Dyspnea

Dyspnea is subjective dyspnea. Breathing is perceived as unpleasant or stressful. It is different experienced by patients, depending on the cause and described. Pathophysiology Although dyspnea is a relatively common problem, the pathophysiology of the respiratory unpleasant feeling is poorly understood. Unlike other types of noxious stimuli, there are no specific receptors for dyspnea (although recent MRI studies have identified a few specific areas in the midbrain that can convey the perception of dyspnea). The sensation of dyspnea is likely to result from a complex interaction between “chemoreceptor stimulation,” mechanical disturbances of the respiratory and the perception of these abnormalities by the CNS. Some authors have described the imbalance between neurological stimulation and mechanical changes in the lung and chest wall as Euro mechanical decoupling. Etiology Dyspnea has many pulmonary, cardiac, and other causes (1) that vary by the violence of the beginning (see table: causes of acute dyspnea *, see Table: Causes of Subacute * dyspnea and see table: causes of chronic * dyspnea). The most common causes are:. Asthma Pneumonia COPD myocardial Physical deconditioning The most common cause of dyspnea in patients with chronic lung or heart disease is worsening her illness However, such patients may also acutely another disease develop (for example, a patient with long-standing asthma a have myocardial infarction, a patient with chronic heart failure may develop pneumonia). Causes of acute dyspnea * Cause Suspicious findings diagnostic approach † Pulmonary causes pneumothorax Sudden onset of severe pain in the chest, tachypnea, decreased breath sounds and hyper resonance on percussion can follow injury or occur spontaneously (especially for large, thin patients and in patients with COPD) chest x-ray pulmonary embolism sudden onset of strong Sch iron out of the chest, tachypnea and tachycardia often risk factors for pulmonary embolism (eg. As cancer, immobilization, TVT, pregnancy, use of oral contraceptives or other estrogen-containing medications, recent surgery or hospitalization, family history) Rare CT angiography, V / Q scintigraphy and possibly arteriography of bronchial asthma, bronchospasm or reactive airway disease wheezing and poor air exchange that to certain stimuli spontaneously or after exposure (z. B. allergens, infection of the upper respiratory tract, cold, movement) are formed may pulsus paradoxus often a pre-existing reactive airway disease Clinical evaluation Sometimes pulmonary function tests or peak flow measurement inhalation of foreign bodies Sudden coughing or wheezing in a patient (typically an infant or child) without infection of the upper respiratory or constitutional symptoms Inspired and expired thoracic radiographs Sometimes bronchoscopy toxin-induced damage to the respiratory tract (eg. For example, by inhalation of chlorine or hydrogen sulphide) Sudden onset after occupational exposure or improper use of detergents in general, it is not difficult to detect an inhalation because the history is quite typical. Chest x-ray Sometimes BGA and observation to determine the severity of cardiac causes Acute myocardial ischemia or infarction Substernales feeling of pressure in the chest or throat, with or without radiation to the arm or jaw, especially in patients with risk factors for CHD EKG “Cardiac enzyme tests” Papillarmuskelsdysfunktion or – break Sudden onset of chest pain, a new or loud holosystolic marbles and signs of heart failure, especially in patients with acute MI auscultation echocardiography Heart failure moisture RG, S3 gallop, and signs of central or peripheral volume overload (eg. As increased neck veins, peripheral edema) dyspnea (while lying flat orthopnea) or 1-2 h after falling asleep (paroxysmal nocturnal dyspnea) auscultation chest x-ray BNP measurement echocardiography Other causes diaphragmatic paralysis Sudden onset after trauma of the phrenic nerve Common orthopnea chest x-ray “Fluoroscopic sniff test “anxiety disorder that causes hyperventilation Situational dyspnea often psychomotor agitation and discomfort in the fingers or around the mouth accompanied Main examination findings and pulse oximetry Measurements Clinical Evaluation The diagnosis is a diagnosis of exclusion. * Acute respiratory distress occurs after the triggering event within minutes. † Most patients should have a pulse oximetry and – unless the symptoms are clearly a slight exaggeration of the known chronic diseases – perform a chest x-ray. BNP = brain (B-type) natriuretic peptide; CAD = coronary artery disease; DVT = deep vein thrombosis; S3 = 3. Heartbeat; V / Q = ventilation / perfusion. Causes of Subacute * dyspnea cause suspicious findings diagnostic approach † Pulmonary causes pneumonia fever, productive cough, dyspnea, sometimes pleuritic chest pain Focal pulmonary findings, including wet RG, decreased breath sounds and Ägophonie chest x-ray sometimes blood and sputum leukocyte count exacerbation of COPD cough, productive or unproductive Poor Luftbeweg ung use of respiratory muscles or breathing with pursed lip Clinical evaluation Sometimes chest x-ray and BGA Cardiac causes angina or coronary heart disease Substernales feeling of pressure in the chest with or without radiation to the arm or jaw, often caused by physical exertion, especially in patients with risk factors for coronary heart disease ECG Cardiac stress test cardiac catheter or pericardial -tamponade Steamed heart sounds or enlarged heart silhouette in patients with risk factors for pericardial effusion (such. As cancer, pericarditis, SLE) may paradoxical pulse echocardiography * Subacute respiratory distress occurs within hours or days. † Most patients should have a pulse oximetry and – unless the symptoms are clearly a slight gain of a known chronic diseases – can perform chest X-ray. CHD = coronary heart disease. Causes of chronic * dyspnea cause suspicious findings diagnostic approach † Pulmonary causes Obstructive Pulmonary Disease Earlier excessive smoking, barrel chest and poor inflow and outflow of air Chest x-ray Pulmonary function test Restrictive (at initial measurement) lung disease progressive dyspnea in patients with known exposure in the workplace or neurological disease Chest x-ray Pulmonary function test Interstitial (at initial measurement) lung disease Fine bubble RG, which is often accompanied by dry cough High-resolution chest CT pleural effusion Pleuritic pain in the breast, lung field with a dull head sound and with reduced respiratory sounds Sometimes past cancer, heart failure, RA, SLE or acute pneumonia chest X-rays often chest CT and Pleurapunktionen Cardiac causes Her zinsuffizienz humidity RG, S3 gallop and signs of central or peripheral volume overload (eg. As increased neck veins, peripheral edema) orthopnea or paroxysmal nocturnal dyspnea auscultation chest x-ray echocardiography Stable angina pectoris or coronary heart disease Substernales feeling of pressure in the chest with or without radiation on the arm or jaw, often caused by physical exertion, especially in patients with risk factors for CHD EKG cardiac stress test Sometimes cardiac catheterization Other causes anemia dyspnea on exertion to dyspnea at rest Normal lung examination and Pulsoxymetriemessung Sometimes sys tolisches heart murmur due to the increased flow of blood Physical deconditioning dyspnea only on exertion in patients with sedentary Clinical Assessment * Chronic respiratory distress occurs within hours to years. † Most patients should have a pulse oximetry and – unless the symptoms are clearly a slight gain of a known chronic disease – chest X-ray perform. CHD = coronary artery disease; S3 = third heart sound. In regard to etiology first Pratter MR, Curley FJ, Dubois J, Irwin RS: Cause and evaluation of chronic dyspnea in a pulmonary disease clinic. Arch Intern Med 149 (10): 2277-2282, 1989. The history judgment history of the present illness should the duration time occurrence (for example, abrupt, gradual.) And initiating or enhancing factors (e.g., contact with allergens, cold. , supine) covering effort. The severity can be obtained by the evaluation of the activity level, which is required in order to cause dyspnea (z. B. dyspnea at rest is more serious than dyspnea, which occurs only when climbing stairs) are determined. Physicians should determine the extent to which dyspnea has changed from the usual condition of the patient. In examining the body systems of possible causes including chest pain or pressure (pulmonary embolism, myocardial ischemia, pneumonia) should be looked for symptoms; dependent edema, orthopnea and paroxysmal nocturnal dyspnea (heart failure); Fever, chills, cough and sputum (pneumonia); black, tarry stools or clinically severe menstrual (occult bleeding that may cause anemia) as well as weight loss or night sweats (cancer or chronic infection of the lungs). The history should known diseases that cause dyspnea such. As asthma, COPD and heart disease and risk factors for various causes include: a history of smoking-cancer, COPD and heart disease family history, high blood pressure and high cholesterol levels-for occult coronary heart disease Current immobilization or surgery, recent long-distance travel, cancer or risk factors or signs of cancer, previous or occurring in the family clotting disorders, pregnancy, use of oral contraceptives, calf pain, swollen legs and known deep occupational venous thrombosis of pulmonary embolism exposures (z. B. gases, fumes, asbestos) should be investigated werden.Körperliche investigation the Vital signs are checked for fever, tachycardia, and tachypnea. The investigation focuses on the cardiovascular and pulmonary systems. It is carried out a full examination of the lungs, including in particular its level of input and efflux of air, symmetry of breath sounds and the presence of damp RG, wheezing, stridor and wheezing. It should be looked for signs of consolidation (z. B. Ägophonie, dull sound head). The cervical, supraclavicular and Inguinalbereiche should be inspected and palpated on lymphadenopathy. The neck veins were inspected for distension and legs as well as the pre-sacral area dented edema (both point to heart failure back) are palpated. The heart sounds were bugged and all occurring additional heart sounds, muffled heart sounds or noises are recorded. The study on paradoxical pulse (a> 12 mmHg drop in systolic BP during inspiration), by inflating the blood pressure cuff to 20 mmHg above the systolic pressure and then slowly drain until the first Korotkoff sounds can only be heard when breathing out, happen. Upon further deflating the cuff is the point at which the first Korotkoff sounds can be heard both during inspiration and expiration, is recorded. If the difference between the first and the second measurement> 12 mmHg, there is a pulsus paradoxus. The conjunctiva should be examined for pallor. A rectal exam and fecal occult blood tests should werden.Warnzeichen performed The following results are of particular importance: dyspnea at rest during the investigation of consciousness or restlessness or confusion use of respiratory muscles and poor air excursion chest pain humidity RG weight loss night sweats palpitations interpretation of results The history and the physical examination often point to the cause and carry out further investigations (see table: causes of acute dyspnea *, see table: causes of subacute * dyspnea and see table: * causes of chronic dyspnea). Several findings are remarkable. Wheezing is an indication of asthma or COPD. In stridor (z. B. Foreign body aspiration, epiglottitis, vocal cord dysfunction) is a extrathoracic airway obstruction to think. Humidity RG indicate a left ventricular failure or interstitial lung disease or no, if there are the same signs of consolidation, a pneumonia. However, the symptoms and signs of life-threatening diseases such as ischemia and pulmonary embolism can be non-specific. In addition, the severity of the symptoms is not always proportional to the seriousness of the cause (eg. Example, a pulmonary embolism in fit, healthy people cause only mild dyspnea). Therefore, a high degree of suspicion at these common diseases is attached. It often makes sense to exclude these diseases before the dyspnoea a less serious cause is attributed. A clinical prediction rule (see Table: Clinical Prädiktionsregel for the diagnosis of pulmonary embolism) can help define the risk of pulmonary embolism. It should be noted that a normal oxygen saturation does not rule out a pulmonary embolism. The hyperventilation syndrome is a diagnosis of exclusion. Because hypoxia may cause tachypnea and unrest, it is unwise to assume that any fast breathing, restless, young person should be performed in all patients at a hyperventilation syndrome leidet.Tests A pulse oximetry, as a chest x-ray, unless the symptoms come clearly from a mild or moderate exacerbation of existing disease. For example, require patients with asthma or heart failure no radiograph with every inflammatory episode unless the clinical findings suggest another cause or an unusually severe attack suspect. For most adults, an ECG should be performed to diagnose myocardial ischemia (and “serum cardiac marker testing” when the strong suspicion), unless a myocardial ischemia can be clinically excluded. In patients with significantly impaired or of insufficient breathing a measurement of the BGAs should be made to quantify the hypoxemia specifically, PaCO2 measured, the acid-base status as a possible cause of hyperventilation is determined and the alveolar-arterial gradient are determined. Clinical Calculator: Aa Gradient patients who have no clear diagnosis by chest x-ray and ECG and a moderate or high risk of pulmonary embolism have (based on clinical prediction rule-see Table: Clinical Prädiktionsregel for the diagnosis of pulmonary embolism) should a CT angiography or undergo ventilation / perfusion scintigraphy. Patients at low risk should eventually perform a d-dimer test (normal d-dimer levels include a pulmonary embolism in a patient with low-risk definitely out). In chronic dyspnea another specific diagnosis such as CT, lung function tests, echocardiography and bronchoscopy should be done. Therapy therapy means the treatment of disorders based. Hypoxia is treated with that administration of oxygen, which is needed to an oxygen saturation treated> 88% or PaO 2> 55 mmHg because values ??above this limit to ensure the maintenance of adequate oxygenation of all organs. Values ??below these limits are located on the steep portion of the oxygen-dissociation curve Hb, which can already result in a small decrease of the oxygen tension to excessive waste of Hb saturation. Threatening myocardial or cerebral ischemia, oxygen saturation should be kept> 93%. The administration of morphine 0.5-5 mg iv can help to take the patient’s anxiety and alleviate perceived as unpleasant shortness of breath in various diseases such. As in myocardial infarction, pulmonary embolism and frequent dyspnea präfinaler patients. In patients with acute airway obstruction (eg., Asthma, COPD) may reduce opiates by a reduction in respiratory drive the oxygen consumption of the diaphragm, which can lead to faster recompensation. (N. D. Talk .: Careful monitoring of blood gases is obligatory. In case of impending hypercapnic pump failure a non-invasive mask ventilation should be used.) Conclusion pulse oximetry is an essential part of Untersuchcung. A low oxygen saturation (<90%) points to a serious problem, but a normal saturation does not mean that there is no problem. The use of the respiratory muscles, a sudden falling oxygen saturation or decreased consciousness make an urgent clarification and hospitalization myocardial ischemia and pulmonary embolism are relatively common, but the symptoms and complaints may be nonspecific. An exacerbation of existing disease (eg., Asthma, COPD, heart failure) is widely used, but patients can also develop new symptoms.

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