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muscles and diaphragm leading to breathlessness.

The causes include Guillain-Barre syndrome, cervical cord injury, muscular dystrophy, myasthenia gravis, organophosphorus poisoning.

Points to be asked on history of breathlessness

• Mode of onset-acute or insidious

• Exercise tolerance-daily physical activities

• Associated symptoms such as – Cough, sputum, haemoptysis – Wheeze, chest pain

• Past history of allergy, cardiac or respiratory disorder

• Occupational history—exposure to dust, pollens, animals, chemical

• Personal history. History of smoking (past and present)

• Recent travel abroad Clinical tips

• Breathlessness with unilateral chest pain (pleurisy) occurs in pneumonia, pulmonary infarction, rib fracture, pneumothorax

• Breathlessness without chest pain, cough and wheeze is seen in pulmonary embolism, tension pneumothorax, shock and metabolic acidosis

• Breathlessness with cough and wheeze but with no chest pain indicates left heart failure, asthma, pneumothorax.

Causes of dyspnoea

Depending on the onset, dyspnoea may be divided into acute (within minutes to hours) and chronic (days to months or years). Acute dyspnoea presents with prominent symptoms at rest while chronic dyspnoea occurs on exertion. The causes are given in the Table 2.16. The differential diagnosis of acute severe dyspnoea is tabulated (Table 2.18).

Table 2.15: Causes of increased ventilatory drive responsible for dyspnoea

Cause/mechanism Disease

• Acidemia (↑H⁺ion concent- • Diabetic ketoacidosis, lactic ration) causing Kussmaul acidosis

breathing

•↑PaCO2 (respiratory acidosis) • Chronic obstructive pulmonary disease

•↓PaO2 (arterial hypoxaemia) • Cyanotic congenital heart stimulates chemoreceptors disease, asthma, COPD,

anaemia, shock, pneumonia

• Increased central arousal • Exercise, anxiety, (sympathetic activity) thyrotoxicosis,

phaeochromocytoma, fever

• Pulmonary ‘J’ receptors • Pulmonary oedema discharge

Table 2.16: Causes of dyspnoea

System Dyspnoea at rest Dyspnoea on exertion

(acute) (chronic)

C.V.S. • Acute left ventricular Chronic heart failure failure

• Myocardial infarction

Respiratory • Acute severe asthma • Chronic asthma

• Acute exacerbation • COPD

of COPD • Bronchial carcinoma

• Pneumonia • Interstitial lung

• Tension disease

pneumothorax • Chronic pulmonary

• Pulmonary embolism thromboembolism

• ARDS • Large pleural effusion

• Lobar collapse • Lymphatic

• Laryngeal oedema carcinomatosis (anaphylaxis)

Miscellaneous • Metabolic acidosis • Severe anaemia (e.g. diabetic • Obesity ketoacidosis, lactic

Mode of onset, duration and progression: Dyspnoea may be of acute or sudden onset (pulmonary oedema, pulmonary embolism, pneumothorax) or slow insidious onset (chronic congestive heart failure, interstitial lung disease, COPD), may be continuous and progressive (diffuse interstial lung disease, occupational diseases) or intermittent /episodic (asthma). Mode of onset, duration and progression help in arriving at the diagnosis.

Aggravating and relieving factors: Diurnal variation of symptoms is characteristic of bronchiectasis, lung abscess. Dyspnoea which improves at weekend or on holidays (rest) suggests occupational asthma or extrinsic allergic alveolitis. Some diseases such as asthma may be provoked by coughing or laughing or exertion or following exposure to allergans/ irritants.

Nocturnal dyspnoea which may awaken the patient from sleep is a typical feature of nocturnal asthma, pulmonary oedema and COPD. Orthopnoea may be seen in heart failure and severe COPD and such patients may have to sleep in the sitting position propped up by pillows.

Associated symptoms. The symptoms associated with dyspnoea include cough, wheeze, sputum, haemoptysis and chest pain. Their significance has been discussed in the Table 2.14.

Severity: Though grading systems exist to assess the cardiac and respiratory disabilities (see Table 2.10

NYHA classification) but simple questions like breath-lessness on daily activities may provide an effective functional assessment of the severity of dyspnoea.

Apnoea: Apnoea is defined as cessation of breathing, can occur in following conditions;

• Voluntarily holding of breath for sometimes.

• Cheyne—stokes breathing in which apnoea alternates with hyperventilation.

• Sleep—apnoea syndrome (Read from the textbook).

Wheeze

Wheezing is described by the patients as whistling or musical sounds produced in the chest. It is due to narrowing of the bronchi as a result of mucus plugging or bronchoconstriction. It is in heard in asthma and COPD. Many patients may become so accustomed to wheeze that they cease to be aware of its presence.

Stridor

It is loud sound produced by partial obstruction of a major airway (e.g. laryngeal oedema, tumour, an inhaled foreign body).

Symptomatology of upper respiratory tract The symptoms originating from upper respiratory tract (nose, nasopharynx, larynx and trachea) are summarised in the Table 2.17.

Table 2.17: Symptoms pertaining to upper respiratory tract

Nose and nasopharynx Larynx Trachea

• Nasal discharge with • Horseness or • Pain

frequent sneezing dysphonia • Cough

(e.g. rhinitis respir- • Stridor

atory catarrh, • Dyspnoea

nasal allergy)

• Intermittent nasal • Dry barking cough obstruction (e.g. in laryngeal oedema adenoids enlarge- and bovine cough ment, deflected in laryngeal paralysis nasal septum or

polyps), bilateral • Stridor—a high-nasal obstruction pitched crowing may result in sound occurring mouth breathing in during inspiration children.

• Epistaxis (bleeding • Laryngeal pain (e.g.

from the nose). It acute laryngitis, may give rise to tubercular laryngitis haemoptysis if and laryngeal carci-blood from posterior noma)

nares is first inhaled and then coughed up.

Clinical clues

• Cough causing sleep disturbance is common in asthma than COPD.

Table 2.18: Differential diagnosis of acute severe dyspnoea

Condition History Signs Chest X-ray Arterial ECG Other tests

blood gas

1. Left ventricular Previous cardiac • Central cyanosis • Cardiomegaly ↓PaO2 • Sinus tachy- • Echocardio-failure (Pulmonary disease or chest • JVP-normal • Upper lobe veins ↓PaCO2 cardia graphy shows oedema) pain, orthopnoea or raised engorgement • Myocardial depressed left

PND and palpita- • Sweating • Pulmonary ischaemia/ ventricular tion. There is pink • Cold extremities oedema infarction function frothy sputum • End-inspiratory • Pleural effusion • Arrhythmias

crackles at bases

2. Massive pulmonary • Recent surgery or • Central cyanosis • Prominent hilar ↓PaO2 • Sinus tachycardia • Echocardio-embolism other risk factors • ↑JVP vessels with ↓PaCO2 • S1,Q3T3 pattern graphy

• Chest pain • Signs of shock oligaemic lung • Inverted T(V₁-V₄) • Lung scan

• Haemoptysis • Unilateral oedema fields • RBB Block • Angiography

• Deep vein • Calf tenderness thrombosis • Pleural rub may

be heard

3. Acute bronchial • History of pre- • Tachycardia • Hyperinflation ↓PaO-2 • Sinus tachycardia asthma vious episode • Pulsus paradoxus • Pneumothorax N or ↓PaCO2

• History of • Cyanosis (late) if complicated (late) asthma • JVP normal

medication • Diffuse bronchi

• Wheeze (rales), sonorous

4. Acute exacerbation • Long duration of • Cyanosis • Hyperinflation ↓PaO2 Signs of right of COPD history of cough • Signs of COPD • Increased lung ↑PaCO2 ventricular

• Repeated hospital (barrel shaped translucency Acidosis hypertrophy if admissions chest, intercostal • Tubular heart cor pulmonale

• History of indrawing, pursed • Low flat diap- develops smoking lips breathing) hragm

• Mucoid or muco- • Signs of CO₂ • Bullae may be purulent sputum retention (warm seen

extremities, ding pulse, flapping tremors)

• Bilateral crackles and rales

5. Pneumonia • Fever, cough • Raised • Pneumonic homo-↓PaO2 Tachycardia chest pain and temperature genous opacity ↓PaCO2

haemoptysis • Signs of in the lung consolidation involved

• Pleural rub may be present

• Cyanosis, if spread disease

6. Psychogenic • Previous • No cyanosis • Normal Normal PaO₂

(Anxiety) episodes • No signs of heart ↓PaCO2

• Acute anxious or lung disease Alkalosis may events precipi- • Hyperventilation be present tate it • Anxious looks

• Carpopedal spasm Abbreviations:

A-absent; N- normal; ↓-decreased ↑-increased

Table 2.19: Distinction between cardiac and pulmonary dyspnoea

Cardiac dyspnoea Pulmonary dyspnoea

History • History or evidence of heart disease • History or evidence of respiratory disease

• Acute or sudden onset. • Gradual onset except when there is an acute exacerbation of COPD or acute asthma

• Associated symptoms, include chest pain, orthopnoea, • Associated symptoms such as cough,wheeze, palpitation, diaphoresis (sweating) etc. haemoptysis, stridor are commnon

• A previous history of left ventricular failure • Previous history of repeated attacks of asthma or chronic bronchitis

• Paroxysmal attacks of dyspnoea (PND) are common, • PND is less common, is relieved by cough relieved by sitting or recumbent position and expectoration

• Wheezing less frequent • Wheezing is marked and even audible

• Dyspnoea is marked with less troublesome • Dyspnoea is marked with productive cough unproductive cough

Signs • Tachycardia, tachypnoea, cyanosis, (both central and • Tachypnoea, tachycardia and central cyanosis are

peripheral) less marked

• Percussion note may be dull at bases • Hyperresonant note may be present

• Trachea central and normal in length • Trachea central but palpable part is decreased

• There is no retraction of supraclavicular fossae or no • Retraction of supraclavicular fossae, indrawing activity of extrarespiratory muscles of ribs, barrel-shape chest and overactivity of

extrarespiratory muscles prominent

• Crackles (crepitations) at the bases with few rhonchi • Diffuse wheezes and crackles (crepitations) (wheezes)

• Apex beat is normal or displaced • Apex beat may not be visible or normal

• Breath sounds normal • Breath sounds with prolonged expiration

• 3rd heart sound may be present (gallop rhythm) • No 3rd heart sound

Chest X-ray • Heart size enlarged, diffuse haze from hilum to • Heart size normal or may be tubular, there is periphery of lungs, Kerley’s B lines may be present. increased translucency of lungs and low flat domes Hydrothorax present in some cases of diaphragm. Bullae may be seen in emphysema ECG • Myocardial ischaemia/infarction, left ventricular • Sinus tachycardia and right ventricular

hypertrophy, conduction defects and arrhythmias hypertrophy if cor pulmonale develops Echocardiogram • Left ventricular ejection fraction depressed at rest and • Right ventricular ejection fraction are low at rest

may decline during exercise and may decline with exercise

Arterial blood gas • PaO2 low • PaO2 low

• PaCO2 low • PaCO2 normal or raised

• Small repeated episodes of frank haemoptysis suggest bronchial carcinoma or adenoma.

• Pleuritic pain suggests underlying pneumonia or malignancy.

Significance of history

1. Past history: Past history of tuberculosis, pneumonia,

In document Teniendo en cuenta lo anterior, considero que el trabajo de la estudiante cumple con los requisitos para su sustentación con la Facultad (página 40-49)