THE COMPLIANT LUNG PARENCHYMA
(3.PARENCHYMAL LUNG DISEASES) SO THAT AN OPEN CONDUCTING
AIRWAY SYSTEM (4.LARYNGEAL AND TRACHEOBRONCHIAL DISEASES) CAN
ADEQUATELY MOVE THE OXYGENATED AMBIENT AIR (5.HIGH ALTITUDE)
FOR THE EXTRACTION OF OXYGEN

RESPIRATORY CAUSES OF DYSPNOEA

THE DISTRIBUTORY CIRCULATORY SYSTEM
THE DISTRIBUTORY CIRCULATORY SYSTEM REQUIRES AN
ADEQUATE AMOUNT OF OXYGEN CARRIERS (6.ANAEMIA AND
HAEMOGLOBINOPATHY) AND AN INTACT SERIES OF
UNIDIRECTIONAL PRIMING (7.ATRIAL AND VALVULAR DISEASES)
AND PUMPS (8.DIASTOLIC AND SYSTOLIC DYSFUNCTION) AS
WELL AS AN OPEN VASCULAR DISTRIBUTORY NETWORK
(9.PULMONARY AND SYSTEMIC VASCULAR DISEASES) TO
DELIVER THE OXYGEN TO THE LUNGS(10.PULMONARY
EMBOLISM AND PULMONARY HYPERTENSION) AND TO THE
END USERS SUCH AS MUSCLES AND VITAL ORGANS.

THE DISTRIBUTORY CIRCULATORY SYSTEM…..
THE HEART HAS TO EXPAND TO RECEIVE AND SEND BLOOD INTO THE
LUNGS AND DISTRIBUTE IT INTO AERATED EXCHANGE UNITS (11.V/Q
MISMATCH AND SHUNTS) BEFORE IT IS RECEIVED INTO LEFT ATRIUM
(12.PULMONARY VENO OCCLUSIVE DISEASES).
THE LEFT HEART THEN DELIVER THIS BLOOD TO THE SYSTEMIC
CIRCULATION THROUGH A SERIES OF VASCULAR CONDUITS
(13.ATHEROSCLEROSIS AND OTHER OBSTRUCTIVE VASCULOPATHY) .
THE OXYGEN FINALLY DIFFUSES FROM THE CAPILLARIES TO
MITOCHONDRIA.

INITIAL ASSESSMENT OF PATIENTS WITH
DYSPNOEA: STARTING WITH ABC
 ASSESSS AIRWAY PATENCY AND LISTEN TO THE LUNGS
 OBSERVE BREATHING PATTERN, INCLUDING USE OF ACCESSORY
MUSCLES
 MONITOR CARDIAC RHYTHM
 MEASURE VITAL SIGNS AND PULSE OXIMETRY
 OBTAIN ANY HISTORY OF CARDIAC , PULMONARY DISEASE OR TRAUMA
 EVALUATE MENTAL STATUS

RED FLAGS FOR SERIOUS FORMS OF DYSPNOEA
 HYPOTENSION
RESPIRATORY RATE >40
ALTERED MENTAL STATUS
HYPOXIA
CYANOSIS
STRIDOR
BREATHING EFFORT WITHOUT AIR
MOVEMENT
TRACHEAL DEVIATION WITH
UNILATERAL BREATH SOUNDS
UNSTABLE ARRHYTHMIA

DIFFERENTIAL DIAGNOSIS
CARDIAC: CCF, CAD , ARRHYTHMIAS, VALVULAR HEART DISEAS, ACUTE MI ,
PERICARDITIS AND CARDIAC TAMPONADE
PULMONARY: COPD , ASTHMA, PNEUMONIA, PNEUMOTHORAX, PUL EMBOLISM,
PLEURAL EFFUSION, METASTATIC DISEASE,GERD WITH ASPIRATION, RESTRICTIVE LUNG
DISEASE
PSYCHOGENIC : PANIC ATTACKS, HYPERVENTILATION, PAIN AND ANXIETY
UPPER AIRWAY OBSTRUCTION: EPIGLOTTITIS, CROUP, FOREIGN BODY, EBV
ENDOCRINE : METABOLIC ACIDOSIS, MEDICATIONS
CNS DISEASES, NEUROMUSCULAR DISORDERS
PAEDIATRIC : BRONCHIOLITIS,CROUP, FOREIGN BODY, MYOCARDITIS

ACUTE DYSPNOEA
ACUTE DYSPNOEA APPEARS SUDDENLY
OR IN A MATTER OF MINUTES
IT TYPICALLY INDICATES ACUTE AND
SEVERE CONDITIONS THAT MAY BE LIFE
THREATENING
ACUTE PUL.EMBOLISM
MYOCARDIAL INFARCTION
ACUTE VALVULAR INSUFFICIENCY
FLASH PULMONARY EDEMA
PNEUMOTHORAX
ANAPHYLAXIS
FB ASPIRATION
CARDIAC TAMPONADE

SUBACUTE DYSPNOEA
SUB ACUTE DYSPNOEA DEVELOPS OVER HOURS TO DAYS
COMMON CAUSES INCLUDE:
ACUTE ASTHMA
EXACERBATION OF COPD
PULMONARY EDEMA
LESS COMMON CAUSES INCLUDE :
MYOCARDITIS
SVC SYNDROME
ACUTE EOSINOPHILIC PNEUMONIA
CARDIAC TAMPONADE

CHRONIC DYSPNOEA
DEVELOPS OVER WEEKS TO MONTHS
IT IS ASSOCIATED WITH CHRONIC PATHOLOGY
5 MAIN AETIOLOGICAL CATEGORIES ACCOUNT FOR MOST CASES OF
CHRONIC DYSPNOEA :
1. CARDIOVASCULAR DISEASE
2. PULMONARY DISEASE
3. RESPIRATORY MUSCLE DYSFUNCTION
4. PSYCHOGENIC DYSPNOEA
5. DECONDITIONING/OBESITY leads to chronic dyspnoea and may result
from immobilisation after medical illness, surgery, trauma, a sedentary
lifestyle

TIME COURSE OF DYSPNOEA
ACUTE DYSPNOEA:
appears suddenly or in
a matter of minutes
SUBACUTE :develops
over hours to days
CHRONIC: develops
over weeks to months
RECURRENT : dyspnoea
occurs in paroxysm
ACUTE PULMONARY
EMBOLISM
ACUTE ASTHMA CCF PAROXYSMAL
TACHYARRHYTHMIAS
MYOCARDIAL
INFARCTION
COPD EXACERBATION COPD INTERMITTENT
CHB
ACUTE VALVULAR
INSUFFICIENCY
PULMONARY EDEMA CARDIOMYOPATHY
PNEUMOTHORAX MYOCARDITIS PHT
ANAPHYLAXIS SVC SYNDROME VALVULAR HD
FB ASPIRATION ACUTE
EOS.PNEUMONIA
ANEMIA
PULMONARY EDEMA CARD.TAMPONADE MUSCULAR
DYSTROPHIES

ASSOCIATED SYMPTOMS
FEVER,COUGH PNEUMONIA, BRONCHITIS, LARYNGITIS
CHEST PAIN CAD, PUL.EMB; PTX, PNEUMOMEDIASTINUM, PNEUMONIA, PLEURO
PERICARDIAL DISEASES
PALPITATION PUL.EMB; TACHYARRHYTHMIAS,VALVULAR HD, ANXIETY ATTACKS
SYNCOPE TACHYARRHYTHMIAS, PUL.EMBOLISM
WHEEZING ASTHMA,COPD, PUL.EDEMA, BRONCHIOLITIS, FB ASPIRATION
CHANGE IN VOICE PNEUMOMEDIASTINUM, AORTIC ANEURYSM, GERD
HEMOPTYSIS BRONCHITIS, BRONCHIECTASIS, CHEST MALIGNANCY,VASCULITIS, TB, PE
DYSPHAGIA PNEUMOMEDIASTINUM, FB ASPIRATION, TETANUS
MUSCLE WEAKNESS
MYALGIA
DECONDITIONG, MUSCULAR DYSTROPHIES, AML, GBS, ARBOVIRAL DISEASE,
LEPTOSPIROSIS
BONE PAIN SCD WITH ACUTE CHEST SYNDROME, FAT EMBOLISM WITH LONG BONE#
ANXIETY PANIC ATTACKS, HYPERVENTILATION, TAKOTSUBO CMP

CLUES TO THE DIAGNOSIS FROM SYMPTOMS
COUGH ASTHMA, PNEUMONIA
SEVERE SORE THROAT EPIGLOTTITIS
PLEURITIC CHEST PAIN PERICARDITIS, PUL.EMBOLISM, PNEUMONIA,
PNEUMOTHORAX
ORTHOPNOEA,PND,EDEMA CCF
TOBACCO USE COPD,CCF, PUL.EMBOLISM
INDIGESTION,DYSPHAGIA GERD,ASPIRATION
BARKING COUGH CROUP

WHEEZING AND STRIDOR
WHEEZING IS EXPIRATORY IN NATURE AND ASSOCIATED WITH LOWER
AIRWAY DISEASE LIKE ASTHMA, AND BRONCHIOLITIS
STRIDOR IS INSPIRATORY IN NATURE AND IS ASSOCIATED WITH
OBSTRUCTION/ NARROWING AT OR ABOVE THE LEVEL OF THE VOCAL
CORDS
IN THE ROUTINE MANAGEMENT OF THE PATIENT WHO CARRIES A
DIAGNOSIS OF ASTHMA AND PRESENTS WITH WHEEZING, IMAGING IS
USUALLY NOT INDICATED
IN A PATIENT WITH NO H/O ASTHMA ( AKA “FIRST TIME WHEEZERS”) IN
MY OPINION IMAGING IS STRONGLY ENCOURAGED

ORGANISE YOUR THOUGHTS
IS DYSPNOEA……..
A NEW PROBLEM ?
EXACERBATION OF OLD PROBLEM?
A COMBINATION?
IS DYSPNOEA…….
CARDIAC?
PULMONARY?
NEITHER?
IS DYSPNOEA ONE OF THE DEADLY BUT SUBTLE DIAGNOSIS
I SHOULD THINK OF EVERY TIME?

IS THE DYSPNOEA ?
A NEW PROBLEM :
MYOCARDIAL INFARCTION
PULMONARY EMBOLISM
PNEUMONIA
TRAUMA
ANAPHYLAXIS
ARRHYTHMIA
KEYS TO DIAGNOSIS:
NO PAST H/O CARDIOPULMONARY DISEASES
ATYPICAL OF OTHER DISEASE PRESENTATIONS
NEW RISK FACTORS Eg. RECENT SURGERY

IS THE DYSPNOEA AN EXACERBATION OF….?
CONDITIONS DIAGNOSTIC CLUES
 COPD/EMPHYSEMA/ASTHMA  PAST MEDICAL HISTORY
 CCF  TYPICAL OR ATYPICAL OF PRIOR
PRESENTATIONS
 INTERSTITIAL LUNG DISEASE  PRECIPITATING OR EXACERBATING
FACTORS
 CARDIAC ARRHYTHMIA Eg. AF WITH FVR  PHYSICAL EXAMINATION FINDINGS
 ANEMIA  LABS AND TESTING
 NEUROMUSCULAR DISEASE
 PLEURAL/PERICARDIAL DISEASE

IS IT A COMBO OF NEW & CHRONIC PROBLEM ?
RECURRENT DISEASE
1. MYOCARDIAL DISEASE
2. PULMONARY EMBOLISM
3. ARRHYTHMIA
MULTIPLE DISEASE CONSPIRING TOGETHER
1. INFECTION EXACERBATING HEART FAILURE
2. ARRHYTHMIAS EXACERBATING HEART FAILURE
3. PNEUMONIA COMPLICATING COPD
4. ANEMIA WORSENING CARDIAC ISCHAEMIA

WHICH OF THE FOLLOWING EXAMS IS MOST USEFUL
IN DIFFERENTIATING COPD FROM ASTHMA?
CHEST X RAY
BNP
PFT
PULMONARY AUSCULTATION
SPIROMETRY WITH BRONCHODILATOR

IS DYSPNOEA CARDIAC ?
MYOCARDIAL ISCHAEMIA
LEFT HEART DISEASE : ACUTE VALVULAR INSUFFICIENCY, LVF
TACHYARRHYTMIAS,
PHT, SLEEP APNOEA
PERICARDIAL EFFUSION,
CARDIAC TAMPONADE
KEYS TO DIAGNOSIS
1. MURMERS
2. ECG
3. BED SIDE ECHO

IS THE DYSPNOEA PULMONARY?
ASTHMA,COPD/EMPHYSEMA
ANAPHYLAXIS
TRACHEAL DISEASE
MUCUS PLUGGING
PNEUMONIA
PULMONARY EMBOLISM
PNEUMOTHORAX
KEY TO DIAGNOSIS
ABNORMAL BREATH SOUNDS, STRIDOR , I/E RATIO
CHEST X RAY

IS DYSPNOEA SOMETHING ELSE ENTIRELY?
 NEUROMUSCULAR DISEASES
 ANEMIA
 ENDOCRINE DISEASES
 METABOLIC DISORDERS
 PSYCHOGENIC
 OBESITY/DECONDITIONING
 TRAUMA
 TOXIC EXPOSURE
 ABDOMINAL DISTENTION (ASCITES, LIVER DISEASES)

ANXIETY AS A CAUSE OF DYSPNOEA
THE MOST DANGEROUS DIFFERENTIAL DIAGNOSTIC CONSIDERATION
DOESN’T REQUIRE CONFIRMATORY LAB OR IMAGING
CAN’T BE DEFINITIVELY EXCLUDED BY ANY DEGREE OF TESTING
“GARBAGE CAN” DIAGNOSIS
BELONGS AT THE BOTTOM OF ANY PATIENT WORK UP
ANY CLINICAL CONDITION THAT CAUSES DISTRESS CAN ALSO CAUSES
ANXIETY
BE VERY, VERY CAREFUL ATTRIBUTING PATIENT SYMPTOMS TO ANXIETY
A THERAPEUTIC RESPONSE TO AN ANXIOLYTIC SUGGESTS ONLY THAT
THERE IS AN ANXIETY COMPONENT; IT DOESN’T R/O ANYTHING

ANXIETY
ANY CLINICAL CONDITION THAT CAUSES PHYSICAL DISCOMFORT WILL
CONTRIBUTE TO DYSPNOEA
WHAT CAME FIRST?
ANXIETY OR PHYSICAL SYMPTOMS
IF ANXIETY FIRST… IT MAY BE A COMPONENT
IF PHYSICAL SX. FIRST… LOOK FIRST TO A PATHOLOGIC EXPLANATION
EVEN IF YOU SUSPECT DIAGNOSIS KEEP IT IN THE BACKYARD OF YOUR
MIND
ADVISE THE PATIENT TO RETURN IF WORSE, NO BETTER, NEW SX, OR
UNEXPECTED PROBLEMS
Weinstock, M. Risk Management Monthly Emergency Medicine.Vol.11,No.6.June2017

DIAGNOSES TO CONSIDER
EVERYTIME
MYOCARDIAL ISCHAEMIA
PULMONARY EMBOLISM
INFECTION
SEPSIS
ARRHYTHMIAS
CARDIAC TAMPONADE
DIAGNOSTIC TEST TO CONSIDER:
 CXR,
 ECHO, ECG
 PULSE OXIMETRY

PULMONARY EMBOLUS IN PATIENTS WITH COPD
PULMONARY EMBOLUS SHOULD BE
CONSIDERED IN DIFFERENTIAL
DIAGNOSIS FOR PATIENTS PRESENTING
WITH COPD EXACERBATION
ONE STUDY HIGH LIGHTED THAT UPTO
25% OF PATIENTS HOSPITALISED WITH
COPD EXACERBATION HAD
CONCOMITANT PULMONARY EMBOLISM
BE SURE TO KEEP YOUR DIFFERENTIAL
DIAGNOSIS BROAD

DIAGNOSTIC WORKUP
• CBC
• BASIC CHEMISTRY PANEL
• BLOOD GAS/PULSE OXIMETRY
• SPIROMETRY WITH BRONCHODILATOR
• PEAK FLOW
• CARDIAC TROPONIN, ECG
• CXR, CHEST CT
• BED SIDE ULTRA SOUND/ECHO
• D-DIMER
• BNP OR NT- BNP

BLOOD GAS ANALYSIS
VENOUS BLOOD GAS IS PREFERRED OVER ABG IN THE EMERGENCY
ROOM
ABG EVALUATES OXYGENATION
VENOUS BLOOD GAS EVALUATES VENTILATION
VENOUS BLOOD GAS CORRELATES CLOSELY TO ABG.
WE WILL GET FAIRLY GOOD IDEA REGARDING THE OXYGENATION FROM
PULSE OXIMETRY

INTERPRETING BLOOD GAS IN ASTHMA & COPD
A NORMALISED BLOOD GAS ( pH 7.4/ PCO2 40) SHOULD BE CONCERNING
IN PATIENTS WITH MODERATE TO SEVERE ASTHMA EXACERBATION
THIS MAY INDICATE THAT THE PATIENT IS TIRING OUT AND IN NEED OF
VENTILATOR SUPPORT
PATIENTS WITH COPD GENERALLY CHRONICALLY RETAIN CO2 AND MAY
HAVE NORMAL pH ALTHOUGH THEY HAVE AN ELEVATED CO2 LEVEL .
IT MAY BE IN THE RANGE OF 60s or 70S

BASIC OFFICE SPIROMETRY
TWO QUESTIONS/STEPS PROVIDE INITIAL GUIDANCE:
STEP1: IS THE FEV1/FVC RATIO NORMAL ( >/= 70% ) OR LOW (<70%)
STEP2: IS THE FVC NORMAL (>/= 80% PREDICTED) OR LOW <80%
PREDICTED
 FEV1 MEASURES HOW MUCH AIR CAN BE EXHALED IN THE FIRST
SECOND
 FVC MEASURES HOW MUCH TOTAL AIR CAN BE EXHALED, FROM
MAXIMAL INSPIRATION TO MAXIMAL EXPIRATION

BASIC SPIROMETRY : A CASE ILLUSTRATED
68 YEAR OLD ,OBESE MALE WITH PROGRESSIVELY WORSENING DOE FOR
6-7 YEARS HAS GOT SIG. ACTIVITY LIMITATION OVER 6 MONTHS
HAS GOT PRODUCTIVE COUGH MOST MORNINGS.
USED TO GET 4-5 EPISODES OF URI EVERY YEAR OVER THE PAST COUPLE
OF YEARS, TREATED WITH SHORT COURSES OF ORAL STEROIDS AND
ANTIBIOTICS BY THE FAMILY PHYSICIAN
SMOKER 1.5 PACKS/DAY
CAD S/P 3V CABG 4 YEARS AGO, HTN, DLP, BPH AND
WELL CONTROLLED T2D

PHYSICAL EXAM
OBESE, RUDDY FACED
GETS VISIBLY SOB WHEN WALKING APPROX. 30 FT
AFEBRILE, BP 162/90 , HR 112 REGULAR, MILDLY RAISED JVP, HS NORMAL
LUNGS: INCREASED AP DIAMETER, DIMINISHED BREATH SOUNDS
THROUGHOUT
NO ADDED SOUNDS
ABDOMEN : OBESE,
EXTREMITIES : 1+ PEDAL EDEMA B/L
NEURO INTACT

LABS ,CXR, AND PFT
ROUTINE BLOOD TEST , LFT, BUN AND SERUM CREAT. AS WELL AS
ELECTROLYTES : NORMAL
CXR PA/LATERAL : EMPHYSEMATOUS , HEART SIZE RELATIVELY SMALL
PUL. FUNCTION TEST:
FLOW VOLUME CURVE: NORMAL INSPIRATORY CURVE BUT VERY
PROLONGED EXPIRATORY CURVE
FEV1 = .88 (38% PREDICTED)
FVC = 1.38 (69% PREDICTED)
FEV1/FVC = 64%

WHAT DO YOU THINK THE MOST LIKELY
DIAGNOSIS ?
1. A PURELY OBSTRUCTIVE PATTERN
2. A PURELY RESTRICTIVE PATTERN
3. A MIX.OF OBSTRUCTION AND RESTRICTION WITH A PREDOMINANT
OBSTRUCTION
4. A MIX. OF BOTH WITH PREDOMINANT RESTRICTION

SPIROMETRY (CONT.)
STEP 1: CALCULATE FEV1/FVC RATIO : DEFINES OBSTRUCTION
IF LOW (< 70% ) OBSTRUCTIVE LUNG DISEASE
(OBSTRUCTION DURING EXHALATION E.g. COPD)
IF NORMAL >70% NO OBSTRUCTION
STEP2: CALCULATE FVC : SUGGESTS RESTRICTION; TLC IS NECESSARY FOR
CONFIRMATION
IF LOW <80% LIKELY RESTRICTIVE DISEASE (RESTRICTED
BREATHING DURING INHALATION)
IF NORMAL > 80% UNLIKELY RESTRICTIVE DISEASE

DIFFUSING CAPACITY FOR CO(DLCO)
IS THE DLCO LOW <80% PREDICTED OR NORMAL (>/= 80%)
IT DEFINES HOW FAST GAS DIFFUSES FROM LUNG ALVEOLI INTO BLOOD
STREAM
LOW DLCO : ALVEOLAR DISEASES ( EMPHYSEMA AND PULMONARY
FIBROSIS)
NORMAL DLCO : CHRONIC BRONCHITIS AS IT IS A DISEASE OF AIRWAYS
DLCO IS USEFUL IN DIFFERENTIATING EMPHYSEMA FROM CHRONIC
BRONCHITIS
DLCO ALSO HELPS TO IDENTIFY IF RESTRICTION IS INSIDE THE LUNG
(PULMONARY FIBROSIS) OR OUTSIDE THE LUNG ( OBESITY,CHEST WALL
DEFORMITIES,NEUROMUSCULAR DISEASES etc.)
NORMAL DLCO SEEN IN EXTRA PULMONARY RESTRICTION

PULSE OXIMETRY/SaO2 INTERPRETATION
ONLY PATIENTS WITH FULLY FUNCTIONAL CARDIOVASCULAR/PULMONARY
SYSTEMS SHOULD HAVE AN SaO2 ~ 100% ON ROOM AIR
OUR PATIENT HAD COPD AND ONGOING TOBACCO USE
WE DON’T EXPECT A PRETTY WELL SaO2 IN THIS PATIENT
Hb LEVELS WILL AFFECT SaO2
Hb(ANEMIA) THE EASIER IT IS TO SATURATE Hb
THE SaO2 MAY BE HIGH, BUT TOTAL O2 CONTENT WILL BE LOW
Hb(POLYCYTHAEMIA) DIFFICULT TO SATURATE THE EXTRA
MOLECULES OF Hb WITH O2 PSEUDO HYPOXAEMIA
---WHEN THE PATIENT’S O2 CONTENT MAY WELL BE NORMAL
Carroll P. RT: For Decision Makers in Respiratory Care.2007

SaO2 INTERPRETATION AND TEMPERATURE
PATIENT’S TEMPERATURE WILL ALSO AFFECT SaO2
READINGS
HYPOTHERMIA TIGHTER Hb- O2 BOND WITH
OXYGEN DELIVERY
HYPERTHERMIA LOOSER Hb- O2 BOND WITH
OXYGEN DELIVERY
Shipsey P. Emergency Medicine Reviews and Perspectives.2012

CYANOSIS
BLUE DISCOLORATION OF SKIN AND OR MUCUS MEMBRANE SECONDARY
TO DEOXYGENATED Hb IN THE BLOOD , OFTEN FIRST VISUALISED IN THE
TONGUE
CENTRAL ( FACE, LIPS ,TONGUE etc )
PERIPHERAL (FINGERS OR TOES)
CENTRAL CYANOSIS USUALLY SEEN > 5G/dL DESATURATED Hb
o DUE TO INADEQUATE BLOOD OXYGENATION FROM CARDIAC OR
PULMONARY DISEASE.
o USUALLY APPARENT WITH SaO2 <85% OR < 75%
ANEMIC PATIENT IS EXTREMELY UNLIKELY TO BE CYANOTIC AS THEY DO
NOT HAVE ENOUGH Hb TO BE DEOXYGENATED
POLYCYTHAEMIC CAN MORE SHOW CYANOSIS
Lundsgard C , et al.Medicine.1923;2(1):1-76

WHICH OF THE FOLLOWING TEST IS MOST USEFUL IN INITIALLY
DIFFERENTIATING COPD EXACERBATION FROM HEART FAILURE?
CALF DIAMETER MEASUREMENTS
CXR
SPIROMETRY WITH BRONCHODILATOR
BNP
BMP

CONGESTIVE HEART FAILURE
INABILITY OF THE HEART TO ADEQUATELY PUMP
NECESSARY BLOOD REQUIRED TO MAINTAIN HOMOEOSTASIS
DIASTOLIC HF : INABILITY OF THE HEART TO RELAX AND ADEQUATELY
FILL RESULTING IN DECREASED SV
SYSTOLIC HF :INABILITY OF THE HEART TO PUMP BLOOD
FORWARDLEADING TO INADEQUATE ORGAN PERFUSION AND LUNG
CONGESTION
ECHOCARDIOGRAPHY IS THE KEY TO UNDERSTANDING
THE CAUSE OF PULMONARY EDEMA AND IF SO WHICH TYPE

D-DIMER
• NEGATIVE D-DIMER
TEST CAN HELP
EXCLUDE PULMONARY
EMBOLISM.
• SPIRAL CT HAS GOT A
DEFINITE ROLE IN THE
DIAGNOSTIC WORK UP
OF PUL.EMBOLISM
• IT MAY EVENTUALLY
REPLACE PULMONARY
ANGIOGRAM

5 CAUSES OF DYSPNOEA
1 AIR PROBLEM EMPTY TANK
2 NEUROMUSCULOSKELETAL
OR VENTILATION PROBLEM
GUILLAIN-BARRE, UNILATERAL DIAPHRAGMATIC
PARALYSIS,RIB FRACTURES , MEDIASTINAL MASS
etc
3 LUNG PROBLEM
PNEUMONIA, PUL EMBOLISM, TUMOR,
PLEURAL EFFUSION, PTX, PULMONARY
CONTUSSION etc
4 HEART PROBLEM
MI,VALVULAR HEART DISEASE, CARDIAC
TAMPONADE etc
5 BLOOD PROBLEM
ANEMIA, CARBOXY HAEMOGLOBINAEMIA,
METHEMOGLOBINAEMIA, SC DISEASE etc
Wahls SA. Am Fam Physician.2012 Jul15;86(2): 173-180

SUMMARY
DYSPNOEA IS A SUBJECTIVE SENSATION OF BREATHING DISCOMFORT
ACTIVATION OF SEVERAL PATHWAYS CAN LEAD TO THE SENSATION OF
BREATHLESSNESS
THE EVALUATION AND MANAGEMENT OF DYSPNOEA IS DIRECTED BY
THE CLINICAL PRESENTATION, FINDINGS FROM THE HISTORY ,
PHYSICAL EXAM AND PRELIMINARY INVESTIGATION RESULT
THE ETIOLOGY COVERS A BROAD RANGE OF PATHOLOGIES
DISEASES OF HEART, LUNG AND NEUROMUSCULAR SYSTEMS ARE THE
MOST COMMON ETIOLOGIES

REFERENCES
1.The pathophysiology, aetiology, clinical presentation and management of dyspnoea are
reviewed. S Afr Med J 2016;106(1):32-36. DOI:10.7196/SAMJ.2016.v106i1.10324
2.Weinstock, M. Risk Management Monthly Emergency Medicine.Vol.11,No.6.June2017
3.Carroll P. RT: For Decision Makers in Respiratory Care.2007
4.Shipsey P. Emergency Medicine Reviews and Perspectives.2012
5.Lundsgard C , et al.Medicine.1923;2(1):1-76
6.Swadron, S. National Emergency Medicine Board Review. August 17,2015
7.Wahls SA. Am Fam Physician.2012 Jul15;86(2): 173-180
8.William Hampton. Quantia MD. Topics: Case: Pulmonology 2017 October.
9.Christopher Kabrhel , MD . Approach to the patient with dyspnea
10.My BMJ Best Practice/monograph

TAKE HOME MESSAGE
IF YOU FIND SOMETHING ANOTHER CLINICIAN MAY HAVE MISSED,
DON’T POINT FINGERS
EXPLAIN THAT THE LAST PHYSICIAN TO SEE A PATIENT FOR A
PARTICULAR COMPLAINT ONLY APPEARS TO BE SMARTER BECAUSE
SHE OR HE HAS EVERYONE ELSE’S KNOWLEDGE TO BUILD UPON.
THANK YOU FOR HAVING ME

Approach to dyspnoea

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