Dyspnea is defined as an abnormal and unpleasant awareness of breathing. It is a symptom that can reveal multiple causes, some of which are life-threatening. Urgent diagnoses such as pulmonary embolism or acute pulmonary edema are diagnoses not to be missed.
CLINIC:
Examination:
It specifies the cardiovascular history, the mode of installation of the dyspnea, its schedule and the triggering circumstances (effort).
Physical examination :
CARDIACEXAMINATION AND VASCULAR:
– Presence of added noise (breathing, galloping, friction), presence of abnormal rhythm;
– BP, pulse, extremities, cyanosis;
– Look for signs of right heart failure: jugular turgidity, hepatic jugular reflux, edema of the lower limbs.
PULMONARY EXAMINATION:
Pulmonary hearth, crackles, sibilants, pleural effusion. An abolition of the vesicular murmur, a tympanism.
GENERAL EXAMINATION:
The patient’s condition, his position, sweats, anxiety.
In general, this first examination defines the urgency of the situation and evokes a diagnostic framework: heart failure, asthma, suspicion of pulmonary embolism
ADDITIONAL EXAMINATION:
Complementary exams in the emergency and in daily practice are limited: an ECG is the most useful exam.
If the acute episode is over, the exams will be directed by the clinic:
– D-dimer in case of suspicion of embolism, followed by ultrasound in urgency;
– Blood gas ;
– Pulmonary radiography.
ETIOLOGICAL DIAGNOSIS:
Obstruction of the airways:
D YSPNEA LARYNGEAL:
It is an inspiratory, noisy dyspnea, with draft and cornea and sometimes laryngeal ictus (acute dyspnea distressing, resolving and relapsing, related to spasm of the larynx). The etiologies are inflammatory, tumoral or traumatic. The emergency ENT examination makes the diagnosis.
DYSPNEA OF TRACHEAL ORIGIN:
It is a slow-acting dyspnea with, in principle, a characteristic wheezing, sometimes misleading, asthmatic type. The causes are multiple, dominated by tumors (cancer, goiter goitre, etc.), post-intubation stenosis, Wegener’s disease, amyloidosis ….
Diagnosis is made by endoscopic examination and chest CT.
ASTHMA ATTACK:
It is expiratory dyspnea, wheezing, with high frequency, with signs of thoracic distention, most often nocturnal.Auscultation perceives sibilant rattles in both lung fields, and there is an accompanying cough with thick mucus emission.
The differential diagnoses are cardiac asthma in the elderly, bronchial superinfection asthma attacks, and low tracheal tumors in the smoker.
Vascular abnormality and pulmonary parenchyma:
PULMONARY EMBOLIA:
In typical cases, dyspnea is acute, with lateralized chest pain occurring in a subject at risk or with recent phlebitis. It’s a diagnostic emergency. Early initiation of anticoagulant therapy is necessary upon suspicion.
– The clinic is unfortunately misleading (50% of cases), the diagnosis is difficult and, it is necessary to think systematically in front of acute dyspnea and affirm or deny it.
This diagnostic tree is classic but difficult to achieve quickly in practice, hence the current interest of helical thoracic CT angiography. Hospitalization is usually essential.
ACUTE NEUMOPATHY:
This is the differential diagnosis of pulmonary embolism. But most often fever is accompanied by shivering, dyspnea is transient, pulmonary signs in focus (clinical and radiology). There is no thrombogenic context.
ACUTE RESPIRATORY DISTRESS SENES (ARDS):
It is revealed by rapid dyspnea with polypnea and cyanosis, hospitalization is required. The chest x-ray shows a “white lung”, usually bilateral. The causes are varied.
ACUTE CARDIOGENIC LUNG (OAP) DME :
It is dyspnea with orthopnea, laryngeal crackles. Sputum is foamy and pinkish.
Pulmonary auscultation notes inspiring crepuscular rales progressing from the bases to the peaks. Cardiac auscultation will look for valve breathing, tachycardia, galloping and arrhythmia.
The history of heart disease will help for the diagnosis, otherwise the search for a myocardial infarction is imperative (ECG, cardiac enzymes).
The chest X-ray shows signs of pulmonary edema, with vascular redistribution to the apices.
ACUTE PERICARDITIS:
It is a dyspnea with orthopnea, associated with chest pain and sometimes signs of right cardiac decompensation, in case of constrictive pericarditis. Auscultation may perceive a pericardial friction. The diagnosis, evoked on the ECG, is posed by echocardiography.
Pleural causes:
PNEUMOTHORAX (PNO):
Brutal dyspnea with lateralized chest pain, immobile hemithorax, tympanic, with abolition of vesicular murmur (MV). X-ray of the frontal lungs must include an inspiratory and expiratory (partial PNO) and shows a retracted lung.
ABUNDANT PUREE:
The dyspnoea is in progressive rule but can become acute in case of rapid increase of the effusion.
It is accompanied by a dullness with the abolition of the vesicular murmur. The chest x-ray shows opacity. The evacuation and exploratory puncture is essential.
Other dyspnoea:
– Anxiety neurosis: the clinical examination is normal. It will be a diagnosis of elimination.
– Inadaptation to the effort: the respiratory functional exploration can help, it is seldom an acute dyspnea.
– Metabolic problems: acidosis (Kussmaul dyspnea), shock, acute anemia.
– Cheyne-Stokes dyspnea.
