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Noble Approach to Patients withDyspnea
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bad breeze (Latin)
Breathlessness
Shortness of breath
Difficulty of breathing
Disordered /inadequate breathing
Uncomfortable awareness of breathing
Air hunger
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Dyspnea Correlates with increased
prevalence of cardiac andpulmonary diseases
Predictor of hospitalization inpxs with chronic lung dse; moreclosely related with survivalthan FEV1
More closely associated withcardiac mortality than angina
Sensation or perception?
Acute or chronic?
O n e o f t h e m o s t c o m m o n d i s tr es s i n g s y m p t o m s o f a
pat ient .
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Population Prevalence of
Dyspnea (%)
References
Cancer (mixed) 10-70 Solano 2006 AIDS 11-62 Solano 2006Lung cancer (primary or metastatic)
62-95 Currow 2010
Heart Disease 60-88 Solano 2006COPD 90-95 Solano 2006Renal Disease 11-62 Solano 2006Stroke 37 Addington-Hall
1995 ALS 47-50 Obrien 1992,
Hicks 1993Dementia 70 Lloyd Williams
1996No cardiorespiratorydisease
45-81 Currow 2010
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a subjective experience of
breath ing d i s c o m f o r t
that consists of qualitativelydistinct
sensations that vary in intensity.
derives from interactions from multiple
physiological, psychological, social and
environmental factors, and may induce
secondary physiological and behavioral
responses.
dyspnea per se can only be perceived by
the person experiencing it.
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
Acute vsChronic
5. RESEARCHPRIORITIES
ATS Statement Mechanisms, Assessment, and Management of Dyspnea :1999 and 2011 update
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Dyspnea --Uncomfortable in work of breathing
Tachypnea -- RR > normal
Hyperpnea (Tidal volume x RR) > normal; pH = normal
Hyperventilation (Tidal volume x RR) > demands; pH =
Dyspnea of exertion (DOE) -- Exertion-induced SOB
Orthopnea -- Recumbent-induced SOB
Paroxysmal nocturnal dyspnea (PND) -- Sudden SOBafter recumbent
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
Acute vsChronic
5. RESEARCHPRIORITIES
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DOMAINS OF DYSPNEA MEASUREMENT
Sensory-perceptual experience : what breathing feelslike; single item ratings of intensity eg Borg, VAS
Affective distress : how distressing breathing feels; multiitem scales of emotional responses such as anxiety
Symptom impact or burden : how dyspnea affectsfunctional ability, QOL; MRC, multidimensional scales of QOL
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
Visual Analog Scale
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QUESTIONNAIRESDYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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Modified Medical Research Council (MRC) Scale
0. I only get breathless with strenuous exercise
1. I get short of breath when hurrying on the level or walking up aslight hill
2. I walk slower than people of the same age on the levelbecause of breathlessness or have to stop for breath whenwalking at my own pace on the level
3. I stop for breath after walking about 100 yards or after a fewminutes on the level
4. I am too breathless to leave the house or I am breathlesswhen dressing
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCHPRIORITIES
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CLUES from HISTORY AND PE
Restricted thoracic motion : air hunger
Bronchoconstriction: chest tightness
COPD: increased effort to breathe
Heart failure: air hunger; suffocation
Cardiovascular deconditioning: heavybreathing
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCHPRIORITIES
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EVALUATION OF ACUTE DYSPNEADYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
Run thru thechecklist!
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TWO MAJOR CATEGORIES
Acute : new onset of breathing discomfortfor whom the underlying cause of dyspnea has not yet been determined
Chronic : those with knowncardiovascular, respiratory, or neuromuscular diseases who areexperiencing worsening dyspnea
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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EVALUATION OF ACUTE DYSPNEADYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
CARDIOVASCULARSYSTEM
Acute myocardialischemia
Heart Failure Cardiac
Tamponade
RESPIRATORYSYSTEM Bronchospasm Pulmonary
Embolism Pneumothorax Pulmonary
infection Upper Airway
Obstruction Aspiration Anaphylaxis
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LAB WORK-UPS FOR ACUTE DYSPNEA
CXR, ABG, ECG
SOB Panel
D Dimer high negative predictive value
NT ProBNP
Myoglobin
Troponin
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES 301 patients in the ER with DOB
Increased sensitivity by 5%Specificity not significantly improved.
Acad Emer Med 2009
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LAB WORK-UPS FOR ACUTE DYSPNEA
Plasma BNP
With chronic and advanced HF, ventricular cells arerecruited to secrete ANP and BNP in response to highventricular filling pressures plasma concentrations
of both hormones increased in patients withsymptomatic or asymptomatic LV dysfunction
Meta analysis: BNP testing at ED in patients withdyspnea can reduce length of stay in the hospital Lam
et.al, Ann of Int Med 2010
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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LAB WORK-UPS FOR ACUTE DYSPNEA
Plasma BNP
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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EVALUATION OF CHRONIC DYSPNEA
LAB TESTING CBC, glucose, BUN,creatinine, electrolytes, Ca, P, TSH
PFT spirometry, bronchoprovocationtesting, lung volumes, lung diffusion,maximal inspiratory pressure, MVV
IMAGING CXR, CT
Others Echocardiography,Cardiopulmonary Exercise Testing, EMG-NCV
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCHPRIORITIES
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TREATMENT primary focus to optimizetreatment of underlying disease
Oxygen advanced heart or lung disease; relatedto changes in chemoreceptor stimulation
Heliox helium with decreased density mixedwith gas decreased resistance to airflow,decreased WOB, decreased severity of hyperinflation, inc exercise capacity, dec dyspnea;?long term studies
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATiON ANDTREATMENT
5. RESEARCHPRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCHPRIORITIES
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Pharmacologic therapy
OPIOIDS can reduce breathlessness inadvanced COPD, ILD, CA, chronic HF
Nebulized opioids not superior tooral/parenteral
NEBULIZED FUROSEMIDE dec breathlessnessinduced in healthy volunteers, vagal afferent
Possible benefit in COPD, but no benefit in CA patients
Still with insufficient data
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATiON ANDTREATMENT
5. RESEARCH
PRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCH
PRIORITIES
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Other agents: Anxiolytics, Antidepressants,Phenothiazines, NaHCO3, inhaled topical
anesthetics lack data
PULMONARY REHABILITATION esp in patientswith chronic lung disease reduction inexertional dyspnea during exercise and improvedexercise tolerance.
Other nonpharmacologic approaches: chest wallvibration, cool air, noninvasive ventilation
Alternative/complementary medicine:acupuncture, yoga training
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATiON ANDTREATMENT
5. RESEARCH
PRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATiON ANDTREATMENT
5. RESEARCH
PRIORITIES
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New treatments and larger clinical trials treatment of dyspnea per se?
Standardized instruments for measuring dyspnea
Neuromodulation, neuroimaging and centralprocessing of dyspneic sensations and associatedunpleasantness.
Interdisciplinary approaches to research indyspnea
DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUAITON ANDTREATMENT
5. RESEARCH
PRIORITIES
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DYSPNEA1. DEFINITION2. MECHANISMS
UNDERLYINGDYSPNEA
3. DYSPNEAMEASUREMENT
4. EVALUATION ANDTREATMENT
5. RESEARCH
PRIORITIES
PatientEducation
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Summary and Recommendations
When developing a differential diagnosis, use aconstruct that distinguishes respiratory ssystemdyspnea fro cardiovascular dyspnea. Also takeinto account chronic conditions contributing todyspnea.
Inquire about the quality of patient s breathingdiscomfort, use assessment tools.
Plasma BNP may be helpful in establishing or excluding the dx of heart failure as cause of dyspnea.
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Summary and Recommendations
History and PE lead to accurate diagnoses of patients in 2/3of cases. CXR and spirometry to screen. CT for ILD, occultemphysema, chronic thromboembolic disease.
CPET is a useful study in patients in whom the cause of their breathing discomfort remains elusive after standard testing, inpatients whom deconditioning is a serious consideration, andin patients who appear to have breathing discomfort out of proportion to their physiologic derangements.
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