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Karan - MBBS Year 1: Respiratory Week 2 > Cases from General Practice - Breathlessness > Flashcards

Cases from General Practice - Breathlessness Flashcards

1
Q

When assessing a patient with shortness of breath, what two types of causes should be considered?

A
  • RESPIRATORY
  • NON-RESPIRATORY
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2
Q

What parts of the brain are involved in breathlessness?

A
  • Anterior insula, anterior cingulate gyrus and prefrontal cortex involved
  • Same areas that feel pain
  • Fear and anxiety exacerbate breathlessness
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3
Q

Define dyspnoea.

A
  • Labored breathing
  • Subject conscious of shortness of breath
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4
Q

What characteristics are indicative of breathlessness?

A
  • Sensation of ‘air hunger’
  • Difficulty in inspiration and expiration
  • Feeling chest is filled up
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5
Q

What causes breathlessness?

A
  • Hypoxia / high CO2
  • Airway obstruction
  • Decreased lung compliance
  • Acute right heart strain
  • Chest wall stiffness
  • Acidosis
  • Anaemia
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6
Q

What are the respiratory causes of sob?

A
  • Asthma
  • COPD
  • Pneumonia
  • Pneumothorax
  • Lung cancer
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7
Q

What are the non-respiratory causes of SOB?

A
  • Hypovolaemic/cardiac/septic shock
  • Anaemia
  • Pulmonary oedema
  • MSK/neurological conditions
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8
Q

How does hypoxia influence breathlessness?

A
  • Increases respiration and sensation of breathlessness
  • Present in patient with pneumonia with low PO2
  • Sensation not increased by hypoxia following chest wall paralysis
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9
Q

What is the effects of increased PCO2 on breathlessness?

A
  • Feeling of air hunger and increases respiration
  • Effects on chemosensitive areas of brainstem
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10
Q

What are the effects of airway obstruction?

A
  • Breathing against resistance sensed by individual
  • Increased input from chest wall muscles and stretch receptors
  • Increase in brain activity
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11
Q

Describe hyperinflation.

A
  • Within airway narrowing and collapse, air trapping and increase in residual volume
  • Sensation increases during exercise
  • Activates pulmonary stretch receptors
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12
Q

Describe sensation from the chest wall.

A
  • Muscle spindle afferents transmit signals reflecting strength of contraction and length of muscle
  • Paralysis or vibration over chest wall reduces inputs send to brain
  • Common when residual volume increased/inflation
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13
Q

Describe what occurs in decreased lung compliance.

A
  • Local congestion activates J receptors in bronchial wall (exception - in transplants)
  • Harder for lungs to expand when full of fluid or inflamed
  • More energy required to expand chest wall
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14
Q

Describe J receptors.

A
  • Situated next to capillaries in bronchial wall
  • Input to brainstem via vagus
  • Activated by congestion, oedema and irritants
  • Activation shortens expiration, increases respiration frequency
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15
Q

Describe acute right heart strain.

A
  • Occurs when pulmonary artery occluded even if hypoxia is mild e.g during pulmonary emboli
  • Rise in arterial pressure due to right heart failure causes pulmonary vasoconstriction. Symptoms worsen
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16
Q

Describe the role of the chest wall and muscles in breathlessness

A
  • Increased load or effort by the chest wall means increased breathlessness
  • Hyperinflation - muscle contraction less efficient. Increased breathlessness
  • Ventilation reduced in chest stiffness/weakened breathing muscles
17
Q

Describe acidosis.

A
  • During metabolic acidosis, increase in respiration and therefore air hunger
18
Q

Describe dysfunctional breathing.

A
  • During hyperventilation, increased expiration of CO2. Produced alkalosis. Increased effort involved in breathing
  • Occurs during spasms of the larynx and reduced size of orifice during inspiration
19
Q

Describe the sensations of breathlessness.

A
  • Consciously sensed
  • Information received from chest wall and lungs
20
Q

Describe hyperventilation.

A
  • Breathless at rest and on exercise - excess ventilation with decrease in PCO2
  • Wide range of causative factors
21
Q

A patient has a rapid onset of breathlessness. What conditions could this indicate?

A
  • Airway obstruction
  • Anaphylaxis
  • Shock
  • Cardiac Arrythmias
  • Pulmonary emboli
22
Q

A patient has gradual onset of breathlessness developing from hours-days. What conditions could this indicate?

A
  • Community acquired pneumonia
  • Influenza
  • Silent MI, PE or bleeds
  • Spontaneous pneumothorax
  • Pulmonary oedema
23
Q

A patient has gradual onset of breathlessness developing from weeks-months. What conditions could this indicate?

A
  • Anaemia
  • Tumour
  • Valve disease
  • COPD
  • Heart failure
24
Q

What factors and signs often present with SOB and what do they indicate?

A
  • Stridor + SOB = Upper airway obstruction
  • Wheeze + SOB = Lower airway obstruction
  • Cough = Airway irritation
  • Sputum = Infection/inflammation
  • Fever = infective cause. Opposite for non-fever
25
Q

In stridor, what conditions could the different speeds of onset and symptoms indicate?

A
  • Gradual onset + no fever = tumour
  • Vary rapid onset + no fever = Aspiration, anaphylaxis
  • Rapid- onset + fever = Epiglottitis, croup
26
Q

In wheeze, what conditions could the different speeds of onset and symptoms indicate?

A
  • Gradual onset + no fever + night sweats + smoker + monophonic = Tumour
  • Very rapid onset + no fever + urticaria = Anaphylaxis
  • Rapid onset + no fever + no urticaria = Acute asthma
  • Gradual onset + no fever + smoker + polyphonic = COPD
27
Q

What should assessments of patients with acute-on-chronic SOB aim to establish?

A
  • Whether cause is exacerbation of pre-existing condition
  • Whether cause is new condition in same body/arising elsewhere
28
Q

What are the two key questions to ask in chronic illness?

A
  • Is this similar to your normal exacerbation of …?
  • If not, what is different this time?
29
Q

What should be beared in mind during the history of presenting complaint? PART 1

A
  • When were they normal
  • What did they first notice
  • What does it feel like
  • Is it at rest or exercise
  • Is there anything else they have noticed at the same time
  • How does it affect their day-to-day life?
30
Q

What should be beared in mind during the history of presenting complaint? PART 2

A
  • Do they smoke?
  • Are they on any treatment?
  • SYSTEMS REVIEW - any fever, weight loss, sputum or night sweats
31
Q

What should be established ina physical examination of a patient with SOB? PART 1

A
  • How fast are they breathing?
  • Are there any difficulties moving around the room?
  • Are they struggling to breath?
  • Any cyanosis or paling?
  • Are there signs of chest inflation?
32
Q

What should be established ina physical examination of a patient with SOB? PART 2

A
  • How many words are they saying per breath?
  • Does breathing ease when they relax?
  • Is breathing noisy or labored?
33
Q

What are some examination findings that would be red flags?

A
  • Difficulty moving chest and reduced expansion
  • Dull percussion
  • Crackled breathing
  • Labored breathing
  • No air entry could mean air trapping or solid lung
34
Q

What tests could be done to measure extent of breathlessness?

A
  • Measure respiratory rate and oxygen saturation
  • Ask them to stand and sit and measure how long it takes
  • Breathless score text - MMRC system (measure before and after interventions)

Karan - MBBS Year 1: Respiratory Week 2 (10 decks)

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