DYSPNEA Assessment& Management-ANIS

7/31/2019 DYSPNEA Assessment& Management-ANIS

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Dyspnea


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Definition of dyspnea published byAmerican Thoracic Society (ATS):

Dyspnea, the subjective experience ofbreathing discomfort t, is the mostcommon that is comprised of qualitatively

distinct sensations that vary in intensity.


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The experience derives from

interactions among:-multiple physiological factor

-psychological

-social-environment

-may induce secondary physiological

& behavioral response


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Dyspnea - common complaint/symptom

shortness of breath or breathlessness

Defined as abnormal/uncomfortable

breathing

Multiple etiologies -

2/3 of cases - cardiac or pulmonaryetiology


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Standard of Care

1.Assessment

2. Diagnosis

3. Education

4. Treatment: Non-pharmacological

5. Treatment: Pharmacological

6. Crisis intervention


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Assessment of Dyspnea

Table 1:Dyspnea Assessment using Acronym O,P,Q,R,S,T,U and V


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Assessment: Physical examination


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Diagnosis

The most significant intervention in themanagement of dyspnea is identifying

underlying cause(s) & treating as appropiate. Whether or not the underlying cause(s) can be

relieved or treated, all patients will benefitfrom management of the symptom using

education, energy conservation and breathcontrol, airflow and medications.


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Clues to diagnosis:


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Education

Providing information & education isfoundational to enhance the patient &

familys ability to cope it: Explain to the patient & family about the

multiple triggers of dyspnea.

Reinforce that this is a symptom thatcan be managed.


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Develop the clear plan for the patient &

family to address the pattern ofShortness of Breath and the patientsway of coping.

Teach the purpose of each medication.Ensure an understanding of usingregular and breakthrough medications.

this is a key to effective management. Known COPD patient often use of

nebulizers & spacer. Ensure patients

compliance


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Treatment: Non-pharmacological

Energy conservation and breathcontrol

-Explain how to incorporate pacingand planning.

-Teach relaxation training and

breath control.

Air flow

-open window & air movement


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Environment

-Cool and humidify dry air, eliminate irritantsin air.

Positioning

-Avoid compression of abdomen or chestwhen positioning.

-Try placing in semi-Fowlers position.

Support

-Offer psychosocial support and/or counseling.

-Alternative therapies for relaxation include:massage, therapeutic touch, visualization, musictherapies.

-Acupuncture or acupressure.


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Treatment: Pharmacological

Opiods : 1st choice in palliation of dyspnea.

-Opioid naive protocol:

Consider hydromorphone in the elderly and if there isdecrease renal function.

Breakthrough of q4h dose (or 10% of TDD)ordered q1h p.r.n.

Morphine 2.5 to 5 mg PO q4h.Uselower dose in the elderly

Hydromorphone 0.5 to 1 mg PO q4h.Use lowerdose in the elderly.

Oxycodone 5mg PO. Titrate dose q4h.


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Oxygen

Canula2-4L

Non-rebreathing mask4-6L

Corticosteroids dexamethasone 8 to 24 mg PO or S.C.or I.V. dailydepending on

severity of dyspnea

Neuroleptics:adjuvant in chronicdyspnea

Methotrimeprazine 2.5 to 5 mg q8h andtitrate to effect.

Benzodiazepines:severe anxiety orrespiratory panicattacks

Lorazepam 0.5 to 2 mg SL q2-4hp.r.n.


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Crisis intervention

Treat aggressively with opioids as well assedatives until comfort is achieved.

Opioid naive use morphine 5 mg I.V. or S.C.bolus q5 to 10 min. Double dose if no effect everythree doses.

Opioid tolerant give full regular PO Q4h dose as

S.C. or I.V. q5 to 10 min (for I.V.) or q10 to 15min (for S.C.) If ineffective double dose as above.


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Use one of the following with opioid:midazolam 5 mg S.C. or I.V. q5 to15min. p.r.n., lorazepam 4 mg I.V. orS.C. q5 to 15 min. p.r.n.,methotrimeprazine 25 mg q5 to 15 min.

p.r.n., phenobarbital 90 to 120 mg q5to 15 min. p.r.n. or diazepam 5 to 10mg I.V. q5 to 15 min. p.r.n.

Use incremental titration until patientcomfortable, determined by subjectiveas well as objective means.


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Differential Diagnosis

Composed of four general categories

Cardiac

Pulmonary

Mixed cardiac or pulmonary

Non-cardiac or Non-pulmonary


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Pulmonary Etiology

COPD

Asthma

Restrictive Lung Disorders

Hereditary Lung Disorders

Pneumonia

Pneumothorax


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Cardiac Etiology CHF

CAD

MI (recent or past history) Cardiomyopathy

Valvular dysfunction

Left ventricular hypertrophy Pericarditis

Arrhythmias


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Mixed Cardiac/PulmonaryEtiology

COPD with pulmonary HTN and/or corpulmonale

Deconditioning

Chronic pulmonary emboli

Pleural effusion


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Noncardiac or NonpulmonaryEtiology

Metabolic conditions (e.g. acidosis)

Pain

Trauma

Neuromuscular disorders

Functional (anxiety,panic disorders,hyperventilation)

Chemical exposure


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Easily Performed DiagnosticTests

Chest radiographs

Electrocardiograph

Screening spirometry


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In cases where test results inconclusive

complete PFTs

ABGs

EKG

Standard exercise treadmill testing/ or

complete cardiopulmonary exercise testing Consultation with

pulmonologist/cardiologist may be useful


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Commonly used to evaluate acute dyspnea

can provide information about altered pH,hypercapnia, hypocapnia or hypoxemia

normal ABGs do not excludecardiac/pulmonary dx as cause of dyspnea

Remember- ABGs may be normal even in cases

of acute dyspnea - ABGs do not evaluatebreathing

ABGs


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Rapid, widely available, noninvasivemeans of assessment in most clinical

situations- insensitive (may be normal in acute dyspnea)

The % of Oxygen saturation does notalways correspond to PaO2

The hemoglobin desaturation curve can beshifted depending on the pH, temperatureor arterial carbon monoxide or carbon

dioxide levels

PULSE OX


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ASTHMA


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What is Asthma?

A Chronic disease of the airways thatmay cause:

Wheezing Breathlessness

Chest tightness

Nighttime or early morning coughing


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The bronchospasm characteristic of theacute asthmatic attack is typically

reversible. It improves spontaneouslyor within minutes to hours of treatment


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Asthma can exist by itself or coexistwith chronic bronchitis, emphysema, or

bronchiectasis


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Symptoms/Chief Complaint

Progressive dyspnea

Cough

Chest tightness

Wheezing/coughing


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The rapidly reversible airflowobstruction of asthma is mainly due to

bronchial smooth muscle contraction


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Focus of Therapy

Pharmacologic manipulation of airway smoothmuscle

Do not overlook physiologic impairment caused bymucous production and mucosal edema

Bronchospasm can be reversed in minutes

Airflow obstruction due to mucous plugging and

inflammatory changes in bronchial walls may notresolve for days/weeks -

may lead to atelectasis, infectious bronchitis,pneumonitis


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Asthma Triggers

Immunologic reaction

Viral respiratory/sinus infections

change in temperature/humidity Drugs/Chemicals -

aspirin, NSAIDS

Exercise

GE reflux

Laughing/coughing

Environmental factors -

strong odors, pollutants, dust, fumes


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Patient Exam

Wheezing

may be audible w/o stethoscope

Use of accessory muscles of inspiration

diaphragmatic fatigue

Paradoxical respirations

- reflect impending ventilatory failure

Altered mental status -

lethargy, exhaustion, agitation, confusion


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Patient Exam

Hypersonance to percussion

decreased intensity of breath sounds

prolongation of expiratory phase w orw/o wheezing


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Patient Exam

The intensity of the wheeze may notcorrelate with the severity of airflow

obstruction

quiet chest- very severe airflow

obstruction


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Managing Asthma:

Indications of a severe attack:

Breathless at rest

hunched forward talking in words rather than sentences

Agitated

Peak flow rate less than 60% of normal


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Treatment Goals of Severe Asthma

Improve airway function rapidly

Avoid hypoxemia

Prevent respiratory failure and death


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COPD

Hallmark symptom - Dyspnea

Chronic productive cough

Minor hemoptysis

pink puffer

blue bloater


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COPD- pulmonary hyperinflation- the diaphragms are at the levelof the eleventh posterior ribs and appear flat.


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COPD - Physical Findings

Tachypnea

Accessory respiratory muscle use

Pursed lip exhalation

Weight loss due to poor dietary intakeand excessive caloric expenditure for

work of breathing


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D i t Cli i l F f


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Dominant Clinical Forms ofCOPD

Pulmonary emphysema

Chronic bronchitis

Most patients exhibit a mixture of

symptoms and signs


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COPD - Advanced Dx

secondary polycythemia

cyanosis

tremor

somnolence and confusion due tohypercarbia

Secondary pulmonary HTN w or w/o corpulmonale


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COPD Treatment Strategy

Elimination of extrinsic irritants

bronchodilator & glucocorticoid therapy

Antibiotics

Mobilization of secretions

respiratory vaccines

Oxygen therapy - if oxygen saturation


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Spirometry


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6th leading cause of death in the US &Indonesia

Respiratory viruses & mycoplasma

responsible for greater than 1/3 ofcases


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Common types of respiratoryinfections

Tracheobronchitis

Pneumonia

Effusions

Empyema

Abscess

Cavitary lesions

post-obstructive


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Common Respiratory Viruses

Influenza A & B

Parainfluenza 1& 3

Respiratory Syncytial Virus

Adenovirus

Cytomegalovirus

Herpes Simplex & Zoster/varicella

Hanta Virus Infection


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Respiratory Syncytial Virus

Rapid diagnosis of RespiratorySyncytial Virus Infection by

immunofluorescence of respiratorysecretions


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Classic Pneumonia Symptoms

Dyspnea, chills

high fever, cough/sputum

pleuritic chest pain


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Viral Pneumonia - symptoms

Chest Pain

Fever

Dyspnea

Prodrome - malaise, upper respiratorysymptoms, and other GI symptoms

Viral pneumonia


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Viral pneumonia -Clinical Findings

Minimal/variable

Chest exam - may reveal wheezing

Fine rales if heard can signify interstitialinvolvement

Chest x-ray - patchy densities or

interstitial involvement

Viral pneumonia


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Viral pneumoniaManagement /Prophylaxis

Supportive treatment - decreaseseverity of symptoms

bed rest analgesics

expectorants

Patients w/

airway obstruction - treatw/bronchodilators

secondary bacterial infection - antibiotics


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Atypical Pneumonia

Accounts for 25% of communityacquired pneumonias

Mycoplasma/chlamyda/legionella

can case extrapulmonary manifestations-

meningitis, encephalitis, pericarditis,hepatitis, hemolytic anemia

typically bilateral infiltrates on chest x-ray

primarily effects younger persons

Atypical Pneumonia


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Atypical PneumoniaTreatment

Antibiotics

Macrolides

fluroquinolones

doxycycline


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Bacterial pneumonia

3.3 million cases yearly in US

responsible for 10% of hospital

admissions unilateral infiltrate on x-ray

high mortality in elderly population

most common cause pneumococcalfollowed by haemophilus influenza


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Pneumococcus pneumonia accounts forup to 90% of all bacterial pneumonias

Patients with a chronic Diagnosis are atan increased risk of contracting

pneumonia

Bacterial pneumonia


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Bacterial pneumoniapresentation

acute shaking - chills

tachypnea

tachycardia malaise

anorexia

myalgias flank or back pain

vomiting


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Lab Tests

WBC

Chest X-ray

Pulse Ox

ABGs

Sputum exam

Blood cultures

pleural fluid exam


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Pneumothorax

Causes of Spontaneous


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Causes of SpontaneousPneumothorax

Pleural blebs

Bullae Emphysema

Interstitial lung disease

Alpha 1 antitrypsin deficiency

Traumatic and Iatrogenic


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Traumatic and IatrogenicCauses

Penetrating wounds

Line placements

Lung biopsies

Mechanical ventilation


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Two most common symptoms

Dyspnea

Chest pain
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Physical Examination

Decreased breath sounds

hyperresonance to percussion

decreased tactile fremitus

In patients with emphysema - clinical

findings may be subtle


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Chest X-ray to Confirm Dx

500ml of air required to visualizepneumothorax on x-ray

Characterized by -

hyperlucency and lack of lung markings at

the periphery of the lung and appearanceof fine line that represents the retraction ofthe visceral from the parietal pleura


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Treatment Options

Observation - if pneumothorax involves< 15-20% of hemithorax and patient

relatively asymptomatic Tube thoracostomy

Simple Aspiration


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Pulmonary Embolism (PE)


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PE History

PE is so common and deadly that thediagnosis should be considered in any

patient who presents with chestsymptoms that cannot be proven tohave another cause


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PE Risk Markers

Hypercoagulable states

Prior history of DVT or PE

Recent surgery or pregnancy

Prolonged immobolization

Underlying malignancy

smoking

birth control pills

trauma

Classic triad of


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Classic triad ofsigns/symptoms

These symptoms are not sensitive orspecific and occur in fewer than 20% ofpatients diagnosed with PE

Hemoptysis

Dyspnea

Chest Pain


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PE Physical Exam

Massive PE causes hypotension due toacute cor pulmonale

Physical findings in early submassive PEmay be completely normal

Initially, abnomal findings are absent in

most patients with PE


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Massive PE - Signs/Symptoms

Tachypnea -96% Rales - 58% Accentuated second heart sound - 53%

Tachycardia - 44% Fever - 43% S3 or S4 gallop - 34% signs/symptoms suggestive of

thrombophlebitis - 32%

Lower extremity edema - 24% Cardiac murmur - 23% Cyanosis - 19%


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Massive PE Diagnostic Studies

VQ scan

Pulmonary angiography

CT

Echocardiography (TEE)

Pulmonary artery catheterization

Diagnostic algorithm

D-dimer

blood gases increased A-a gradient


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A-a gradient

A-a gradient = predicted pO2 observed PO2

PAO2 = (FIO2 X 713) (PaCO2/0.8) at sealevel

PAO2 = 150-(PaCO2/0.8) at sealevel on room air

Normal range 10-15mm > 30 years of ageNormal range 8mm < 30 years of age

Increased A-aDO2=diffusion defectRight to left shuntV/Q mismatch


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Treatment Strategies

Fluid administration

anticoagulation

Vena caval interruption Thrombolytics

oxygen

pulse ox


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CHF


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Left sided Failure

Blood/fluid back-up into the lungs -result in

Shortness Of Breath Fatigue

Cough (especially at night)

Paroxymal Nocturnal Dyspnea orthopnea


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Right sided Failure

Build-up of fluid in the veins -

Edema of feet, legs and ankles

may effect liver/portal circulation and 3rdspacing into soft tissue/ascites/pleuraleffusion


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Causes of CHF

Variety of cardiac diseases

Most common cause of CHF - CAD

other causes - valvular heart dx,

HTN,cardiomyopathies, myocarditis, renaldx,fluid overload,liver dx w/loss of proteinand osmotic forces,high altitude and manyothers


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Physical Findings

Peripheral edema

JVD

tachycardia

tachypnea, using accessory muscles of respiration

Skin - diaphoretic/cold/gray/cyanotic

Wheezing/rales on ausculation

Apical impulse displaced laterally ascites

hepatosplenomegaly


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Diagnostic Work-Up

History

Physical exam

EKG Echo

Chest x-ray

BNP

ABG/pulse ox


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Treatment

Diuretics

Digitalis

Peripheral vasodilators/NTG Positive inotropic agents

ACE inhibitors

Beta blockers Oxygen

MS04

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DYSPNEA Assessment& Management-ANIS

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