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130110110177|Gabriella Chafrina| 27/11/13

DYSPNEA
Definition: Breathlessness or shortness of breath, difficult or labored breathing
Types of dyspnea:
a) Dyspnea on exertion: dyspnea provoked by physical effort or exertion
b) Cardiac dyspnea: caused by cardiac disease
c) Expiratory dyspnea: caused by hindrance to the free exhalation of air from lungs
d) Inspiratory dyspnea: caused by hindrance to the free inhalation of air into lungs
e) Functional dyspnea: often associated into anxiety status
f) Nocturnal dyspnea: minimal in the morning and gradually and become severe at night
g) Non-expansional dyspnea: caused by inadequate expansion of chest
h) Paroxysmal nocturnal dyspnea: respiratory distress that awakens patients from sleep and is
related to posture. Usually attributed to congestive heart failure with pulmonary edema and
sometimes in patients with chronic pulmonary disease
i) Orthostatic dyspnea: occurs in erect position
j) Renal dyspnea: anemia/volume overload associated with kidney disease
Common causes of dyspnea:
a) Upper airway: foreign body/mass, allergic reaction, airway stenosis, tracheomalacia
b) Lung/lower airway: pneumonia, pneumothorax, pleural effusion, pulmonary embolism,
pulmonary hypertension, interstitial lung disease, adult respiratory distress syndrome, COPD,
asthma, mass
c) Cardiac: myocardial ischemia, CHF, pericardial effusion, valvular disease, arrhythmia
d) Metabolic/hematologic: Thyrotoxicosis, Hb abnormality, anemia, disorder of phosphate/K
+
/Ca
2+
,
sepsis/fever, acidosis
e) Neuromuscular: GBS, myasthenia gravis, myopathy, neuropathy
f) Psychogenic: panic disorder, hyperventilation, deconditioning
g) Massive ascites
h) Drug withdrawal

Mechanism of dyspnea in chronic obstructive
pulmonary disease (COPD). Airways narrow on
expiration but, in normal individuals, the elasticized
alveolar attachments prevent closure so the alveoli
empty. In COPD there is a loss of elastin fibers as a
result of elastases, which means that even in mild
COPD small airways close to a greater extent. As
COPD becomes more severe, the thickness of small
airways increases and alveolar attachments may be
disrupted so that a peripheral airway may close
during expiration, which results in air trapping and
hyperinflation that leads to dyspnea and a reduced
exercise capacity






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130110110177|Gabriella Chafrina| 27/11/13
COUGH Adult (chronic)
DIAGNOSTIC ISSUES HISTORY PHYSICAL EXAM
Cigarette smoking Minimal sputum Usually normal but eventually leads
to abnormalities
Chronic lung disease
(chronic bronchitis and
emphysema)
Dyspnea; cough and sputum production
tend to be wose after arising from sleep.
Patient is usually a heavy cigarette smoker
or has had chronic exposure to industrial
dusts
Hyperresonant lung fields, distant
breath sounds, scattered rhonchi or
wheezes, prolonged expiration
Secondary to medication Captopril or other angiotensin converting
enzyme inhibitor; beta-blockers may
aggravate an asthmatic cough
Normal
Gastrointestinal reflux Heartburn occasionally noted Normal exam
Psychogenic Mostly in daytime Barking, loud cough; normal exam
Lung tumor Change in cough pattern. Hemoptysis and
chest ache may occur. Patient is usually a
cigarette smoker
Usually normal. Enlarged
supraclavicular nodes may be
palpated
Tuberculosis Fever, night sweats, weight loss; chronic
cough and occasional hemoptysis. Some
patients note a recent exposure to active
tuberculosis or a history of a positive
tuberculin test
Exam is usually normal; apical
rales/crackles, weight loss, and fever
may be present
Congestive heart failure or
mitral stenosis
Nocturnal coughing, orthopnea, dyspnea,
paroxysmal nocturnal dyspnea
Moist rales/crackles at both bases;
ankle edema. Heart exam may
reveal an S
3
gallop, a diastolic
murmur, or a loud pulmonic
component of the second heart
sound

SPUTUM
Also called mucus or phlegm, is a protective substance produced by the lungs to aid in the trapping and
removal of foreign particles. It is expelled by coughing or clearing of the throat. Patients with COPD
usually produce small amounts of tenacious sputum when they cough. A copious amount of thick
sputum is often associated with a bacterial lung infection, which can exacerbate COPD symptoms. The
color and consistency of sputum may change when a bacterial infection is present.
1. Bloody (Hemoptysis)
1. blood-streaked sputum - inflammation of throat, bronchi; lung cancer;
2. Pink sputum - sputum evenly mixed with blood, from alveoli, small bronchi;
3. massive blood - cavitary tuberculosis of lung, lung abscess, bronchiectasis, infarction, embolism.
2. Rusty colored - usually caused by pneumococcal bacteria (in pneumonia)
3. Purulent - containing pus. The colour can provide hints as to effective treatment in Chronic
Bronchitis Patients:
1. a yellow-greenish (mucopurulent) color suggests that treatment with antibiotics can reduce
symptoms. Green color is caused by Neutrophil Myeloperoxidase
2. a white, milky, or opaque (mucoid) appearance often means that antibiotics will be ineffective in
treating symptoms. (This information may correlate with the presence of bacterial or viral
infections, though current research does not support that generalization)
4. Foamy white - may come from obstruction or even edema.
5. Frothy pink - pulmonary edema
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130110110177|Gabriella Chafrina| 27/11/13
AMINOPHYLLINE

SALBUTAMOL

FUROSEMIDE


BMI
In our patient: BMI = 48/((1.65)
2
) = 17.63

From WHO 2000 BMI and Protein Energy Malnutrition (PEM) Category








BMI Grade
<16 Grade III PEM
16.0-16.9 Grade II PEM
17.0-18.5 Grade I PEM (Underweight)
18.5-24.9 Normal
25.0-29.9 Overweight
30.0-34.9 Class I Obese
35.0-39.9 Class II Obese
>40 Class III Severe Obesity
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VITAL SIGN (ADULT)
BLOOD PRESSURE
CATEGORY SYSTOLIC (mmHg) DIASTOLIC (mmHg)
HYPERTENSION
STAGE 3 (SEVERE) >180 >110
STAGE 2 (MODERATE) 160-179 100-109
STAGE 1 (MILD) 140-159 90-99
HIGH NORMAL 130-139 85-59
NORMAL <130 <85
OPTIMAL <120 <80

HEART AND PULSE RATE TEMPERATURE RESPIRATORY RATE
Normal: 60-100 beats/minute Normal: 36.5-37.5
o
C Normal: 16-24 breath/minute

PROLONGED EXPIRATION
Respiratory condition wherein there is an increase in the expiratory time of a person compared to the
inspiratory time which is often characterized by a person's difficulty in breathing.
In COPD, expiration is prolonged as the patient forces his breath out through obstructed airways

PURSED LIPS BREATHING
The act of exhaling through tightly pressed,
pursed lips. Doctors and respiratory
therapists teach the technique to their
patients to ease shortness of breath and to
promote deep breathing, also referred to as
abdominal or diaphragmatic breathing. The
purpose of PLB is to create back-pressure
inside airways to splint them open; moving
air thus then takes less work.
Spontaneous breathing through pursed lips,
especially after physical exercise, is also one
of the signs that health workers use to
detect possible chronic obstructive
pulmonary disease (COPD) in patients.
Some therapists say that using PLB has
positive effects in treating stress and anxiety related disorders.

JUGULAR VENOUS PRESSURE
A. Normal: 4 cm or less
B. Increased >4 cm (Jugular Venous Distention)
1. Right-sided Heart Failure (most common)
a. Increased right atrial pressure
2. Constrictive Pericarditis
3. Tricuspid stenosis
4. Superior Vena Cava Obstruction
5. Valsalva phenomenon (laughing, coughing)


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BARREL SHAPED CHEST
- Increase in the anterior posterior diameter of the
chest wall resembling the shape of a barrel, most
often associated with emphysema
- Characteristic: round and bulging chest, large ribcage,
very round torso, large lung capacity, and can
potentially have great upper body strength
- In COPD: lungs chronically overinflated with air rib
cage stays partially expanded all the time
breathing less efficient and aggravates any existing
shortness of breath

LUNG LIVER BORDER

The upper border of liver dullness is defined by:
o 5th intercostal space in the midclavicular line
o 7th intercostal space in the midaxillary line
o 9th intercostal space in the scapular line
Note: 9th intercostal space is located approximately at the inferior border of the scapula

HYPERSONAR
Also called hyperresonant. In percussion, heared tympanic or drum-like, as
opposed to dull
Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.
Hyperresonant sounds that are louder and lower pitched than resonant sounds are
normally heard when percussing the chests of children and very thin adults.
Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air,
such as may occur in patients with COPD, or patients having an acute asthmatic attack.
An area of hyperresonance on one side of the chest may indicate a pneumothorax.
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WHEEZING AND CRACKLES
Crackles are discontinuous, explosive, "popping" sounds that
originate within the airways. They are heard when an obstructed
airway suddenly opens and the pressures on either side of the
obstruction suddenly equilibrates resulting in transient, distinct
vibrations in the airway wall. The dynamic airway obstruction can
be caused by either accumulation of secretions within the airway
lumen or by airway collapse caused by pressure from inflammation
or edema in surrounding pulmonary tissue. Crackles can be heard
during inspiration when intrathoracic negative pressure results in
opening of the airways or on expiration when thoracic positive
pressure forces collapsed or blocked airways open. Crackles are
heard more commonly during inspiration than expiration. They are
significant as they imply either accumulation of fluid secretions or
exudate within airways or inflammation and edema in the
pulmonary tissue.

Wheezes are continuous musical tones that are most
commonly heard at end inspiration or early expiration. They
result as a collapsed airway lumen gradually opens during
inspiration or gradually closes during expiration. As the
airway lumen becomes smaller, the air flow velocity increases
resulting in harmonic vibration of the airway wall and thus the
musical tonal quality. Wheezes can be classified as either high
pitched or low pitched wheezes. It is often inferred that high
pitch wheezes are associated with disease of the small
airways and low pitch wheezes are associated with disease of
larger airways. However, this association has not been
confirmed. Wheezes may be monophonic (a single pitch and
tonal quality heard over an isolated area) or polyphonic
(multiple pitches and tones heard over a variable area of the
lung). Wheezes are significant as they imply decreased airway
lumen diameter either due to thickening of reactive airway
walls or collapse of airways due to pressure from surrounding
pulmonary disease.

CLUBBING FINGER
Also called drumstick finger or watch-glass nails.
Clubbing finger is a deformity of
the fingers and fingernails associated with a number of
diseases, mostly of the heart and lungs







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NORMAL LABORATORY TEST (IN PAGE)

Hemoglobin


WBC

DIFFERENTIAL COUNT

PLATELET


EMPHYSEMATOUS LUNG
Emphysema is a chronic lung condition in which the lungs'
natural airspaces, called alveoli, become larger but
decrease in number. The tissue surrounding the alveoli loses
elasticity so that the airspaces can no longer expand and
shrink as usual. This reduces the amount of oxygen
transferred by the
lungs to the
bloodstream,
making it more
difficult for you to
breathe






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130110110177|Gabriella Chafrina| 27/11/13
SPIROMETRY

BLOOD GAS ANALYSIS








ECHOCARDIOGRAPHY

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BOHR EFFECT
A shift of the oxygen hemoglobin dissociation curve to the
right in response to increases in blood carbon dioxide and
hydrogen ions has a significant effect by enhancing the
release of oxygen from the blood in the tissues and
enhancing oxygenation of the blood in the lungs. As the
blood passes through the tissues, carbon dioxide diffuses
from the tissue cells into the blood. This increases the blood
Po2, which in turn raises the blood H
2
CO
3
(carbonic acid) and
the hydrogen ion concentration. These effects shift the
oxygen-hemoglobin dissociation curve to the right and
downward, forcing oxygen away from the hemoglobin
and therefore delivering increased amounts of oxygen to the
tissues. Exactly the opposite effects occur in the lungs,
where carbon dioxide diffuses from the blood into the
alveoli. This reduces the blood Pco2 and decreases the hydrogen ion concentration, shifting the oxygen-
hemoglobin dissociation curve to the left and upward. Therefore, the quantity of oxygen that binds with
the hemoglobin at any given alveolar Po2 becomes considerably increased, thus allowing greater oxygen
transport to the tissues.

FACTOR INFLUENCE O
2
BIND TO Hb
- pH H
+
and O
2
both compete for binding to the Hb molecule
- CO
2
concentration influences intracellular pH and CO
2

accumulation causes carbamino compounds to be generated
through chemical interactions, which bind to Hb forming
carbaminohemoglobin
- blood temperature when will weaken and denature bond
between oxyhemoglobin
- 2,3-biphosphoglycerate (BPG) an organophosphate which is
created in erythrocytes during glycolysis