Dyspnea

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Pathophysiology

Etiologies

Airway obstruction

(' resistance to airflow)

Asthma, COPD. bronchiectasis (permanent dilation of airways with obliteration by secretions, infections, fibrosis), tumor or foreign body

Parenchymal disease

(t resistance to expansion)

Pulmonary edema cardiogenic: LV systolic or diastolic dysfxn noncardiogenic: ALI/ARDS ILD

Vascular

(V/Q mismatch)

Large vessel: PE. tumor emboli

Small vessel: PHT. vasculitis. ILD. emphysema

Bellows

(T resistance to CW/diaphragm expansion; weakness of respiratory muscles)

Pleural disease: effusion, fibrosis

Chest wall/diaphragm: kyphoscoliosis, i abd girth

Neuromuscular disorders

Hyperinflation (COPD. asthma)

Stimulation of receptors ; Oj carrying cap. (but nl P.Oj)

Chemoreceptors: hypoxemia, metabolic acidosis Mechanoreceptors: ILD. pulmonary edema. PHT. PE Anemia, methemoglobinemia. CO poisoning

Psychological

Anxiety, panic attack, depression, somatization

Evaluation

• Cardiopulmonary exam. S,Oj. CXR. ECG

predictors of CHF: h/o CHF. PND. S). CXR w/ venous congestion. AF ^ama 2005:294:1944) dyspnea w/ nl CXR — CAD. asthma. PE. PHT. early ILD. anemia, acidosis. NM disease

• Based on results of initial evaluation: PFTs. chest CT.TTE. cardiopulmonary testing

• BNP & NT-proBNP t in CHF (but also t in AF. RV strain from PE. COPD flare. PHT)

BNP -100:90% Se. 76% Sp for CHF causing dyspnea (NijM 2002.347 161) NT-proBNP: >300 pg/mL - 99% Se. 60% Sp for CHF ( use 300 to rule out) to rule in use age-related cutpoints: >450 pg/mL if 50 y. 900 if 50-75 y. 1800 if ^75 y - 90% Se. 84% Sp (£HJ 2006:27:330) t in chronic heart failure, need to compare to known "dry BNP"

PULMONARY FUNCTION TESTS (PFTs)

• Spirometry: evaluate for obstructive disease

Flow-volume loops: diagnose and/or localize obstruction

Bronchodilator: indicated if obstruction at baseline or asthma clinically suspected Methacholine challenge: helps dx asthma if spirometry nl. 20% i FEN^ — asthma

• Lung volumes: evaluate for restrictive disease including NM causes

• DlCO: evaluates functional surface area for gas exchange; helps differentiate causes of obstructive and restrictive diseases and screens for vascular disease & early ILD

Figure 2-1 Approach to abnormal PFTj

Approach to abnormal PFTs fev./fvc <0.75

OBSTRUCTIVE PATTERN

TLC <80% predicted

RESTRICTIVE PATTERN

FEV, response to bronchodil. 1

i dlco

FEV, response to bronchodil. 1

Abnl dt co w/ normal spirometry / \ 1 dlco t dlco

Asthma ILD Hemorrhage CHF Polycythemia t Pulm blood vol. (e.g.. obesity, mild CHF. L-»R shunts)

nl Dl co

/iPimax ij,

Pleural disease?

disease

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