Shortness of Breath Flashcards

1
Q

List some broad mechanisms that can lead to shortness of breath. Give an example of a disease that falls under each of these mechanisms.

A

Insufficient oxygen entering the lungs – COPD
Insufficient oxygen entering the blood - emphysema
Insufficient oxygen reaching the tissues - anaemia
Increased respiratory drive - acidaemia

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2
Q

Which diseases can cause an inability to fully inflate the lungs?

A

Increased work – due to obesity and stiffness due to interstitial lung disease
Weak respiratory muscles – Guillain-Barre syndrome, myasthenia gravis
Hyperinflated lungs – COPD

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3
Q

Which diseases can cause insufficient oxygen to be delivered across the body?

A

Anaemia
Reduced cardiac output (e.g. heart failure, aortic stenosis)
Shock (e.g. sepsis, hypovolaemia)

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4
Q

What are two important features of the history of presenting complaint of a patient presenting with shortness of breath?

A

Time of onset

Alleviating/exacerbating factors

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5
Q

When does asthma tend to get worse?

A

At night
On exercise
On exposure to triggers (e.g. the cold)

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6
Q

List some important risk factors that are associated with various causes of shortness of breath.

A
Smoking 
Pets 
Occupational history 
Medications 
Past medical history
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7
Q

Which occupational disease is associated with chronic dust inhalation?

A

Pneumoconiosis

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8
Q

List some drugs that are associated with interstitial lung disease.

A

Methotrexate
Amiodarone
Nitrofurantoin

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9
Q

List some autoimmune diseases that are associated with interstitial lung disease.

A

Rheumatoid arthritis
Sarcoidosis
SLE

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10
Q

List some important associated symptoms that you should enquire about in a patient presenting with shortness of breath.

A
Cough (and haemoptysis)
Chest pain 
Muscular weakness or fatigue 
Tender limbs 
Weight loss, loss of appetite, night sweats 
Fever 
Loss of blood
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11
Q

Describe the pattern of cough in:
Pneumonia
Chronic bronchitis
Asthma

A
  • Pneumonia
    3-4 day history of persistent, productive cough
  • Chronic bronchitis
    Persistent, productive cough on most days of the past 3 months and spanning years
  • Asthma
    Dry cough present mainly during episodes of shortness of breath or at night
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12
Q

List some causes of blood-stained sputum.

A

Cavitating pneumonia
PE
Lung cancer
Bronchiectasis

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13
Q

List some diseases that cause pleuritic chest pain and shortness of breath.

A

Pneumonia
PE
Pneumothorax

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14
Q

Which differentials would you consider if a patient complains of shortness of breath and muscle weakness/fatigue?

A
Myasthenia gravis 
Lambert-Eaton syndrome 
Motor neurone disease 
Guillain-Barre syndrome 
Polymyositis
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15
Q

Why is it important to ask about loss of blood (e.g. GI, menstrual)?

A

Chronic blood loss can lead to anaemia which, in turn, leads to breathlessness

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16
Q

List some differentials for sudden-onset (seconds to minutes) shortness of breath.

A
Bronchospasm (e.g. acute asthma)
Anaphylaxis 
Laryngeal oedema 
PE 
Pneumothorax 
Foreign body
Hysterical hyperventilation
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17
Q

List some differentials for shortness of breath that occurs over hours/days.

A
Pneumonia 
Heart failure 
Pleural effusion 
ARDS
Post-operative atelectasis
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18
Q

List some differentials for gradual-onset (weeks to months) shortness of breath.

A
COPD 
Chronic asthma 
Heart failure 
Pulmonary fibrosis 
Anaemia
Bronchiectasis
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19
Q

Which inherited condition can cause emphysema and liver disease?

A

a1-antitrypsin deficiency

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20
Q

List some signs of COPD on physical examination.

A
Chest wall deformity (e.g. barrel chest)
Breathing through pursed lips 
Use of accessory muscles 
Reduced chest expansion 
Prolonged expiratory phase
21
Q

Which atopic conditions might a patient with asthma also suffer from?

A

Hay fever
Eczema
Allergies
Nasal polyps

22
Q

List some drugs that exacerbate the symptoms of asthma.

A

NSAIDs
Beta-blockers
Aspirin

23
Q

List some signs of interstitial lung disease on physical examination.

A

Clubbing
Reduced chest expansion
Late inspiratory fine crackles

24
Q

List some presenting symptoms of heart failure.

A

SOBOE
Orthopnoea (=SOB when lying flat)
Paroxysmal nocturnal dyspnea
Swollen ankles

25
Q

List some signs of heart failure on physical examination.

A
Displaces apex beat 
S3 and S4 heart sounds 
Bibasal crackles 
Raised JVP
Hepatomegaly
Peripheral oedema
26
Q

List some signs of anaemia on physical examination.

A
Cyanosis
Koilonychia (if severe iron deficiency)
Glossitis 
Angular stomatitis 
Conunctival pallor
27
Q

List some blood tests that would be performed when investigating a patient with possible heart failure.

A

FBC – check for anaemia
Cholesterol, glucose, HbA1c – major risk factors for heart failure
TFTs – hyperthyroidism can cause high-output cardiac failure
U&Es – baseline electrolyte levels are important, especially if diuretics are being used
BNP – released when ventricular cells are excessively stretched (low specificity for heart failure)

28
Q

List the features of heart failure seen on CXR.

A
Alveolar shadowing 
Kerley B lines 
Cardiomegaly
Upper lobe diversion
Pleural effusion
29
Q

Which features of an ECG might indicate that the patient has previously suffered an MI?

A

Pathological Q waves

Bundle branch block

30
Q

State two investigations that you would perform to investigate a respiratory cause of shortness of breath.

A

Peak expiratory flow rate

Spirometry

31
Q

Explain why heart failure causes orthopnoea.

A

Lying down leads to increased venous return to a failing heart
This leads to congestion in the pulmonary vasculature, forcing more fluid into the alveoli
This leads to breathlessness

32
Q

Explain why heart failure causes bibasal crackles.

A

The increase in fluid in the lungs dilutes surfactant meaning that it is less able to keep the alveoli open
Alveoli collapse
Breathing in deeply makes these alveoli pop open causing the crackling sound

33
Q

Describe how acute pulmonary oedema caused by heart failure is managed.

A

Sit up
Oxygen
Venodilators (e.g. diamorphine, furosemide, GTN)

34
Q

Which drugs are used in the management of chronic pulmonary oedema?

A

Furosemide (loop diuretic)

Spironolactone (aldosterone receptor antagonist)

35
Q

Which two physiological systems are activated in heart failure and have the potential to worsen the situation?

A

Sympathetic system

Renin-Angiotensin system

36
Q

Describe the medical measures taken to combat these two systems.

A

Sympathetic system –> beta-blockers

Renin-angiotensin system –> ACE inhibitors + ARBs

37
Q

What is the most common cause of heart failure?

A

Coronary artery atherosclerosis

38
Q

List some causes of post-operative breathlessness.

A
Post-operative atelectasis 
Pneumonia
Pulmonary oedema
PE
Anaemia
Pneumothorax
39
Q

Describe the typical presentation of asthma.

A

Intermittent episodes of reversible SOB
Worse in the evenings and when exercising
Associated with a dry cough
Family/personal history of atopic disease

40
Q

Outline the management of asthma.

A

Avoid triggers
Bronchodilation
Reduce immune response in the lungs

41
Q

List some agents used as bronchodilators in asthma.

A

Beta-2 agonists (e.g. salbutamol)
Anti-muscarinics (e.g. ipratropium bromide)
Phosphodiesterase inhibitors (e.g. aminophylline)

42
Q

Outline the management of COPD.

A

Stop smoking
Inhaled therapy (Beta-2 agonists and steroids)
Pulmonary rehabilitation (physiotherapy, exercise etc.)
Vaccination
Non-invasive ventilation
Long-term oxygen use
Manage exacerbations

43
Q

Define type II respiratory failure.

A

PaO2 < 8 kPa

PaCO2 > 6.5 kPa

44
Q

What is the difference between type I and type II respiratory failure?

A

T1 = a low level of oxygen in the blood (hypoxemia) without an increased level of carbon dioxide in the blood (hypercapnia), and indeed the PaCO2 may be normal or low
T2 = Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa)
essentially: T1 = failure of oxygenation, T2 = failure of ventilation

45
Q

Outline the management of type II respiratory failure.

A
Controlled oxygen therapy (maintain oxygen sats 88-92%)
Improve ventilation (if CO2 fails to drop with oxygen therapy)
Treat underlying cause
46
Q

Describe the typical presentation of Pneumocystic jiroveci pneumonia.

A

Dry cough, SOB, desaturation on exercise, diffuse interstitial shadowing on CXR
NOTE: tends to be in young patients from Africa

47
Q

Which tests should you perform if Pneumocystic jiroveci pneumonia is suspected?

A

HIV

TB

48
Q

List some causes of interstitial lung disease.

A

Congenital – neurofibromatosis, Gaucher disease
Systemic inflammatory disease – rheumatoid arthritis, ankylosing spondylitis, sarcoidosis
Chemicals – asbestos, silica
Drugs – methotrexate, amiodarone, nitrofurantoin
Hypersensitivity – Bird-fancier’s lung
Radiation
Idiopathic

49
Q

What are Reed-Sternberg cells?

A

Binucleate lymphocytes – associated with Hodgkin’s lymphoma