Approach to Dyspneu

Stephanie Wirjomartani
40138166

Description
Dyspnea derives from Greek for
hard breathing. It is often also
described as shortness of
breathing.
This is subjective sensation of
breathing, from mild discomfort to
feelings of suffocation.

Management
1. Airways Breathing Circulation (ABC)
2. Create a stability of these aspects of
the patients vitals
3. Proceed to history and physical part
of the assessment

During assessment, one can initiate management

based on initial assessment :
1. Place all patients on supplemental oxygen, pulse
oximetry, and cardiac monitor
2. Initiate therapy for suspected cause of dyspnea
such as :
Asthma/COPD nebulized bronchodilators and I.V.
streoids
Congestive heart failure diuresis, morphine, nitrates,
sit upright
*Intubate patiens if impending respiratory failure

Etiology
Etiology for dyspnea arising from 5
main categories :
Respiratory
Cardiac
Neuromuscular
Psychogenic
Systemic causes

History
Onset
Very sudden onset : minutes, usually life
threatening conditions (such as those with an * in
the above table)
Acute : hours (pneumonia, CHF with pulmonary
edema, ACS, pericardial disease, valvular heart
disease, ARF, acidosis, thyrotoxicosis, and cirrhosis)
Subacute : days/weeks (pneumonia, TB, CHF,
pericardial disease, and anemia)
Chronic : reccurent/months (COPD, CHF,
Neuromuscular problems, pulmonary hypertension,
anemia, and asthma)

Ask about the following associated

symptoms :
Stridor
Cough (sputum
production and
color)
Fever and chills
Sweats
Lethargy
Chest pain
Wheeze
Chest tightness

Hemoptysis
Hoarseness
Edema
Weight loss/gain
Orthopnea
PND
Anxiety
Confusion
Lightheadedness

Positionally
Orthopnoea (CHF, asthma, COPD, inflammatory
and degenerative neurological diseases, gastrooesophageal reflux, pericardial, and bilateral
diaphragmatic paralysis
Platypnoea : worsening dyspnea on an upright
position, with alleviation on supine (patent
foramen ovale, abdominal muscle deficiency, or
status post-penumonectomy)
Trepopnoea : present only in lateral decubitus
position (CHF)

Drug history
Medications which induce metabolic
acidosis (topiramate), induce
bradycardia and chronotropic
insufficiency (digoxin, CCB, betablockers). Beta blockers may worsen
airway obstruction in COPD and asthma

Physical Examination
Tachycardia, tachypnea, fever and hypertension
Weight increase may signal worsening CHF
Contractions of the accessory muscles of respiration
suggest severe difficulty
Retraction of the supraclavicular fossa implies tracheal
stenosis
Pursed-lips breathing and prolonged expiratory phase
are signs outflow obstruction
Retraction of intercostal muscles on inspiration is
characteristic of emphysema
Percuss for dullness and hyperresonance
Auscultate for wheezes, and quality of breath sounds

 Crackles suggest fluid in the airway, as occurs with

bronchitis, pneumonitis and CHF
Normal findings on lung examination do not rule out
pulmonary pathology but do lessen its probability and
the likelihood that it is severe
The cardiac examination should focus on signs of leftsided heart failure, detection of left-sided murmurs, and
signs of pulmonary hypertension and its consequences
(accentuated and delayed P2, RV heave, RV S3, rightsided systolic regurgitant murmur of TR, increased JVP,
and peripheral edema)
Examine the abdomen for ascites and hepatojugular
reflux well as the legs for edema

Workup
Standard workup for dyspnea :
CXR
ECG assess ACS
ABG calculate A-a gradient and assess
acidosis
CBC assess anemia and WBC for
infectious processes
Electrolytes, BUN, Creatinine, Blood
Glucose assess metabolic derangements

References
http://bestpractice.bmj.com/best-prac
tice/monograph/862/diagnosis.html
http://unmfm.pbworks.com/f/approac
h%20to%20dyspnea.pdf
(Clinical Clerk Seminar Series)