Case 28 - 58 yo with shortness of breath

Question 1

Paroxysmal nocturnal dyspnea

Answer 1

Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing. It is most closely associated with congestive heart failure, relieved by sitting up (not just orthopnea because doesn’t occur immediately on lying down)

Question 2

Orthopnea

Answer 2

dyspnea that occurs while lying flat, relieved by sitting up, often people sleep with multiple pillows

Question 3

COPD definition

Answer 3

obstructive lung disease that encompasses both chronic bronchitis and emphysema

Question 4

COPD etiology

Answer 4

assoc with long term smoking or air pollution, also can be caused by alpha-1 antirypsin defiency (seen in younger people with COPD)

Question 5

COPD diagnosis

Answer 5

adults with dyspnea, chronic cough and history of tobacco use, must do spirometry before and after bronchodilator, COPD is NON-REVERSIBLE with bronchodilator (unlike asthma), will see FEV1/FVC ratio <70% predicted

Question 6

Differences between COPD and asthma

Answer 6

COPD - onset in mid life, hx of smoking, air flow limitation is irreversible, mechanism is inflammatory and destructive
Asthma - onset early in life, sx vary day to day, related to rhinitis, allergy or eczema, FVC always decreased

Question 7

Complications of COPD

Answer 7

• COPD exacerbation - change in baseline dyspnea, cough and/or sputum
• heart failure - chronic hypoxia causes pulmonary vasoconstriction which increased blood pressure in pulmonary vessels - right heart eventually fails

Question 8

Differential diagnosis of dyspnea

Answer 8

1. Asthma
2. Bronchitis - chronic vs acute
3. Congestive heart failure (CHF) - paroxysmal nocturnal dyspnea, orthopnea
4. Chronic obstructive pulmonary disease (COPD) - dispnea on exertion, develops slowly over years, almost always assoc with smoking
5. Lung cancer
6. Pneumonia
   Less likely: angina, pulmonary emboli, panic disordrr

Question 9

Physical exam for dyspnea

Answer 9

• COPD see increased AP diameter of the chest, decreased diaphragmatic excursion, end-expiratory wheezing, prolonged expiratory phase, shorter largyngeal height
• CHF - inspiratory crackles or dullness to percussion, s3 heart sound, diffuse and laterally displaced PMI, edema, JVD, hepatojugular reflex

Question 10

Inhaler instructions

Answer 10

• shake inhaler
• place spacer over mouthpiece
• place lips and teeth over spacer and breathe in slowly while squeezing top of canister, continue breathing after the squeeze
• after inhaling, remove spacer from mouth and hold breath for 10 seconds

Question 11

Diagnosis of COPD

Answer 11

PFTs gold standard
- FEV1/FVC is less than 70% predicted for COPD
Mild COPD is <30% predicted FEV1

Question 12

Tests for dyspnea

Answer 12

PFTs
Chest x-ray - recommended to obtain at first presentation, in COPD might see hyperinflation, hyperlucency of lungs, rapid tapering of vascular markings

Question 13

Management of COPD

Answer 13

• hospitalization for more intensive treatment than at home
• bronchodilators (albuterol, anticholinergic - ipratropium) for exacerbations
• Inhaled glucocorticoids - for patients with FEV1 <50% and repeated exacerbations
• Systemic glucocorticoids - may be useful during acute exacerbations
• smoking cessation

Question 14

5As of smoking cessation

Answer 14

Ask if they have thought about it
Advise to quit
Assess willingness
Assist with rx
Arrange for follow-up

Question 15

Immunizations in COPD

Answer 15

influenza vaccine annually in adults 50 and older
pneumococcal polysaccharide vaccine in those 65 and older or under 65 with FEV1 <40% predicted
Rdap

Question 16

Treatment of COPD exacerbation

Answer 16

• inhaled bronchodilator
• antibiotics if increased sputum purulence or sputum volume
• noninvasive ventilation in exacerbations
• education about exacerbations