I Can t Breathe! Physiology and Evaluation of the Dyspneic Patient. Christopher Parker, MD Pulmonology, Norman Regional Health Systems
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1 I Can t Breathe! Physiology and Evaluation of the Dyspneic Patient Christopher Parker, MD Pulmonology, Norman Regional Health Systems Photo by James Heilman, MD / CC BY-SA 3.0
2 Disclosures No Financial Disclosures
3 Objectives Etymology and pronunciation Definition Epidemiology Pathophysiology Differential diagnosis, acute vs chronic Evaluation
4 Etymology and pronunciation \ ˈdis(p)-nē-ə \ From Greek dys (painful) and pneuma (breath)
5 Definition American Thoracic Society statement: Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors
6 Epidemiology Dyspnea causes 2.7% of all ER visits 3.7 million ER visits 8.2% for other dypnea related complaints
7 Pathophysiology Respiratory Controller Ventilatory Pump Gas Exchanger
8 Respiratory Controller
9 Respiratory Controller Dorsal Respiratory Group (DRG)
10 Respiratory Controller Ventral Respiratory Group (VRG)
11 Respiratory Controller Pontine Respiratory Group - Apneustic Center - Pneumotaxic center
12 Respiratory Physiology. Physiology, by Linda S. Costanzo, Third ed., Wolters Kluwer, 2006, pp
13 Central Chemoreceptors ph responsive only
14 Peripheral Chemoreceptors O 2 CO 2 H +
15 Other Receptors Lung stretch (Hering-Breuer reflex) Joint and Muscle Irritant receptors J receptors
16 Ventilatory Pump Chest wall muscles Narrowing of airways Elastic Properties of the Lung
17 Gas Exchanger Pulmonary Vasculature Aveolus
18 Other Causes of Dyspnea Psychological Dysfunction Multifactorial
19 Evaluation of Acute Dyspnea History and Physical Labs and Radiology Bedside Diagnosis
20 The Toolbox Chest Radiograph ECG Arterial Blood Gas Chemistry and Complete Blood Count BNP Cardiac Enzymes Echocardiogram CT Angiogram
21 Bedside Ultrasound
22 The Original BLUE Study (Bedside Lung Ultrasound in Emergency) 300 consecutive adults with respiratory failure admitted to the ICU Ultrasound Profile used to characterize and narrow differential Separated different disease processes into Ultrasound Profiles
23 Figure 1 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
24 Figure 2 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
25 Figure 3 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
26 Figure 5 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
27 Figure 7 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
28 Figure 9 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
29 Figure 10 CHEST , DOI: ( /chest ) Copyright 2015 The American College of Chest Physicians Terms and Conditions
30 Evaluation of Chronic Dyspnea History and Physical Labs and Radiology Special Studies
31 History and Physical to Narrow Focus Quality of the symptoms Persistence or variability of symptoms Aggravating or precipitating factors Examination clues
32 5 Most Common Causes of Chronic Dyspnea Asthma COPD ILD Myocardial Ischemia Obesity and Deconditioning
33 The Basic Toolbox CBC Chemistry BNP ECG Echocardiogram Spirometry and Plethysmography CXR TSH Ambulatory Pulse Ox
34 Respiratory Causes of Dyspnea Spirometry Restricted? Obstructed? Normal? Lung volumes by Plethysmography Diffusing Capacity of Carbon Monoxide (DLCO) Methacholine Challenge High Resolution CT Scan
35 Deadend? Work up has all been normal PFT s abnormal Explain symptoms? Undifferentiated dyspnea
36 Cardiopulmonary Exercise Testing (CPET) Comprehensive test Pulmonary Cardiac Musculoskeletal Typically on Stationary Bike or Treadmill Continuous monitoring of multiple data points
37 How It Works: Steady ramp of workload Measurement of Vitals Specialized Equipment to Measure exhaled CO2 and O2 Direct or calculated work rate Continue ECG monitoring
38 Specialized Equipment Closed circuit mask with metabolic flow sensor
39 Specialized Equipment Closed circuit mask with metabolic flow sensor Viewed on 8/19/2018.
40 Accessed 8/19/2018.
41 Usefulness of CPET Undifferentiated Dyspnea Risk Assessment
42 Raw Data Collection Vital signs RR, Pulse, Blood Pressure, Tidal Volume, SpO2 V O 2 Oxygen Consumption V CO 2 Carbon Dioxide Production V E Minute Ventilation ECG Changes Baseline and Stressed Spirometry
43 Determining Anaerobic (Ventilatory) Threshold
44 Abnormal Patterns of Response in CPET
45
46 Limitations of CPET Submaximal effort by patient Some minimal exercise tolerance required May precipitate an adverse event Inaccurate or inconclusive data
47 Enigmatic Causes of Dyspnea Vocal Cord Dysfunction Psychological (rather than physiological) This Photo by Unknown Author is licensed under CC BY-ND
48 Vocal Cord Dysfunction (VCD) Inappropriate adduction of the vocal cords during inhalation (and sometimes exhalation) Often misdiagnosed or comorbid with asthma Munchausen s Stridor 3:1 Female predominance Wide Range of presentations
49 Distinguishing Signs and Symptoms Often indicate throat as source Dry powder inhalers worse, Nebulized better Very rapid resolution when sedated or ventilated
50 Diagnosis of VCD History Laryngoscopy
51 Flexible Laryngoscopy A. Paradoxical vocal cord motion with inspiration B. Same Patient after speech therapy Vocal Cord dysfunction: a review. Asthma Research and Practice. 2015
52 Summary Causes of Dyspnea multifactorial Best aide is history and physical Acuity vs Chronicity guides testing Use all of your armamentarium including bedside ultrasound and CPET If symptoms are not responding, reevaluate and lean on your consultants
53 Thank You This Photo by Unknown Author is licensed under CC BY
54 Works cited y/2011_ed_web_tables.pdf (accessed July 29 th 2018) Chapter 29: Dyspnea. Murray and Nadel s Textbook of Respiratory Medicine, by V. Courtney Broaddus, et al., Elsevier/Saunders, 2016, pp. Page Respiratory Physiology. Physiology, by Linda S. Costanzo, Third ed., Wolters Kluwer, 2006, pp Lichtenstein, Daniel A. BLUE-Protocol and FALLS- Protocol. Chest. Vol.147, no. 6, 2015, pp , doi: /chest Balady, Gary J., et al. Clinician s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement from the American Heart Association. Circulation. Vol 122, No. 2, 2010, pp Dunn, Neha M., Katial, Rohit K., Hoyte, Flavia C.L. Vocal Cord dysfunction: a review. Asthma Research and Practice. 2015, 1:9
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