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303 - Medicine > Dyspnoea > Flashcards

Dyspnoea Flashcards

1
Q

Dyspnoea

A
  • The subjective sensation of breathlessness which is excessive for a given level of activity
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2
Q

History in patient with SOB - Severity

A
  • Quantify the severity by exercise capacity(e.g. distance walked on the flat or on hills, while dressing or climbing stairs) Has this changed in recent times? Does it affect daily activities?
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3
Q

What does acute onset of dyspnoea indicate

A
  • Acute onset may indicate a sudden new change such as aspiration of a foreign body, pneumothorax, PE, acute asthma or acute pulmonary oedema
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4
Q

What does subacute onset of dyspnoea indicate

A
  • More suggestive of parenchyma disease, pleural effusion and carcinoma of the bronchus or trachea
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5
Q

What does chronic onset of dyspnoea and progressive indicate

A
  • Associated with COPD
  • Interstitial lung disease
  • Non-respiratory causes such as progressive heart failure
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6
Q

Dyspnoea - precipitating factors

A
  • Exercise increases demand for O2 and as such, many pulmonary and cardiac causes of dyspnoea are aggravated by exercise.
  • Cold and airborne material (such as pollen) can irritate the airways and cause dyspnoea in the context of asthma.
  • Dyspnoea that improves at weekends or on holiday may imply a trigger factor at work
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7
Q

Dyspnoea aggravating factors

A
  • Position can affect dyspnoea; orthopnoea is the term used for shortness of breath on lying flat and often indicates underlying cardiac dysfunction
  • Paroxysmal nocturnal dyspnoea is breathlessness that wakes the patient from their sleep and, again, is generally a symptom of cardiac disease
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8
Q

Dyspnoea associated features

A
  • Cough
  • Sputum production
  • Haemoptysis
  • Stridor
  • Wheeze
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9
Q

What is stridor

A
  • A harsh sound caused by turbulent airflow through a narrowed airway.
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10
Q

Inspiratory stridor indication

A
  • Upper airway obstruction and may indicate impending aitway compromise
  • Laryngeal obstruction
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11
Q

Inspiratory + expiratory stridor indication

A
  • Fixed obstruction in upper airway

- Subglottic or glottic anomaly

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12
Q

Wheeze

A
  • A wheeze is a whistling noise in expiration caused by turbulent airflow through narrowed intrathoracic airways
  • Caused by lower airway narrowing
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13
Q

Most common causes of wheeze

A
  • Asthma

- COPD

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14
Q

Relevance of occupational history in dyspnoea

A
  • Including exposure to asbestos and dusts.
  • Occupational lung disease is important as changing the working environment may improve symptoms or the patient may benefit from financial compensation
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15
Q

Medications that provoke obstructive lung disease –> dyspnoea

A

Adenosine
Beta Blockers
NSAIDs or Aspirin

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16
Q

Medications that can cause pneumonitis or interstitial lung diseases

A 
Amiodarone
Bleomycin
Chlorambucil
Cyclophosphamide
Melphalan
Methotrexate
Nitrofurantoin
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17
Q

Pleural effusion - trachea position

A
  • Central or deviated away from effusion if massive
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18
Q

Conditions in which percussion is dull

A
  • Pleural effusion
  • Pneumonia
  • Pulmonary fibrosis
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19
Q

Conditions in which there is hyper-resonance

A
  • Pneumothorax
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20
Q

Pneumothorax - trachea position

A
  • Central or deviated away
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21
Q

Pneumonia - trachea position

A
  • Central or deviated towards if associated with lobar collapse
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22
Q

Pulmonary fibrosis - position of trachea

A
  • Central or deviated towards if upper lobe involvement
23
Q

Conditions in which tactile vocal fremitus is reduced

A
  • Pleural effusion
  • Pneumothorax
  • Emphysema
24
Q

Conditions in which tactile vocal fremitus is increased

A
  • Pneumonia

- Pulmonary fibrosis

25
Q

Why is vocal fremitus reduced in pleural effusion, pneumothorax and emphysema.

A
  • Air is a poor conductor of low sound frequencies whereas a solid or dense medium increases the transmission of low sound frequencies
  • Vocal fremitus is decreased in bronchial asthma, emphysema, or bronchial obstruction due to air trapping and decreased density of lung parenchyma
  • In case of pleural effusion and pneumothorax, air/fluid accumulates in the potential space between the chest wall and lung parenchyma, decreasing the transmission of lower frequency sound vibrations.
  • Vocal fremitus also may be decreased in individuals with obesity.
26
Q

Why is vocal fremitus increased in pneumonia and pulmonary fibrosis

A
  • Inflammation and consolidation create a dense medium which increases the transmission of lower frequency sounds and vocal fremitus
27
Q

Pleural effusion breath sounds

A
  • Reduced with bronchial breathing at top of effusion
28
Q

Pneumothorax breath sounds

A
  • Reduced
29
Q

Pneumonia breath sounds

A
  • Increased vocal resonance
  • Bronchial breathing (absent if obstruction of bronchus)
  • Coarse crepitations
30
Q

What is bronchial breathing

A

Bronchial breath sounds are tubular, hollow sounds which are heard when auscultating over the large airways (e.g. second and third intercostal spaces).

They will be louder and higher-pitched than vesicular breath sounds.

For example, bronchial (loud & tubular) breath sounds are abnormal in peripheral areas where only vesicular (soft & rustling) sounds should be heard.

When bronchial sounds are heard in areas distant from where they normally occur, the patient may have consolidation (as occurs with pneumonia) or compression of the lung.

31
Q

Pulmonary fibrosis breath sounds

A
  • Fine crepitations

- End inspiratory crackles

32
Q

Respiratory causes of clubbing

A
  • Carcinoma of the bronchus; suppurative lung disease (e.g. empyema, lung abscess, bronchiectasis, cystic fibrosis); fibrosing alveolitis; chronic suppurative pulmonary tuberculosis; mesothelioma
33
Q

Why is there lip pursing in patients with severe obstructive airways disease

A
  • By pursing the lips, the patient can achieve positive end expiratory pressure (auto-PEEP) which will ease the work of breathing.
34
Q

What does barrel-shaped chest indicate

A
  • Emphysema
35
Q

Cardiac causes of acute dyspnoea

A

Severe pulmonary oedema.
Acute myocardial infarction.
Cardiac arrhythmia.
Pericarditis and pericardial effusion.

36
Q

Pulmonary causes of acute dyspnoea

A 
Pneumonia.
Pneumothorax.
Pulmonary embolism.
Asthma.
Acute exacerbation COPD.
Acute respiratory distress syndrome.
Large airway obstruction - eg, anaphylaxis, foreign body, lung cancer and epiglottitis.
37
Q

Non-cardio-resp related causes of acute dyspnoea

A 
Pain.
Diabetic ketoacidosis.
Drugs - eg, aspirin overdose.
Trauma - eg, to the larynx.
Hyperventilation and panic attack.
Thyrotoxicosis.
Altitude sickness.
38
Q

Cardiac causes of chronic dyspnoea

A

Left ventricular disease.
Heart valve disease (mitral and aortic stenosis).
Arrhythmias.
Pericardial disease

39
Q

Pulmonary causes of chronic dyspnoea

A 
Asthma.
COPD.
Lung fibrosis.
Pleural effusion.
Emphysema.
Lung cancer.
Bronchiectasis.
40
Q

Other causes of chronic dyspnoea

A 
Severe anaemia
Psychogenic - eg, anxiety.
Neuromuscular causes - eg, myasthenia gravis, Guillain-Barré syndrome.
Thromboembolic disease.
Thyroid disease.
Obesity
41
Q

Assessment of dyspnoea

A

modified Medical Research Council (MRC) dyspnoea score:

Grade 0: not troubled by breathlessness except on strenuous exertion.
Grade 1: short of breath when hurrying on level ground or walking up a slight incline.
Grade 2: walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
Grade 3: stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground.
Grade 4: too breathless to leave the house or breathless on dressing or undressing.

No single best assessment of dyspnoea

42
Q

Bedside investigations - dyspnoea

A

Lung function tests - eg, peak flow measurement, spirometry.

Pulse oximetry.

43
Q

Dyspnoea - bloods

A

Venous blood tests: FBC, brain natriuretic peptides (BNPs).
Arterial blood gases.
Blood glucose

44
Q

Imaging - dyspnoea

A
  • CXR
  • Echocardiogram.
  • High-resolution CT scan.
  • V/Q scan.
  • Radioallergosorbent test (RAST) measurement or skin prick testing to common aero-allergens.
45
Q

Purpose of spirometry in investigations

A

Distinguish between obstructive and restrictive lung pathology. This is best done for diagnosis when the patient is well. Lying and standing vital capacity will screen for diaphragm weakness.

46
Q

Purpose of bronchoscopy

A
  • If an endobronchial lesion is suspected
47
Q

Acute causes of stridor

A
  • Foreign body inhalation
  • Epiglottitis
  • Laryngotracheobronchitis(croup)
  • Laryngitis
  • Anaphylaxis
  • Neck space abscess
48
Q

Chronic causes of stridor

A
  • Laryngomalacia
  • Subglottic stenosis
  • Vocal cord paralysis
  • Subglottic haemangioma
  • Respiratory papillomatosis
  • Macroglossia or microgathia
  • Malignancy
49
Q

What does an expiratory stridor suggest

A
  • Suggests a tracheobronchial obstruction
50
Q

Stridor red flag signs

A
  • Stridor is a red flag sign
  • Potentially more concerning is when thevolume of the stridor sound decreases, as that can mean the patient is becoming tired and less air is being shifted by the lungs.
51
Q

Signs to investigate in stridor

A

• Important signs to assess for in all cases of stridor includetorticollisandtrismus, inability to swallow anddrooling,absence of a cough,cyanosis, evidence ofsystemic infection, orpoor responseto initial management

52
Q

Initial investigation for chronic or non-emergency cases of stridor

A
  • Fornon-emergency or chronic cases, visualisation of the upper airway will normally be done viafibreoptic nasal endoscopy* as a quick and minimally invasive means to differentiate where the pathology lies.
  • Further imaging studies, such as CT scanning, can be used in the case of abscess or malignancy, whilst bronchoscopy can be used it visualisation below the vocal cords is warranted, such as suspected subglottic stenosis
53
Q

When should airway examination be avoided

A
  • In cases of suspected epiglottitis or croup, as can predispose to sudden airway closure
54
Q

Acute management of stridor

A

For acute causes that requireurgent management, initial steps should involve:

  1. Stabilise the patient, starthigh-flow oxygen, andalert suitable senior specialists(ENT and / or anaesthetics)
  2. Try tosuction secretionsor clear any foreign body from airway if obvious or visible
  3. Giveadrenalineorsteroids(IV or inhaled), as necessary
  4. Takebloods, including an ABG or cultures if indicated
  5. In emergency situations, be prepared to perform or assist with an emergency cricothyroidotomy or intubation

303 - Medicine (10 decks)

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