DR IMRAN MEHFOOZ KHAN ASSITANT PROFESSOR EAST MEDICAL

DR. IMRAN MEHFOOZ KHAN ASSITANT PROFESSOR EAST MEDICAL WARD MAYO HOSPITAL, LAHORE

Breathlessness (LVF)

Case history A 70 years old lady presented with the complaint of shortness of breath for the last 6 months. This complain has been progressive. Initially breathlessness was on exertion only but now she feels breathless on lying in bed without three pillows. She also wakes up from sleep a number of times at night. She lives on second floor and has to climb a flight of 10 stairs. Recently she has started to experience chest discomfort along with breathlessness. WHAT IS THE DIAGNOSIS?

Heart failure is a complex syndrome resulting from structural or functional cardiac disorder that impairs the ability of heart to act as a pump to support physiologic circulation and is characterized by symptoms such as breathlessness and fatigue and signs of fluid retention. Symptoms; left ventricular failure (LVF) may result in dyspnea , orthopnea , paroxysmal nocturnal dyspnea , nocturnal cough or fatigue. Signs; Hypotension Tachycardia Third heart sound Edema Bibasal crepitations/crackles

NYHA classification of heart failure Class 1 – no limitations Class 2 – slight limitation of physical activity Class 3 – marked limitation of physical activity Class 4 – symptoms at rest

Definitions Breathlessness/dyspnea; Undue awareness of breathing. It is normal with strenuous physical exercise. Hypoapnea; Shallow breathing or low respiratory rate. Orthopnea; Breathlessness on lying flat. Paroxysmal nocturnal dyspnea; Breathlessness that wakes up the patient from sleep. Tachypnea; Increased rate of breathing. Hyperventilation; Inappropriate overbreathing

History Mode of onset Duration Progression Variability Aggravating /relieving factors Severity Associated symptoms

Mode of onset , duration and progression of breathlessness In minutes; Pulmonary thromboembolism Pneumothorax Acute pulmonary edema Acute attack of asthma Inhaled foreign body In hours/day; Pneumonia Exacerbation of COPD

Mode of onset , duration and progression of breathlessness Weeks to months; Pleural effusion Anemia Pulmonary Months tuberculosis to years; COPD Pulmonary fibrosis Congestive cardiac failure

Severity of breathlessness: medical research council (MRC) classification Grade 1; breathless when hurrying on the level ground or walking up a slight hill Grade 2; breathless when walking with people of own age on level ground Grade 3; has to stop because of breathlessness when walking on level ground at own pace

Associated symptoms No chest pain; Pulmonary Metabolic edema acidosis Anemia Pleuritic chest pain; Pneumonia Pneumothorax Pulmonary Rib embolism fracture

Associated symptoms Central chest pain; Myocardial infarction leading to acute left ventricular failure Massive Wheeze pulmonary embolism/infarction cough; Asthma Chronic obstructive pulmonary disease

Causes of heart failure Ischemic heart disease Hypertension Valvular heart disease. Aortic stenosis. Arrhythmias – AF Cardiomyopathy Myocarditis Pericardial High disease output failure – thyrotoxicosis, anemia.

Differential diagnosis Cardiac causes; Left ventricular failure Mitral valve disease Congestive cardiac failure Cardiomyopathy Pericardial effusion Respiratory causes; Airway: Foreign body Asthma COPD Bronchiectasis Lung cancer

Differential diagnosis Parenchymal: Pulmonary fibrosis Tuberculosis Pneumonia Pulmonary circulation: Pulmonary thromboembolism Pulmonary hypertension Pleural: Pneumothorax Effusion Chest wall: Kyphoscoliosis Neuromuscular: Myasthenia Guillian gravis barre syndrome

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