Dyspnea(呼吸困難)幻燈片

DyspneaDefinitionDyspneaisdefinedasanawarenessofdifficultyinbreathing.Mostpatientssufferfromactualdifficulty,somepatientsjusttasteanawarenessofhyperventilation(換氣過度).HowtodescribethesesensationsCannotgetenoughairAirdoesnotgoallthewaydownSmotheringfeelinginthechestTightnessinthechestFatigueinthechestDefinitionDilatationofnares(鼻翼扇動),cyanosis(紫紺),useofaccessorymusclesofrespirationAbnormalitiesofrespiratoryrate,depthorrhythmEtiologyRespiratorydiseaseCardicdiseaseToxicNero-PsychogenicHaematologicaldiseaseIncreaseofabdominalpressure(massiveascites(腹水),pregnancy(懷孕)etc)RespiratorydyspneaRespiratorydyspneaiscausedbyabnormalventilationandgasexchange.Reductioninventilatorycapacity,hypercapnia(二氧化碳潴留)andhypoxemia(低氧血癥)resultingfromrespiratorydisease.Threeclinicaltypes:inspiratorydyspnea,expiratorydyspnea,mixeddyspnea.InspiratorydyspneaClinicalcharacteristics:visibleindrawingoverthesternalnotch,thesupraclavicularspaces,theintercostalspacesandtheepigastriumintheinspiration(三凹癥).Accompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.Stenosisandobstructionoflarynx,trachea,andbronchiExpiratorydyspneaClinicalcharacteristics:expirationisprolongedandlabouredwithwheezing.Cause:thedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchi.Familiardiseases:emphysema(肺氣腫),bronchialasthma(支氣管哮喘)andchronicasthmaticbronchitis(喘慢支).MixeddyspneaClinicalcharacteristics:breathingisdifficultduringbothinspirationandexpiration.Respiratoryfrequencyincreaseandrespirationsuperficial.Cause:decreaseofventilatorsandgasexchangecapacityFamiliardiseases:severepneumonia(肺炎),pulmonaryfibrosis(肺纖維化),massiveatelectasis(大片肺不張)etcCardiacdyspneaCardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.Dyspneaistheprimarysymptomofleftheartfailure.LeftheartfailureBasaldiseases:CoronaryheartdiseaseHypertensiveheartdiseaseRheumaticheartdiseaseCongenitalheartdiseaseLeftheartfailureMechanism:LungcongestiondecreasegasdispersionAlveoliarestiffandmoreworkisneededtoovercomeelasticrecoilThehighalveolarpressurestimulatestretchreceptorHighpulmonarycirculationpressurestimulaterespiratorynervecenterLeftheartfailureClinicalrepresentation:Exhausteddyspnea(勞力性呼吸困難)Orthopnea(端坐呼吸)Paroxysmalnocturnaldyspnea(夜間陣發(fā)性呼吸困難)ExhausteddyspneaDifficultyinbreathingwhenthepatientisinactivityrelivedwhenherelax.Doingexerciseimpelmorebloodintopulmonarycirculation.Moreoxygenisneededforbodydemand,especiallytheheart.FunctionalclassificationClassⅠ–nolimitation:OrdinaryphysicalactivitydoesClassⅡ–slightlimitationofphysicalactivityClassⅢ–MarkedlimitationofphysicalactivityClassⅣ–inabilitytocarryoranyphysicalactivitywithoutdiscomfortOrthopneaDifficultyinbreathinginthesupinepositionrelivedbysittingupReducethedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesImprovethediaphragmaticmovementIncreasevitalcapacityParoxysmalnocturnaldyspnea

Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Physicalexamination:moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm(cardiacasthma心源性哮喘).ParoxysmalnocturnaldyspneaReason:Supinepostureforsleepimpelmorebloodintopulmonarycirculation,anddecreasevitalcapacity.Vagusexcitementcausecoronaryarteryconstrictionandbronchiolesspasm.RightheartfailureBasaldiseases:Acutecorpulmonale(肺心病)whichcausedbypulmonaryembolism(肺栓塞)Chroniccorpulmonalewhichcausedbychronicobstructivepulmonarydisease(慢阻肺)RightheartfailureMechanism:Thepressureofrightatriaandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.Hypoxemiaandtheaccumulationoftheacidmetabolitesstimulaterespiratorycenter.Therestrictionoftherespiratorymovementcausedbyenlargementofliver,ascitesandpleuraleffusion.BiventricularfailureLeftheartfailureplusrightheartfailuremaycauseseveredyspnea?ToxicdyspneaInthemetabolicacidosis(uremia尿毒癥anddiabeticacidosis糖尿病性酸中毒),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespiration(Kussmanul)withsnoring.ToxicdyspneaTheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingslowrespirationorCheyne-Stokessrespiration.Neuro-PsychogenicdyspneaTherespiratorycenterlosesthebloodsupplyoriscompressedwhilepatientsufferingfromcerebrovasculardisease.Therespirationbecomesdeep,slowandirregular.Nero-PsychogenicdyspneaPatientsufferfromhysteriawillbeseenrepetitivedeep,signingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.HaematologicldyspneaThedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreaseheartrate,suchassevereanemia,carbonmonoxide.Hypotensioncanstimulaterespirationwhenpatientsufferfromshock.AccompanyingsymptomsParoxysmaldyspneawithwheezing,Itispresentinbronchialasthmaandcardiacasthma.Paroxysmalseveredyspneaisoftenseeninacutelarynxedema(急性喉水腫),spontaneouspneumothorax(自發(fā)性氣胸),massivepulmonaryembolism.AccompanyingsymptomsDyspneawithchestpain.Itisfrequentlyobservedinlobarpneumonia(大葉性肺炎),pulmonaryinfarction(肺梗塞),spontaneouspneumothorax,acuteexudativepleurisy(急性滲出性胸膜炎),acutemyocardialinfarction(急性心肌梗死),andbronchialcarcinoma(支氣管肺癌).AccompanyingsymptomsDyspneawithfever.Itiscommonlynotedinpneumonia,lungabscess(肺膿腫),pulmonarytuberculosis(肺結(jié)核),pleurisy,acutepericarditis(急性心包炎),andnervoussystemdiseases.AccompanyingsymptomsDyspneawithcoughandpurulentsputum.Itisoftenpresentinchronicbronchitis,obstructivepulmonaryemphysemawithinfection,purulentpneumonia,andlungabscess;Dyspneawithlargeamountoffoamysputumisoftenseeninacuteleftventricularheartfailureandorganophosphoruspoisoning(有機磷中毒).AccompanyingsymptomsDyspneaw