Dyspnea

Dyspnea or breathlessness is
defined as the feeling of an
uncomfortable need to breathe
 Pathophysiology:

• Airflow obstruction (asthma; chronic

obstructive pulmonary disease [COPD])
• Changes in pulmonary compliance (interstitial
fibrosis, congestive heart failure)
• Changes in chest wall compliance (obesity,
pleural disease)
• Intrinsic respiratory muscle weakness
( neuromuscular disease, chronic respiratory
failure)
• Weakness conveyed by the mechanical
disadvantage of hyperinflation (asthma or
emphysema)
 Pathophysiology
• Acute hypercapnia (↑CO2) is therefore a
potent stimulus to dyspnea, while
hypoxemia(↓O2) is usually a weak one

• Stimulation of irritant receptors in the

airways intensifies dyspnea, while stimulation
of pulmonary stretch receptors decreases it
 Causes of Dyspnea
• Acute dyspnea at rest
• Asthma
• Pulmonary infection
• pulmonary edema
• Pneumothorax
• Pulmonary embolus
• Metabolic acidosis, or acute respiratory distress syndrome (ARDS)
• Panic attacks
• Orthopnea (dyspnea on recumbency) and nocturnal dyspnea
suggests asthma, gastroesophageal reflux disease (GERD), left
ventricular dysfunction, or obstructive sleep apnea
• Foreign body inhalation and epiglottitis in children
 Chronic Dyspnea

• Progressive
• Symptoms appear during exertion
• Patients limit their activity
• Episodic dyspnea suggests congestive heart
failure, asthma, acute or chronic bronchitis, or
recurrent pulmonary emboli
• Constant dyspnea is most commonly due to
COPD but may indicate interstitial lung disease
(eg, pulmonary fibrosis), pulmonary vascular
disease, or fixed airflow obstruction from severe
asthma
 Chronic Exertional Dyspnea

• COPD:
Varies little day to day
Exercise capacity falls steadily
Relief of dyspnea at rest and overnight
Orthopnea +
Exacerbations in winter
Smoking history likely
• Heart Disease
Impaired left ventricular function can cause
exertional dyspnea
Cough, wheeze and orthopnea may be present
History of angina or hypertension +
Raised JVP, displaced cardiac apex, murmers +
Cardiomegaly on x-ray
Arterial blood gasses
• Asthma
Associated with episodes of wheeze and chest tightness
Worse in the morning, may wake the patient overnight
History of childhood wheeze
History of Rhinitis provoked by pollens, dusts, pets or
occupational allergens
Exercise induced asthma provoked by exercise
• Interstitial or alveolar diseases of the
lung
Dyspnea is relentless and progressive
Chest X-ray shows intertitial shadowing
Pulmonary function tests
Arterial blood gasses
• Pulmonary Thromboembolism

Acute breathlessness with or without chest

pain
May present with gradual onset
Leg swelling or ↑ JVP +
• Psychogenic Breathlessness or
Hyperventilation Syndrome
Inability to take a deep breath
Frequent sighing/erratic ventilation at rest
Short breath-holding time in the absence of
respiratory disease
Normal O2, ↓CO2 and alkalosis
Difficulty in performing/inconsistent spirometery
manoeuvres
Associated digital paraesthesias
 Assessment
• Level of conciousness
• Degree of central cyanosis
• Evidence of anaphylaxis
• Patency of upper airway
• Ability to speak
• Cardiovascular status (heart rate, rhythm, BP)
• Pulmonary edema
• Presence of wheeze or prolonged expiration
• Pneumothorax
• Pulmonary embolus
• Edema
• ABGs, Chest X-ray, ECG
 Treatment
• Oxygen improves survival in those who are
hypoxemic and can improve the exercise
tolerance of all patients
• Anxiety can be relieved by judicious use of
benzodiazepines such as lorazepam, 0.5–1 mg
orally every 6–8 hours
• Pulmonary rehabilitation can improve respiratory
function and train patients in energy
conservation and breathing techniques that help
moderate their sense of respiratory effort
• Fresh air or a fan may offer additional
relief
• Smokers with progressive exertional
dyspnea should know that they can limit
future loss of function through smoking
cessation
• Urgent endotracheal intubation
 Cough
Cough is an important physiologic
mechanism that defends against
respiratory pathogens and helps
clear the tracheo-bronchial tree of
mucus, foreign particles, and noxious
aerosols
 Clinical Findings

• Acute Cough (< 3 weeks)

• Subacute Cough (3–8 weeks)
• Chronic Cough(> 8 weeks)
 Acute cough

• Commonly follows viral or bacterial upper respiratory tract

infection
• Within 2 days after onset of the common cold, 85% of
untreated patients cough; 25% are still coughing 14 days
later; in a few, cough will persist for 6–8 weeks
• Many patients with persistent cough following upper
respiratory tract infection have underlying asthma
• Other causes of acute cough include aspiration,
pneumonia, pulmonary embolism, and pulmonary edema.
 Chronic cough
• Most common cause is a low-grade chronic
bronchitis secondary to exposure to tobacco
smoke
• Over 90% of nonsmokers presenting for
evaluation of chronic cough suffer from postnasal
drip, GERD, or asthma (even without other
symptoms)
• Angiotensin-converting enzyme (ACE) inhibitors
have become another common cause
 Clinical Assessment

• The history and physical examination

• A nasal discharge, frequent need to clear
the throat, and mucoid or mucopurulent
secretions in the posterior pharynx
suggest postnasal drip
• Sinus radiographs may be diagnostic of
acute or chronic sinusitis
• Wheezing on chest auscultation or airflow
obstruction on pulmonary function tests
suggests asthma
• GERD has fewest clinical clues; cough, in
the absence of heartburn, may be the only
symptom. Esophageal pH monitoring may
be necessary for diagnosis
• Chest radiographs for evaluation in
smokers and patients with hemoptysis or
symptoms such as fever and weight loss
 Treatment
• Eliminate irritant exposures such as tobacco
smoke (primary or secondary) and
occupational agents
• Discontinue medications such as ACE
inhibitors or β-blockers, including eyedrops.
Cough due to ACE inhibitors should subside
within 1–4 days after discontinuing the
medication
• Postnasal drip syndrome due to allergic
rhinitis that does not respond to
antihistamines should be treated with
intranasal corticosteroids
 Treatment
• Chronic sinusitis may require prolonged antibiotics
directed against Haemophilus influenzae
• Cough due to GERD require proton pump inhibitors
since H2 blockers may be inadequate
• Patients whose cough began after an upper
respiratory tract infection usually respond to
treatment with an antihistamine-decongestant
combination or treatment for asthma.
 Expectoration
Bloody sputum
Blood streaked sputum caused by inflammation in the nose,
nasopharynx, gums, larynx or bronchi

• Pink sputum results from blood mixed with secretions in alveoli,

or smaller bronchioles.e.g. pulmonary edema or pneumonia

• Massive bleeding due to erosion of a bronchial artery by

cavitary pulmonary tuberculosis, aspergilloma, lung abcess,
bronchiectasis, pulmonary infarction, pulmonary embolism,
bronchogenic CA, or bronchiolith

• Frank bleeding can occur from lungs in mitral stenosis

 Bloody Gelatinous sputum or Current
Jelly sputum
• Copious, tenacious and pathognomonic for pneumonia
caused by Klebsiella pneumoniae or Streptococcus
pneumoniae

Rusty sputum Prune juice sputum

• Purulent sputum containing changed blood pigment. Typical
of pneumococcal pneumonia

Stringy Mucoid sputum

• Occurs in asthma; retained mucous is mobilized during
resolution from an acute attack
 Frothy sputum
• Occurs in pulmonary edema.
• It is a thin secretion containing air bubbles and mucous
• Left ventricular failure and acute lung injury produces this
sign

Purulent sputum
• Colour may be yellow, green or dirty grey
• Small amount of expectorate is present in acute bronchitis,
resolving pneumonia, small T.B cavity or lung abscess
• Copious amounts are present in lung abcesses,
bronchiectasis, bronchopleural fistula communicating with
empyema
• Fetid sputum shows anaerobic infection/ lung abscess
 Hemoptysis

Hemoptysis is the expectoration of blood

that originates below the vocal cords
• The lungs are supplied with a dual circulation

• The pulmonary arteries arise from the right ventricle to

supply the pulmonary parenchyma in a low-pressure circuit

• The bronchial arteries arise from the aorta or intercostal

arteries and carry blood under systemic pressure to the
airways, blood vessels, hila, and visceral pleura

• The bronchial arterial circulation is a high-pressure circuit

that provides the blood supply to the airways and lesions
within those airways

• Bronchial circulation represents only 1–2% of total

pulmonary blood flow, it can increase dramatically under
conditions of chronic inflammation—eg, chronic
bronchiectasis—and is frequently the source of hemoptysis.
 Causes of Hemoptysis
• Airways: In chronic bronchitis, bronchiectasis, and
bronchogenic carcinoma

• Pulmonary vasculature: In left ventricular failure, mitral

stenosis, pulmonary emboli, and arteriovenous
malformations

• Pulmonary parenchyma: In pneumonia, inhalation of

crack cocaine, or autoimmune diseases such as
Goodpasture's disease or Wegener's granulomatosis

• Iatrogenic hemorrhage: Transbronchial lung biopsies,

anticoagulation, or pulmonary artery rupture due to distal
placement of a balloon-tipped catheter.
 Clinical Features
• Bronchial carcinoma: repeated small hemoptysis and
blood streaking of sputum, finger clubbing, signs of malignancy

• Tuberculosis: fever, night sweats,weight loss

• Pneumonias: rusty or purulent sputum,±abcess, fever, signs

of consolidation,

• Bronchiectasis: finger clubbing, Bronchial hemorrhage

• Pulmonary embolism: pleurisy, DVT signs

 Investigations
• Chest radiograph: Pneumonia, TB, Bronchial CA, Pulmonary
infarction

• Complete blood count, platelet count and coagulation studies

• Flexible bronchoscopy reveals endobronchial cancer in 3–6% of

patients with hemoptysis who have a normal chest radiograph

• High-resolution CT of the chest is complementary to bronchoscopy,

Unsuspected bronchiectasis and arteriovenous malformations and
central endobronchial lesions. Test of choice for suspected small
peripheral malignancies

• Ventilation/Perfusion lung scan: pulmonary thromboembolism

 Management
• Identifying and treating the specific cause
• Massive hemoptysis is life-threatening
• Airway must be protected, ventilation ensured, and
effective circulation maintained
• If the location of the bleeding site is known, the patient
should be placed in the decubitus position with the
involved lung dependent
• In stable patients, flexible bronchoscopy may localize the
site of bleeding, and angiography can embolize the
involved bronchial arteries
• Uncontrollable hemorrhage warrants rigid bronchoscopy
and surgical consultation