同济医学院诊断学-呼吸障碍课件

Dyspnea

1Definition:

Dyspneaisdefinedasanawarenessofdifficultyinbreathing

Itisthereforeasymptom,usuallydescribedbythepatientas“shortofbreath,”whetherthesensationisduetoactualdifficultyinbreathingorisessentiallyanawarenessofhyperventilation.Ifthesymptombecomesstriking,italwayscompanieswithdilatationofnares,cyanosis,useofaccessorymusclesofrespirationandabnormalitiesofrespiratoryrate,depthorrhythm.Definition:2RespiratorydiseasesCirculatorydiseasesPoisoningHematologyNeuropsychogenicfactorsEtiologyRespiratorydiseasesEtiology3RespiratorydyspneaCausedbyabnormalventilationandgasexchange,reductioninventilatorycapacity,hypercapniaandhypoxemiaresultingfromrespiratorydisease.Threeclininaltypes:InspiratorydyspneaExpiratorydyspneaMixeddyspneaRespiratorydyspneaCausedbya4InspiratorydyspneaTendstooccurprimarilywhenthereisobstruction(suchasinflammation,edema,tumorandforeignbody)inlarynx,tracheaandmajorbronchi.Characterizedbythedepressionsigh,inwhichvisibleindrawingoverthesternalnotch,thesupraclavioularspaces,theintercostalspacesandtheepigastriumintheinspirationcanbeseen.Oftenaccompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.InspiratorydyspneaTendstooc5ExpiratorydyspneaExpiratorydyspneaisduetothedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchiasinemphysema,bronchialasthmaandasthmaticbronchitis.Expirationisprolongedandlabouredwithwheezing.ExpiratorydyspneaExpiratoryd6MixeddyspneaOccurswiththeextensivelungdisease,suchasseverepneumonia,pulmonaryfibrosis,massiveatelectasis,pleuraleffusionandpneumothorax.Resultsinthedecreaseofventilatorsandgasexchangecapacity.Breathingisdifficultduringbothinspirationandexpiration.MixeddyspneaOccurswiththee7Cardiacdyspnea

Cardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.CardiacdyspneaCardiacdysp8CardiacdyspneaInLeft-sidedheartfailure,complianceisreduced,andtherefore,ventilationisdecreasedtotheedematouslungregionsandvitalcapacityreduced.Alveoliarestiffandmoreworkisneededtoovercomeelasticrecoil,thehighalveolarpressurewillstimulatestretchreceptorandinitiatetheinflationreflexresultinginearlyturningoffofinspirationandanincreaseinrespiratoryrate.CardiacdyspneaInLeft-sidedh9Cardiac

dyspneaThedyspneacausedbyright-sidedheartfailureislessseverethanthatonecausedbyleft-sided.Mechanism:(1)Thepressureofrightatrialandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.(2)Thedecreaseofoxygencontentandtheaccumulationoftheacidmetabolites,suchaslactic,stimulaterespiratorycenter.(3)Therestrictionoftherespiratorymovementcausedbyenlargementofliverresultingfromcongestion,ascitesandpleuraleffusion.CardiacdyspneaThedyspneacau10Cardiac

dyspneaSymptomsofcongestiveheartfailurecancauseorthopneaandparoxysmalnocturnaldyspneawhenelevated-fillingpressureispresent.CardiacdyspneaSymptomsof11orthopneaOrthopneaisdifficultyinbreathinginthesupineposition,thismayberelivedbysittingup,whichreducesthedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesandloweringleftventricularfillingpressures,improvingthediaphragmaticmovement,increasingvitalcapacity.orthopneaOrthopneaisdifficul12paroxysmalnocturnaldyspneaSymptoms:Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Inthemostadvancedcases,thepatientsbecomeacutelydyspneic,cyanoticandveryfrequentlyproducefoamysputumtingedwithblood.Signs:Moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm,themarkedlyaccentuatedsecondheartsoundinthepulmonicarea.paroxysmalnocturnaldyspneaSy13Mechanism:Supinepostureforsleepresultsinresorbtionofextracellularfluidintotheintravascularspace,causingariseinfillingpressure.

Theparoxysmaldyspneaistermedascardiacasthma.Itcanbeseeninthehypertensiveheartdiseaseandcoronaryheartdisease.paroxysmalnocturnaldyspneaMechanism:Supineposturefor14Toxic

dyspneaInthemetabolicacidosis(uremiaanddiabeticketosis),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespirationwithsnoring.TheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingdeeprespirationorCheyne-StokessrespirationToxicdyspneaInthemetabolic15

Neuro-Psychogenic

dyspneaInpatientssufferingfromcerebrovasculardiseases(intracranialhemorrhage,elevatedintracerebralpressure),therespiratorycenterlosesthebloodsupplyoriscompressed.Therespirationbecomesdeep,slowandirregular.Insomecasesthedyspneamaybepsychogenic,whichischaracterizedbyrepetitivedeep,sighingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.Thesearealsomanifestationsofacutehypocapniaandrespiratoryalkalosis.Neuro-PsychogenicdyspneaInp16Hematological

dyspnea

Insevereanemia,sulfhemoglobinemia,methaemoglobinemiaorcarbonmonoxidepoisoningthedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreasedheartrate.Therespirationratealsoincreasesinshockwhichstimulatesrespirationcenterbecauseofhypotension.HematologicaldyspneaInsever17AccompaniedSymptomParoxysmaldyspneawithwheezing.Dyspneawithchestpain.Dyspneawithfever.Dyspneawithcoughandpurulentsputum.Dyspneawithcoma.

AccompaniedSymptom18Paroxysmaldyspneawithwheezing

Itispresentinbronchialasthmaandcardiacasthma.Paroxysmalseveredyspneaisoftenseeninacutelarynxedema,foreignbodyinbronchi,massivepulmonaryembolism,andspontaneouspneumothorax.Paroxysmaldyspneawithwheezi19Dyspneawithchestpain.

Itisfrequentlyobservedinlobarpneumonia,pulmonaryinfarction,spontaneouspneumothorax,acuteexudativepleurisy,acutemyocardialinfarction,andbronchialcarcinoma.Dyspneawithchestpain.20Dyspneawithfever.Itiscommonlynotedinpneumonia,lungabscess,pulmonarytuberculosis,pleurisy,acutepericarditis,andnervoussystemdiseases.Dyspneawithfever.21Dyspneawithcoughandpurulentsputum.

Itisoftenpresentinchronicbronchitis,obstructivepulmonaryemphysemawithinfection,purulentpneumonia,andlungabscess;Dyspneawithlargeamountoffoamysputumisoftenseeninacuteleftventricularheartfailureandorganophosphoruspoisoning.Dyspneawithcoughandpurulen22Dyspneawithcoma.

Itsuggestscerebralhemorrhage,meningitis,pneumoniawithshock,uremia,diabeticketoacidosis,andacutepoisoning.Dyspneawithcoma.23

Dyspnea

24Definition:

Dyspneaisdefinedasanawarenessofdifficultyinbreathing

Itisthereforeasymptom,usuallydescribedbythepatientas“shortofbreath,”whetherthesensationisduetoactualdifficultyinbreathingorisessentiallyanawarenessofhyperventilation.Ifthesymptombecomesstriking,italwayscompanieswithdilatationofnares,cyanosis,useofaccessorymusclesofrespirationandabnormalitiesofrespiratoryrate,depthorrhythm.Definition:25RespiratorydiseasesCirculatorydiseasesPoisoningHematologyNeuropsychogenicfactorsEtiologyRespiratorydiseasesEtiology26RespiratorydyspneaCausedbyabnormalventilationandgasexchange,reductioninventilatorycapacity,hypercapniaandhypoxemiaresultingfromrespiratorydisease.Threeclininaltypes:InspiratorydyspneaExpiratorydyspneaMixeddyspneaRespiratorydyspneaCausedbya27InspiratorydyspneaTendstooccurprimarilywhenthereisobstruction(suchasinflammation,edema,tumorandforeignbody)inlarynx,tracheaandmajorbronchi.Characterizedbythedepressionsigh,inwhichvisibleindrawingoverthesternalnotch,thesupraclavioularspaces,theintercostalspacesandtheepigastriumintheinspirationcanbeseen.Oftenaccompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.InspiratorydyspneaTendstooc28ExpiratorydyspneaExpiratorydyspneaisduetothedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchiasinemphysema,bronchialasthmaandasthmaticbronchitis.Expirationisprolongedandlabouredwithwheezing.ExpiratorydyspneaExpiratoryd29MixeddyspneaOccurswiththeextensivelungdisease,suchasseverepneumonia,pulmonaryfibrosis,massiveatelectasis,pleuraleffusionandpneumothorax.Resultsinthedecreaseofventilatorsandgasexchangecapacity.Breathingisdifficultduringbothinspirationandexpiration.MixeddyspneaOccurswiththee30Cardiacdyspnea

Cardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.CardiacdyspneaCardiacdysp31CardiacdyspneaInLeft-sidedheartfailure,complianceisreduced,andtherefore,ventilationisdecreasedtotheedematouslungregionsandvitalcapacityreduced.Alveoliarestiffandmoreworkisneededtoovercomeelasticrecoil,thehighalveolarpressurewillstimulatestretchreceptorandinitiatetheinflationreflexresultinginearlyturningoffofinspirationandanincreaseinrespiratoryrate.CardiacdyspneaInLeft-sidedh32Cardiac

dyspneaThedyspneacausedbyright-sidedheartfailureislessseverethanthatonecausedbyleft-sided.Mechanism:(1)Thepressureofrightatrialandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.(2)Thedecreaseofoxygencontentandtheaccumulationoftheacidmetabolites,suchaslactic,stimulaterespiratorycenter.(3)Therestrictionoftherespiratorymovementcausedbyenlargementofliverresultingfromcongestion,ascitesandpleuraleffusion.CardiacdyspneaThedyspneacau33Cardiac

dyspneaSymptomsofcongestiveheartfailurecancauseorthopneaandparoxysmalnocturnaldyspneawhenelevated-fillingpressureispresent.CardiacdyspneaSymptomsof34orthopneaOrthopneaisdifficultyinbreathinginthesupineposition,thismayberelivedbysittingup,whichreducesthedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesandloweringleftventricularfillingpressures,improvingthediaphragmaticmovement,increasingvitalcapacity.orthopneaOrthopneaisdifficul35paroxysmalnocturnaldyspneaSymptoms:Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Inthemostadvancedcases,thepatientsbecomeacutelydyspneic,cyanoticandveryfrequentlyproducefoamysputumtingedwithblood.Signs:Moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm,themarkedlyaccentuatedsecondheartsoundinthepulmonicarea.paroxysmalnocturnaldyspneaSy36Mechanism:Supinepostureforsleepresultsinresorbtionofextracellularfluidintotheintravascularspace,causingariseinfillingpressure.

Theparoxysmaldyspneaistermedascardiacasthma.Itcanbeseeninthehypertensiveheartdiseaseandcoronaryheartdisease.paroxysmalnocturnaldyspneaMechanism:Supineposturefor37Toxic

dyspneaInthemetabolicacidosis(uremiaanddiabeticketosis),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespirationwithsnoring.TheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingdeeprespirationorCheyne-StokessrespirationToxicdyspneaInthemetabolic38

Neuro-Psychogenic

dyspneaInpatientssufferingfromcerebrovasculardiseases(intracranialhemorrhage,elevatedintracerebralpressure),therespiratorycenterlosesthebloodsupplyoriscompressed.Therespirationbecomesdeep,slowandirregular.Insomecasesthedyspneamaybepsychogenic,whichischaracterizedbyrepetitivedeep,sighingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.Thesearealsomanifestationsofacutehypocapniaandrespiratoryalkalosis.Neuro-PsychogenicdyspneaInp39Hematological

dyspnea

Insevereanemia,sulfhemoglobinemia,methaemoglobinemiaorcarbonmonoxidepoisoningthedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreasedheartrate.Therespirationratealsoincreasesinshockwhichstimulatesrespirationcenterbecauseof