Objectives. Objectives. Definition. Physiology. Evaluation of the Dyspneic Patient. B. Celli Disclaimer

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1 Evaluation of the Dyspneic Patient Bartolome R. Celli Harvard Medical School Brigham and Women s Hospital Boston B. Celli Disclaimer No stocks or ownership in any company. No Tobacco funds No promotional talks Grants: GSK, B.I., Almirall, Novartis, Forrest, Aeris Advisory boards: GSK, B.I., Dey, Altana, Astra Zeneca, Almirall, Sepracor, Pfizer. Rox. Definition Dyspnea, shortness of breath (SOB), or air hunger, is the subjective symptom of breathlessness Uncomfortable sensation of breathing Pathophysiology of dyspnea Thorax

2 Perception Perception Central Drive Central Drive Cross-talk Pathophysiology Dyspnea How to measure dyspnea Functional dyspnea scale Modified Medical Research Council BDI-TDI SGRQ. CAT CRQ Exercise scale Borg VAS Functional dyspnea scale Medical Research Council 0 I only get breathless with strenuous exercise. 1 I get short of breath when hurrying on level ground or walking up a slight hill 2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace. 3 I stop for breath after walking about 100 yards or after a few minutes on level ground 4 I am too breathless to leave the house or I am breathless when dressing

3 Multicenter in Japan n = 222 F/U for 5 years Outcome: Mortality Mortality: Dyspnea How to measure dyspnea Functional dyspnea scale Modified Medical Research Council BDI-TDI SGRQ. CAT CRQ Exercise scale Borg VAS Nishimura Chest 2002;121:1434 Exercise dyspnea No SOB Worst SOB ever O 2 Respiration CPET Air Ventilation Circulation Muscle Mitochondria CO 2

4 Exercise Test: Cardiac R L O 2 delivered = CO x O 2 content O 2 content = Hgb x 1.34 x % sat Low exercise capacity (VO 2 ) Decreased heart rate reserve (HR/Pred HR) Large ventilatory reserve (VE/MVV) Early AT ECG or BP changes No ABG changes Exercise Test: Respiratory Low exercise capacity (VO 2 ) Low breathing reserve (VE/MVV) Large heart reserve (HR/Pred HR) PaO 2 or O 2 sat may decrease PaCO 2 rises or fails to decrease AT not reached No ECG or BP change Example : COPD COPD: Patho-radiology Normal Disease Progression Static IC IRV V T ERV Air Trapping at Rest RV Years - Decades Rest

5 IC Normal IRV V T ERV RV Disease Progression Years - Decades Static Air Trapping at Rest Rest Dynamic Additional Air Trapping During Exercise Seconds - Minutes Exercise Pathophysiology Dyspnea Pharmacotherapy LVR Oxygen Central Drive Sedation Rehab Bronchodilator therapy, Therapy pulmonary and Health rehabilitation Status and health status Change in CRQ total score Threshold for clinical signficicance significance Mahler D et al. Chest 1999; 115: Placebo Salmeterol Ipratropium Pulm Rehab Griffiths TL, et al. Lancet 2000; 355: From ZuWallack Repeated P.R. courses over 7 years Rehabilitation Unbeatable Evidence A Observational study N = 48. FEV 1 = 58% 5 courses, OP Outcomes: FEV 1 SGRQ BDI/TDI BODE Change p value FEV 1 (ml) -18 (22) <0.001 SGRQ (u) -9.6 (14) < BODE (u) 0.71 (1.6) <0.001 Foglio et al Respir Med 2007;101:1961

6 LVRS in COPD Patho-bio-physiology R.Y. 58 years Emphysema FEV 1 = 38 % FRC = 192 % DLCO = 49 % MMRC = ¾ 6MWD = 198 m BODE = 7 Brantigan et al ARRD 1959 Patho-bio-physiology FEV 1 = 41 FRC = 172 % 6MWD = + 78 m MRC = - 2 DLCO = 49 % BODE = 5 Conclusions Dyspnea is a frequent symptom in the clinic The cause can be the lungs, heart, vascular, anemia, muscle or idiopathic Dyspnea can be measured and should be measured functionally or during stimulus A CPET may help determine origin should be directed at the cause References Graded comprehensive CPET in the evaluation of dyspnea unexplained by routine evaluation. Martinez FJ, Stanopoulos I, Acero R, Becker FS, Pickering R, Beamis JF. Chest. 1994;105: Measuring shortness of breath in heart failure (SOB-HF): development and validation of a new dyspnoea assessment tool. Ekman I, Granger B, Swedberg K, Stenlund H, Boman K. Eur J Heart Fail. 2011;13: American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Mahler DA, Selecky PA, Harrod CG, Benditt JO, Carrieri- Kohlman V, Curtis JR, Manning HL, Mularski RA, Varkey B, Campbell M, Carter ER, Chiong JR, Ely EW, Hansen-Flaschen J, O'Donnell DE, Waller A. Chest. 2010;137: