Professional Documents
Culture Documents
Approach to SOB
Badr Alsayed, MBBS MPH
Dyspnea (SOB)
• 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, and it may induce
secondary physiological and behavioral
responses
Mechanisms of Dyspnea
Mechanisms of Dyspnea
DYSPNEA IN HPI
“QUESTIONS”
DIFFERENTIAL DIAGNOSIS OF
DYSPNEA
Non-cardiorespiratory
• Anemia
• Metabolic acidosis
• Obesity
• Psychogenic
• Neurogenic
Cardiac
• LVF
• Mitral valve disease
• Cardiomyopathy
• Constrictive pericarditis
• Pericardial effusion
Respiratory
Airways
– Laryngeal tumor – Lung cancer
– Foreign body – Bronchiolitis
– Asthma – Cystic fibrosis
– COPD
– Bronchiectasis
Respiratory
Parenchyma
• Pulmonary fibrosis • Tumor (Metastatic,
• Alveolitis lymphangitis)
• Sarcoidosis • Diffuse infections (PCP)
• TB
• Pneumonia
Respiratory
Pulmonary circulation
• PE
• Pulmonary vasculitis
• Primary pulmonary arterial hypertension
Respiratory
others
• Pleural:
– Pneumothorax
– Effusion
– Fibrosis
• Chest wall:
– Kyphoscoliosis
– Ankylosing spondylitis
• Neuromuscular:
– MG
– Neuropathies
– GBS
BRONCHIAL ASTHMA
Definition
• Chronic reversible inflammatory airway
disease characterized by airway remodeling
and hyperresponsiveness lead to recurrent
attacks of breathlessness and wheezing
• Greek verb (aazein), that means “panting” or
“gasping”
Bronchial asthma
• “A chronic inflammatory disorder of the airways
in which many cells and cellular elements play a
role. The chronic inflammation is associated with
airway responsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in
the early morning. These episodes are usually
associated with widespread, but variable, airflow
obstruction within the lung that is often reversible
either spontaneously or with treatment”
GINA 2015
Airway Remodeling
• Structural alteration of the airway with
characteristic changes in the nature, content,
and distribution of airway elements
Challenges
• No feature is unique to asthma
• No feature is universal in ALL asthmatic
• No gold standard diagnostic test for asthma!
GINA 2015
Bronchial
Asthma
Bronchial
Asthma
Pulmonary Pneumonitis
Fibrosis
Cardiac
COPD
OSA
BE
31
64
Jun Ma1,2, Peg Strub et al, Annals of the American Thoracic Society, 2015
Genetics
• Polygenic inheritance
• Poorly defined
• Atopic: runs in families
• Non-atopic: intrinsic or late asthma
• Severity of asthma: genetically determined
• Response to therapy: genetically
determined
Tobacco Use and Environmental
Exposure
• An increased risk of abnormal lung
function
• Wheezing illnesses in childhood, an effect
that persists into adulthood
• Population-based studies demonstrate
that environmental tobacco exposure in
childhood also results in an increased risk
of asthma
Coexisting Disorders and Conditions
• GERD
• Sleep disorders
• Beta-blockers induced
• NSAIDs (including ASA) allergies
• Allergic Rhinitis
Clinical Features
• Wheezing
• Dyspnea
• Coughing
• Difficulty in filling their lungs with air
• May worse at night
• Increased mucus production
• The pattern of symptoms
Investigations
• Spirometry
• Serial peak expiratory flow rate (PEFR)
• Bronchoprovocation testing is paned in SA
• Trial of inhaled steroids or bronchodilator
Peak Flow Meter
Morning dipping
Pathophysiology
Flow-Volume Loop in early and late
asthma
Skin Testing
Clinical Assessment
• Assess asthma control
• Document current treatment (side effects,
adherence, and inhaler technique)
• Written asthma action plan
• Assess comorbidities such as rhinosinusitis,
GERD, obesity, obstructive sleep apnea, and
anxiety (You may refer)
• Close monitoring for patients with severe
asthma (You may refer)
Asthma Control Test
• Controlled: an ACT score of ≥20
• Partially controlled: an ACT score of 16–19
• Uncontrolled: an ACT score of <16.
Controlled
All of the following:
1) No daytime symptoms or <1x/wk
2) Limitations of activities: none
3) Nocturnal awakening: none
4) Need for reliever (rescue) medication: <2x/wk
5) FEV1 or peak flow: normal
6) Exacerbations: none
Partly controlled
Any measure present, in any week:
1) Symptoms >2x/wk
2) Limitations of activities: any
3) Nocturnal awakening: any
4) Need for reliever (rescue) medication: >2x /wk
5) FEV1 or peak flow: <80% predicted or of personal
best (if known)
6) Exacerbations: one or more a year
Uncontrolled
• Three or more features of partly controlled
asthma
• Present in any week
• An exacerbation in any 1 week makes a poorly
controlled asthma week
Severity Classification
• Mild asthma: Controlled asthma at step 1 or 2 (as
needed
reliever treatment, monotherapy of low-dose ICS, or
leukotriene receptor antagonist [LTRA])
• Moderate asthma: Controlled asthma at step 3 (on
combination of ICS/long-acting beta 2 agonist [LABA] or
other alternative options at steps 3)
• Severe asthma: Asthma that requires treatment step 4
or 5
(on combination of high-dose ICS/LABA with or without
add-on treatment).
Serious Complications
• Pneumothorax
• Coma
• Respiratory failure/arrest
Classification
• Mild-intermittent
• Mild-persistent
• Moderate-persistent
• Severe
• Very sever (life-threatening)
Clinical classification of severity[
Use of short-
acting beta2-
Severity in
Symptom Nighttime %FEV1 of agonist for
patients ≥ 12 FEV1Variability
frequency symptoms predicted symptom control
years of age [9]
(not for
prevention of EIB)
Intermittent ≤2 per week ≤2 per month ≥80% <20% ≤2 days per week
SINA 2016
Nonpharmacological Management
• Indoor allergens and air pollutants
• Outdoor allergens
• Occupational exposures
• Food and drugs
• Influenza vaccination
SINA 2016
Take Home Message
• Educate your patients: Triggers
• Importance of maintenance therapy
• No “addiction” to inhalers
• Do not underestimate asthma attack
• If not certain about the diagnosis, “?”
• Use referral system wisely
• Encourage family support
THANKS