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Internal and Emergency Medicine Aug 2023Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The... (Review)
Review
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
Topics: Humans; Dyspnea; Lung; Emergency Service, Hospital; Respiratory Insufficiency; Ultrasonography
PubMed: 37266791
DOI: 10.1007/s11739-023-03322-8 -
The Lancet. Respiratory Medicine Aug 2023Although the exact prevalence of post-COVID-19 condition (also known as long COVID) is unknown, more than a third of patients with COVID-19 develop symptoms that persist... (Review)
Review
Although the exact prevalence of post-COVID-19 condition (also known as long COVID) is unknown, more than a third of patients with COVID-19 develop symptoms that persist for more than 3 months after SARS-CoV-2 infection. These sequelae are highly heterogeneous in nature and adversely affect multiple biological systems, although breathlessness is a frequently cited symptom. Specific pulmonary sequelae, including pulmonary fibrosis and thromboembolic disease, need careful assessment and might require particular investigations and treatments. COVID-19 outcomes in people with pre-existing respiratory conditions vary according to the nature and severity of the respiratory disease and how well it is controlled. Extrapulmonary complications such as reduced exercise tolerance and frailty might contribute to breathlessness in post-COVID-19 condition. Non-pharmacological therapeutic options, including adapted pulmonary rehabilitation programmes and physiotherapy techniques for breathing management, might help to attenuate breathlessness in people with post-COVID-19 condition. Further research is needed to understand the origins and course of respiratory symptoms and to develop effective therapeutic and rehabilitative strategies.
Topics: Humans; Post-Acute COVID-19 Syndrome; COVID-19; SARS-CoV-2; Dyspnea; Pulmonary Fibrosis; Disease Progression
PubMed: 37216955
DOI: 10.1016/S2213-2600(23)00159-5 -
Seminars in Respiratory and Critical... Oct 2023Substantial advances have been made recently into the discovery of fundamental mechanisms underlying the neural control of breathing and even some inroads into... (Review)
Review
Substantial advances have been made recently into the discovery of fundamental mechanisms underlying the neural control of breathing and even some inroads into translating these findings to treating breathing disorders. Here, we review several of these advances, starting with an appreciation of the importance of V̇:V̇CO:PaCO relationships, then summarizing our current understanding of the mechanisms and neural pathways for central rhythm generation, chemoreception, exercise hyperpnea, plasticity, and sleep-state effects on ventilatory control. We apply these fundamental principles to consider the pathophysiology of ventilatory control attending hypersensitized chemoreception in select cardiorespiratory diseases, the pathogenesis of sleep-disordered breathing, and the exertional hyperventilation and dyspnea associated with aging and chronic diseases. These examples underscore the critical importance that many ventilatory control issues play in disease pathogenesis, diagnosis, and treatment.
Topics: Humans; Respiration; Dyspnea; Chronic Disease; Exercise; Sleep
PubMed: 37494141
DOI: 10.1055/s-0043-1770342 -
Radiology Oct 2023An 81-year-old man living in South Korea was referred to the pulmonology clinic because of abnormal findings at routine surveillance CT (Fig 1A, 1B). His past medical...
An 81-year-old man living in South Korea was referred to the pulmonology clinic because of abnormal findings at routine surveillance CT (Fig 1A, 1B). His past medical history included right radical nephroureterectomy for ureteral cancer in 2016, transurethral resection of a bladder tumor in 2015, and tuberculous pleurisy in his third decade of life that was complicated by a chronic calcified empyema (Fig 1C). He had been doing well clinically until 6 months prior, when he presented to an outside hospital with progressive right-sided chest pain and dyspnea and was found to have active tuberculosis. During that hospitalization, he underwent chest CT and CT-guided biopsy of an incidentally found thoracic lesion (Fig 2), which revealed chronic active inflammation. His symptoms improved after initiation of antituberculous medication, and he was discharged home to complete treatment. Because of interval growth of this lesion noted on a subsequent surveillance CT scan, he was referred to pulmonology for further evaluation. Laboratory tests obtained during his visit revealed mild leukocytosis (1258 cells × 10/L; normal range, 4000-10 000 cells × 10/L) with neutrophilic predominance (82% neutrophils; normal range, 50%-75% neutrophils), and a mildly elevated C-reactive protein level (3.17 mg/dL; normal range, 0-0.5 mg/dL). A sputum culture was negative for tuberculosis. The patient reported mild chest discomfort and dyspnea. Liver MRI was performed to further evaluate an abnormal lesion seen at CT (Fig 3). Given the patient's recent nonspecific biopsy results and tuberculosis treatment, no further work-up was pursued. Contrast-enhanced chest CT was performed 6 months later because the patient developed worsening chest pain and dyspnea (Fig 4). He remained afebrile, with persistent leukocytosis (1485 cells × 10/L) and an elevated C-reactive protein level (3.56 mg/dL). On the basis of the imaging findings, repeat CT-guided biopsy and PET/CT were performed (Fig 5), thereby enabling confirmation of the diagnosis, and appropriate treatment was initiated.
Topics: Male; Humans; Aged, 80 and over; Positron Emission Tomography Computed Tomography; C-Reactive Protein; Leukocytosis; Tuberculosis; Chest Pain; Dyspnea
PubMed: 37906006
DOI: 10.1148/radiol.223089 -
European Heart Journal Nov 2023Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g....
Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.
Topics: Humans; Acute Disease; Heart Failure; Edema; Hospitalization; Patient Discharge; Dyspnea
PubMed: 37850661
DOI: 10.1093/eurheartj/ehad617 -
Therapeutische Umschau. Revue... Aug 2023Dyspnea is one of the most common symptoms in patients with lung diseases. The term "dyspnea" refers to the subjective sensation of uncomfortable breathing, which is... (Review)
Review
Dyspnea is one of the most common symptoms in patients with lung diseases. The term "dyspnea" refers to the subjective sensation of uncomfortable breathing, which is experienced and described very differently between individuals. Because of this, diagnosis can be very challenging and similar to pain, no true objective measurement parameters of dyspnea exist. A detailed symptom history and clinical examination are critical in establishing the diagnosis, but the severity of pulmonary functional impairment does not always correlate with the clinical picture. The diagnosis of lung diseases is led by pulmonary function tests and imaging techniques, which measure the response to therapy and assess the prognostic course of the disease. The purpose of this article is to review the causes of pulmonary dyspnea, present a guide to diagnostic work-up, and introduce common differential diagnoses.
Topics: Humans; Dyspnea; Lung; Lung Diseases
PubMed: 37855528
DOI: No ID Found -
Thorax Aug 2023Idiopathic pulmonary fibrosis (IPF) is characterised by worsening dyspnoea and exercise intolerance. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Idiopathic pulmonary fibrosis (IPF) is characterised by worsening dyspnoea and exercise intolerance.
RESEARCH QUESTION
Does a long-term pulmonary rehabilitation improve exercise tolerance in patients with IPF treated with standard antifibrotic drugs, which are expected to reduce disease progression?
METHODS
This open-label randomised controlled trial was performed at 19 institutions. Stable patients receiving nintedanib were randomised into pulmonary rehabilitation and control groups (1:1). The pulmonary rehabilitation group underwent initial rehabilitation which included twice-weekly sessions of monitored exercise training for 12 weeks, followed by an at-home rehabilitation programme for 40 weeks. The control group received usual care only, without pulmonary rehabilitation. Both groups continued to receive nintedanib. The primary and main secondary outcomes were change in 6 min walking distance (6MWD) and change in endurance time (using cycle ergometry) at week 52.
RESULTS
Eighty-eight patients were randomised into pulmonary rehabilitation (n=45) and control (n=43) groups. Changes in 6MWD were -33 m (95% CI -65 to -1) and -53 m (95% CI -86 to -21) in the pulmonary rehabilitation and control groups, respectively, with no statistically significant difference (mean difference, 21 m (95% CI -25 to 66), p=0.38). Changes in endurance time were significantly better in the pulmonary rehabilitation (64 s, 95% CI -42.3 to 171)) than in the control (-123 s (95% CI -232 to -13)) group (mean difference, 187 s (95% CI 34 to 153), p=0.019).
INTERPRETATION
Although pulmonary rehabilitation in patients taking nintedanib did not improve 6MWD in the long term, it led to prolonged improvement in endurance time.
TRIAL REGISTRATION NUMBER
UMIN000026376.
Topics: Humans; Idiopathic Pulmonary Fibrosis; Exercise; Indoles; Exercise Tolerance; Dyspnea; Quality of Life
PubMed: 37012071
DOI: 10.1136/thorax-2022-219792 -
Revue Medicale Suisse Sep 2023Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by dyspnea (platypnea) and arterial desaturation (orthodeoxia) upon changing from a lying...
Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by dyspnea (platypnea) and arterial desaturation (orthodeoxia) upon changing from a lying to a standing or sitting position. The underlying physiopathological mechanisms involved are complex. Hypoxemia is attributed to the mixing of deoxygenated venous blood with arterial blood through a shunt, which can be intracardiac, or extracardiac. Patent foramen ovale is the main cause of intracardiac shunting. The transthoracic bubble contrast echocardiogram with intravenous agited saline is the most important test in the diagnosis process. Management is specific to the underlying etiology.
Topics: Humans; Platypnea Orthodeoxia Syndrome; Dyspnea; Heart; Arteries; Echocardiography
PubMed: 37671763
DOI: 10.53738/REVMED.2023.19.840.1619 -
Chest Oct 2023Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited.
RESEARCH QUESTION
Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea?
STUDY DESIGN AND METHODS
This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72 months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8 weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire).
RESULTS
A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95% CI, 17.7-88.3; P = .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95% CI, -0.09 to 0.00; P = .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention.
INTERPRETATION
In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov; No.: NCT03405480; URL: www.
CLINICALTRIALS
gov.
Topics: Humans; Quality of Life; Exercise; Exercise Therapy; Pulmonary Embolism; Exercise Tolerance; Dyspnea; Pulmonary Disease, Chronic Obstructive
PubMed: 37149257
DOI: 10.1016/j.chest.2023.04.042 -
The European Respiratory Journal Jan 2024
Topics: Humans; Critical Illness; Respiration, Artificial; Dyspnea
PubMed: 38237994
DOI: 10.1183/13993003.01565-2023