Plan

1. Review anatomo- physiology

2. Definition
3. Pathophysio
4. Sign et symptom => form Clinique
5. Diagnostic -> Clinique et paraclinique
6. Priniciple of traitement
7. Advice to patients
 Chapter 2

Dysnpnea (Harrison )

Defi : experience of breathing discomfort

- Experience derives from interaction among multiple physiological , psychological , social and
environment

Mechanisms of dyspnea

- Respiratory center ( respiratory drive )

- Efferent : outgoing ( motor output from brain to ventilator muscles )
- Afferent : incoming ( sensory input from receptors )

Motor efferents

- Muscles
- When increase resistance or stiffness > increase work of breathing => increase effort to breathe
- The increase neural output fromt the motor cortex is sended via coroally discharge, coroally
discharge ->send to sensory cortex , at the same time motor output is directed to the ventilator
muscle.

sensory afferents

- Chemoreceptor ( carotid body and medulla ) activated by hypoxemia , acute hypercapnia and
acidemia- > increase in ventilation-> air hunger
- Mechanoreceptors -> chest tightness -> bronchospasm
- J receptor -> stimulated -> interstitial edema ,and acute changes in pulmonary artery pressure->
air hunger.
- Metaboreceptors -> located muscle -> changes in the local biochemical milieu of tissue active
during exercise and when stimulated -> breathing discomfort

integration : efferent reafferent mismatch

- Mismatch between the feed-forward and feed back

- Feed forward -> with respect to the instructions sent to the muscles
- If the feed forward and feedback messages do not match , an error signal is generated and the
intensity of dyspnea increases.
 - Occur in asthma or chronic obstructive pulmonary disease ( COPD )

anxiety

Increase respiratory rate that accompanies acute anxiety leads to hyperinflation , increased
work and effort of breathing and a sense of an unsatifying breath

Assessing dyspnea

Descriptor
Chest tightness or constriction
Increases work or effort of breathing
Air hunger , need to breathe , urge to breathe
Unsatisfying breath
Pathophysiology
Bronchoconstriction , interstitial edema ( asthma
, myocardial ischemia
COPD , asthma , airway obstruction
Pulmonary edema
Hyperinflation , asthma , pulmonary fibrosis

Differential diagnosis

- Dyspnea deviation from normal function in the cardiopulmonary systems

- Most diseases of the respiratory system are associated with alteration mechanical properties of
the lungs and/ or chest wall, -> frequently airway disease or lung parenchyma.

respiratory system dyspnea

Disease of the airway

- Expiratory airflow obstruction -> most common obstructive lung disease -> Asthma and COPD
- Both asthma and COPD may lead to hypoxemia and hypercapnia from ventilation perfusion( V/Q
mismatch )
Disease of the chest wall
- Kyphoscoliosis , or weaken ventilatory muscles-> myasthenia gravis or the guillain barre
syndrome
Diseases of the lung parenchyma
- From infection
- Occupational exposures
- Autoimmune disorders
 cardiovascular system dyspnea

Diseases of the left heart

- Coronary artery disease , Cardiomyopathy -> Greater left ventricular end-diastolic volume and
elevation of LV end diastolic , as well as pulmonary capillary pressures
interstitial edema > hypoxemia due to V/Q mismatch
Diseases of the pulmonary vasculature
- Disease : pulmonary thromboembolic and disease of pulmonary circulation ( Primary pulmonary
hypertension , pulmonary vasculitis )
Diseases of the pericardium
- Constrictive pericarditis and cardiac tamponade -> increase pressure intra cardiac and
pulmonary vascular pressure.
- To extent that cardiac output -> stimulation of metaboreceptor and chemoreceptors.

dyspnea with normal respiratory and cardiovascular systems

- During exercise -> stimulation of metaboreceptor

- Obesity -> high cardiac output and impaired ventilatory pump function (decreased compliance
of the chest wall)

approach to the patient

 Treatment

First goal : underlying problem responsible for the symptom.

If not -> supplemental O2 (O2< 89 % or if the patients saturation drops to these levels with
activity

PULMONARY EDEMA

Fluid accumulate in the intestitium of the lung depends on the balance of hydrostatic and
oncotic forces within the pulmonary capillaries and in the surrounding tissue
Causes : cirrhosis , nephrotic syndrome
cardiogenic pulmonary edema
- Cardiac abnormalities -> increase in pulmonary venous pressure shift the balance of forces
between the capillary and the interstitium( interstitial edema alveolar edema )
- Signs : dyspnea and orthopnea , chest x ray : peribronchial thickening , prominent vascular
markings in the upper lung zones , and kerley B lines. , sever condition => alveoli fill with fluid ->
perihilar distribution.

noncardiogenic pulmonary edema

- Lung water increase due to damage of the pulmonary capillary lining with leakage of proteins
and other macromolecules into the tissue
- Cause : dysfunction of the surfactant lining the alveoli to callapse at low lung volumes
- Categorize the cause : injury to the lung { direct( truma) , indirect( mediators reach the lung via
blood stream ) , or pulmonary vascular causes(acute changes in pulmonary vascular pressure }

diagnostic differential

Chest x ray : cardiogenic pulmonary edema > enlarged cardiac silhouette , vascular
redistribution , interstitial thinkening, and prehilar alveolar infiltrate, pleural effusions are
common., chest x ray for non card : size of heart normal , alveolar infiltrate are distributed more
uniformly throughout the lungs, and pleural effusions are uncommon,