Differential Diagnosis Of Dyspnea Research Articles

The LUSBI Protocol (Lung Ultrasound/BREST Score/Inferior Vena Cava)-Its Role in a Differential Diagnostic Approach to Dyspnea of Cardiogenic and Non-Cardiogenic Origin.

Background and Objectives: PoCUS ultrasound applications are widely used in everyday work, especially in the field of emergency medicine. The main goal of this research was to create a diagnostic and therapeutic protocol that will integrate ultrasound examination of the lungs, ultrasound measurements of the inferior vena cava (assessment of central venous pressure) and BREST scores (risk stratification for heart failure), with the aim of establishing a more effective differential diagnostic approach for dyspneic patients. Materials and Methods: A cross-sectional study was conducted in the emergency medicine department with the educational center of the community health center of Banja Luka. Eighty patients of both sexes were included and divided into experimental and control groups based on the presence or absence of dyspnea as a dominant subjective complaint. Based on the abovementioned variables, the LUSBI protocol (lung ultrasound/BREST score/inferior vena cava) was created, including profiles to determine the nature of the origin of complaints. The biochemical marker of heart failure NT pro-BNP served as a laboratory confirmation of the cardiac origin of the complaints. Results: The distribution of NT pro BNP values in the experimental group showed statistically significant differences between individual profiles of the LUSBI protocol (p < 0.001). Patients assigned to group B PLAPS 2 had significantly higher average values of NT pro-BNP (20159.00 ± 3114.02 pg/mL) compared to other LUSBI profiles. Patients from the experimental group who had a high risk of heart failure according to their BREST scores also had a significantly higher average maximum expiratory diameter compared to those without heart failure (p = 0.004). A statistically significant difference (p = 0.001) in LUSBI profiles was observed between the groups of patients divided according to CVP categories. Conclusion: The integration of the LUSBI protocol into the differential diagnosis of dyspnea has been shown to be very effective in confirming or excluding a cardiac cause of the disease in patients.

To estimate prevalence of pulmonary arterial hypertension in HIV patients and its association with CD4 cell count

IntroductionHIV infection is considered as one of the leading infectious cause of pulmonary arterial hypertension (PAH) and it exhibits higher rate of development of this condition than general population. The prevalence of HIV associated PAH has not been established accurately and varies based on factors such as geographical distribution, gender, duration of HIV and ART etc. This study aims to estimate the prevalence of PAH in HIV infected patients who are on first line ART and to study the association of PAH with CD4 count and viral load. MethodsThis cross-sectional study was conducted on 150 HIV positive patients who visited medical OPD and ART centre, JLN medical college and hospital, Ajmer and were above 18 years of age and were on first line ART. PAH was identified through transthoracic doppler echocardiographic screening and systolic pulmonary artery pressure (sPAP) estimation of more than 35 mmHg was used to diagnose PAH. ResultIn this study, out of 150 patients, PAH was diagnosed in 12 patients and hence the prevalence of PAH came out to be 8 % (95 % CI: 3.65; 12.34). Significant association of PAH has been observed with viral load (p value = 0.04). While no significant association has been found between PAH and CD4 count. ConclusionPAH in HIV patients was found to be 8% which is considerably higher than the already established global prevalence. Hence, PAH should be an important consideration for clinicians in differential diagnosis of dyspnea in HIV patients.

Post-intubation tracheal stenosis in pediatric age group: single-center experiences of 24years.

Post-intubation tracheal stenosis (PITS) is an iatrogenic injury that involves some patients. Given the importance of this issue and the referral of a significant number of children with tracheal stenosis to Masih Daneshvari Hospital in Tehran, Iran, the present study investigated tracheal stenosis following prolonged intubation in the pediatric age group. In this observational retrospective study, from 1994 to 2018, the medical records of all children under 14years of age with a history of PITS were reviewed. Demographic and clinical characteristics including signs and symptoms, the underlying condition that leads to intubation, duration of intubation, type of stenosis, and the therapeutic approach, type of surgery, and follow-up were collected and analyzed using SPSS. Among 161 patients with a mean age of 9.8 ± 4.2years, 69% were male. The site of stenosis was limited to the trachea in 47% and others both trachea and subglottic area were involved. The most common cause of intubation was trauma. The most common symptoms were dyspnea and wheezing. Success rates of reconstruction were 93.75% in type I, 82.15% in type II, and 35.70% in type III. Among the 16 patients who underwent Type III surgery, decannulation was not performed in 11 patients. Traction in the anastomosis and complications were stated in 26 and 10% of the patients respectively, a mortality rate of 8.7% was also reported. In the case of endotracheal intubation, PITS should be considered in the differential diagnosis of dyspnea in children as well as adults.

Cardiopulmonary exercise test in patients with persistent dyspnea after COVID-19 disease

Abstract Introduction Persistent dyspnea in patients who have suffered from COVID-19 disease has become a constant in cardiology in recent months. Healther workers have been one of the population groups mainly affected during the pandemic. Chronic involvement by COVID-19 infection, such as dyspnea, is frequent, and so far, of unknown mechanism. CardioPulmonary Exercise Test (CPET) is currently the gold standard technique in the differential diagnosis of dyspnea. Therefore, CPET could be useful in the evaluation of patients after infection by the SARS-COV2 virus; a role still unknown in this context. Objective Evaluate the parameters obtained in CPET in patients who had suffered from COVID-19 disease and who presented persistent dyspnea. Methods We conducted a single-center and prospective study that included healthcare workers who suffered from COVID-19 disease with mild-moderate intensity symptoms, without the need for hospitalization, between March-December 2020 and who presented dyspnea on exertion at least 3 months after infection, in the absence of structural heart disease. An echo was performed, and a baseline spirometry followed by a CPET. Some of the variables collected such as VO2, OUES and PulseO2 have been quantified as a percentage (%) of the predicted according to predicted equations. Results 64 healthy patients with an active baseline life (without exertional dyspnea prior to infection) were included. 7 patients were excluded for presenting previously unknown structural heart disease. Of the 57 patients (Figure 1), more than half had a functional capacity lower than predicted (50th percentile), highlighting, among the cardiovascular response variables, a peak VO2 of 79% (SD: 14.0%) of the predicted, denoting slightly depressed functional capacity. In addition, in this subgroup, a VO2 at the level of the first ventilatory threshold (VT1) of 51.1% (SD: 4.2%) is observed over the predicted value -value that is considered in the lower limits of normality-; and a PulseO2 (systolic volume reflex) and an OUES in normal ranges with respect to those predicted. In the total of the 57 patients, no alterations were observed in the ventilatory efficiency parameters with effort, nor in the baseline spirometry, nor in the breathing reserve (BR), nor in final oxygen saturation (SatO2). Conclusion CPET has made it possible to identify that more than half of the patients show a deterioration -at least slight- in functional capacity (the majority of which are women) reaffirming the value of this test. The combination of this pattern that we observed in our serie is usually seen in patients with physical deconditioning and/or obesity, and is secondary to alterations in the peripheral use of oxygen, mainly at the muscular level. Based on this, a direct or indirect potential myopathic effect of the virus cannot be ruled out as responsible for the deterioration of the functional class of patients after COVID-19 disease. Funding Acknowledgement Type of funding sources: None.

Results from a Spanish national survey on the application of ultrasound in pulmonology services

BackgroundThis was an observational, cross-sectional, and multicentre study carried out from October to December 2020, through a survey sent to Spanish Society of Pulmonology and Thoracic Surgery members in public hospitals with different levels of complexity. Our objective was to complete a national analysis of clinical practice, organisation, infrastructure, the services portfolio, teaching, and research activity related to ultrasound.ResultsData from 104 hospitals were analysed. Ultrasound was used in 56.7% of cases, both in the area of bronchopleural techniques and on conventional wards, with no differences between centres. Lung ultrasound (LUS) was performed more often in the procedures area in intermediate-complexity centres compared to high- and low-complexity centres (36% vs. 31% and 6.25%, respectively). More high-complexity centres had three or more ultrasound scanners than intermediate-complexity centres (38% vs. 16%); 43% of low-complexity centres shared their ultrasound equipment with other specialties. Fewer than 6% of centres did not have an ultrasound machine. LUS was most often used during the treatment of pleural effusion (91.3%), in the differential diagnosis of dyspnoea (51.9%), and to rule out iatrogenic pneumothorax (50.9%). Only 5.7% of the centres had a pulmonologist specialised in LUS. Finally, fewer than 35% of the hospitals were teaching centres and fewer than 18% participated in research projects.ConclusionsThe use and availability of LUS has grown in pulmonology services, however, still relatively few pulmonologists are specialised in its use. Moreover, teaching and research activity in this field is scarce. Strategies are necessary to improve physicians’ skill at using LUS and to promote its use, with the ultimate goal of improving healthcare activity.

Lung ultrasonography: what the cardiologist should know

In recent years, lung ultrasonography has acquired an important role as a valuable diagnostic tool in clinical practice. The lung is usually poorly explorable, but it provides more acoustic information in pathological conditions that modify the relationship between air, water and tissues. The different acoustic impedance of all these components makes the chest wall a powerful ultrasound reflector: this is responsible for the creation of several artifacts providing valuable information about lung pathophysiology. Lung ultrasonography helps in the diagnostic process of parenchymal and pleural pathologies, in the differential diagnosis of dyspnea and in the clinical and prognostic evaluation of the SARS-CoV-2 infection.

Ventilatory efficiency in pulmonary vascular diseases.

Cardiopulmonary exercise testing (CPET) is a frequently used tool in the differential diagnosis of dyspnoea. Ventilatory inefficiency, defined as high minute ventilation (V' E) relative to carbon dioxide output (V' CO2 ), is a hallmark characteristic of pulmonary vascular diseases, which contributes to exercise intolerance and disability in these patients. The mechanisms of ventilatory inefficiency are multiple and include high physiologic dead space, abnormal chemosensitivity and an altered carbon dioxide (CO2) set-point. A normal V' E/V' CO2 makes a pulmonary vascular disease such as pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) unlikely. The finding of high V' E /V' CO2 without an alternative explanation should prompt further diagnostic testing to exclude PAH or CTEPH, particularly in patients with risk factors, such as prior venous thromboembolism, systemic sclerosis or a family history of PAH. In patients with established PAH or CTEPH, the V' E/V' CO2 may improve with interventions and is a prognostic marker. However, further studies are needed to clarify the added value of assessing ventilatory inefficiency in the longitudinal follow-up of patients.

Case Reports of Implantable Cardiac Device Physiologic Sensor Changes in Subjects with Coronavirus Disease-2019 Infection

The severe acute respiratory syndrome novel coronavirus-2 pandemic has established a new set of challenges to health care delivery. Remotely monitored physiologic sensors on implantable cardiac devices can provide insight into the differential diagnosis of dyspnea in the heart failure population. We report on a unique pattern of sensor deviations that seem to occur specifically with severe acute respiratory syndrome novel coronavirus-2 infection.

The Role of Ultrasound in Assessment of Diaphragmatic Dysfunction in I.C.U Patients

Background: Diaphragm dysfunction (DD) is frequently seen in critically ill patients, and ultrasound could be a useful tool to detect it and to predict extubation success or failure in mechanically ventilated patients. Besides, it would also be useful in differential diagnosis of dyspnea and respiratory failure. Aim of work :The aim of work is to evaluate usefulness and accuracy of ultrasound in assessment of DD in intensive care unit (ICU) patients in comparison with clinical outcome of patients.. In this prospective study, we compared the performance of ultrasound in visualization of diaphragm, detection of paradoxical movement, measurement of tidal and maximal thickness, and excursion, and calculation of thickening fraction (TF) of the diaphragm in quiet breathing. Patients and Method: The present study was performed on50 patients (26 males and 24 females) admitted in RICU in Benha university hospital The field study was conducted from March 2019 to September 2019. Ultrasound of the Rt, hemidiaphragm was done on the day of admission or soon after admission (1-2) days. Results: there was no statistical significant difference between the studied groups regarding ultrasound measurement (DTF, DE and DT) and patient outcome with p value (0.273,0.245 and 0.497)respectively.Conclusion: ultrasound of diaphragm in ICU patients may be a reliable, noninvasive and convenient way to assess the DD in ICU patients to predict their outcome.

Lung Ultrasound in Cardiology: A Window to Pulmonary Edema

Pulmonary Ultrasound, a technique that has innovated the way of doing ultrasound and cardiology, basing the interpretationof the image on artefacts and modifying the diagnostic and therapeutic approach of patients with heart disease. The cardiologistcan perform pulmonary ultrasound with the transducer and echocardiography screen settings and must recognize the 4ultrasound patterns: Aerated / Dry Lung Pattern, Wet or Interstitial Lung, Pleural Effusion and Consolidation. The InterstitialPattern is the basis of the applications of this technique in the cardiological area, which are summarized in 7 clinical situations:differential diagnosis of dyspnea, heart failure syndrome, identification of acute respiratory distress, extreme situationssuch as high altitude edema, apnea diving and iron man, dialysis nephropaths, Acute coronary syndrome and alveolo-capillarystress ultrasound test. Cardiopulmonary ultrasound is proposed as mandatory and not optional for the cardiologist.

Pneumocystis Pneumonia and Acute Pulmonary Embolism in Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Abstract Severe immunosuppression and the presence of opportunistic infections in human immunodeficiency virus/acquired immunodeficiency syndrome are strongly associated with incidence of venous thromboembolism especially deep venous thrombosis and pulmonary embolism (PE). The co-occurrence of 2 diseases with similar clinical presentation can pose diagnostic and treatment challenges. We describe the case of a 54-year-old male, with no significant past medical history who presented with complaints of a 6-week history of shortness of breath. He was diagnosed with human immunodeficiency virus 1 infection with a CD4 count of 121 cells/μL and severe Pneumocystis jirovecii pneumonia. After 5 days of treatment without significant improvement, we obtained a computed tomography pulmonary angiogram, which showed concurrent acute PE. His clinical condition improved with anticoagulation therapy. Clinicians need to have a high index of suspicion and consider PE in the differential diagnosis of dyspnea and hypoxemia, particularly when P. jirovecii pneumonia infection or other acquired immunodeficiency syndrome defining illnesses are suspected.

Can Diaphragm Dysfunction Be Reliably Evaluated with Pocket-Sized Ultrasound Devices in Intensive Care Unit?

Background Diaphragm dysfunction (DD) is frequently seen in critically ill patients, and ultrasound could be a useful tool to detect it and to predict extubation success or failure in mechanically ventilated patients. Besides, it would also be useful in differential diagnosis of dyspnea and respiratory failure. The aim of this study is to evaluate usefulness and accuracy of pocket-sized ultrasound devices (PSDs) in assessment of DD in intensive care unit (ICU) patients in comparison with standard ultrasound devices (SD). Methods In this prospective observational study, we compared the performance of PSD and SD in visualization of diaphragm, detection of paradoxical movement, measurement of tidal and maximal thickness, tidal and maximal excursion, and calculation of thickening fraction (TF) of the diaphragm. We used Bland and Altman test for agreement and bias analysis and intraclass correlation analysis to evaluate interobserver variability. Results Thirty-nine patients were included in the study. In 93% of the patients, diaphragm was visualized with PSD. There was very good agreement between the measurements of the devices, and there was no proportional bias in the measurements of tidal inspiratory and expiratory thickness, tidal TF, tidal excursion, and maximal inspiratory thickness. In interobserver reliability analysis of all measurements for both devices, ICC coefficients were higher than 0.8. Total diaphragm examination times of the devices were similar (p > 0.05). Conclusion These results suggest that PSD can be useful in ICU patients for evaluating DD. But further studies are required to determine the exact place of these devices in evaluation of DD in ICU patients.

Uterine carcinosarcoma-induced pulmonary tumor thrombotic microangiopathy: A case report

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare complication of cancer. It is histologically characterized by fibrocellular intimal proliferation in small pulmonary arteries and arterioles in patients with metastatic carcinoma. It is most frequently caused by adenocarcinoma. We report a case of PTTM caused by uterine carcinosarcoma in a 62-year-old female, who exhibited reductions in blood pressure and oxygen saturation. This is the first case report about uterine carcinosarcoma-induced PTTM. Histologically, the primary uterine carcinosarcoma included serous carcinoma and homologous sarcoma components. Many tumor emboli were observed across large regions of both lungs. PTTM was found in the lower lobes. Interestingly, the embolized tumor cells were all derived from the adenocarcinoma component. Immunohistologically, the primary carcinosarcomaexhibited weak positivity for tissue factor (TF), but was negativefor vascular endothelial growth factor-A (VEGF-A). The PTTM tumor cells were positive for TF and weakly positive for VEGF-A. This case suggests that any tumor containing adenocarcinoma can cause PTTM, and immunostaining of the primary tumor might be worthless for determining whether PTTM will develop. PTTM should always be considered during the differential diagnosis of dyspnea in patients with adenocarcinoma.

The Differential Diagnosis of Dyspnea.

Dyspnea is a common symptom affecting as many as 25% of patients seen in the ambulatory setting. It can arise from many different underlying conditions and is sometimes a manifestation of a life-threatening disease. This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines. The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. A distinction is drawn between dyspnea of acute onset and chronic dyspnea: the latter, by definition, has been present for more than four weeks. The history, physical examination, and observation of the patient's breathing pattern often lead to the correct diagnosis, yet, in 30-50% of cases, more diagnostic studies are needed, including biomarker measurements and other ancillary tests. The diagnosis can be more difficult to establish when more than one underlying disease is present simultaneously. The causes of dyspnea include cardiac and pulmonary disease (congestive heart failure, acute coronary syndrome; pneumonia, chronic obstructive pulmonary disease) and many other conditions (anemia, mental disorders). The many causes of dyspnea make it a diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of disease.

Usefulness of electrocardiography in the differential diagnosis of dyspnoea

We report a case of a 88-year-old female, admitted to the hospital with tachycardia, chest pain and dyspnoea. ECG revelead a recent new-onset atrial fibrillation. A pharmacological cardioversion with amiodarone was performed, and restoration of sinus rhythm was obtained. Sotalol for rhythm control was administered. On the eighth day after the admission, she presented with severe dyspnoea and hypotension. An ECG revelead torsade de pointes, associated with prolonged QT interval. Several factors are involved in determining dyspnoea. ECG, although not specific, is an important instrument that supports clinicians in assessment of dyspnoea.

Biomarcadores en la insuficiencia cardiaca aguda

The care of patients with acutely decompensated heart failure is being reshaped by the availability and understanding of several novel and emerging heart failure biomarkers. The gold standard biomarkers in heart failure are B–type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, which play an important role in the diagnosis, prognosis, and management of acute decompensated heart failure. Novel biomarkers that are increasingly involved in the processes of myocardial injury, neurohormonal activation, and ventricular remodeling are showing promise in improving diagnosis and prognosis among patients with acute decompensated heart failure. These include midregional proatrial natriuretic peptide, soluble ST2, galectin–3, highly–sensitive troponin, and midregional proadrenomedullin. There has also been an emergence of biomarkers for evaluation of acute decompensated heart failure that assist in the differential diagnosis of dyspnea, such as procalcitonin (for identification of acute pneumonia), as well as markers that predict complications of acute decompensated heart failure, such as renal injury markers. In this article, we will review the pathophysiology and usefulness of established and emerging biomarkers for the clinical diagnosis, prognosis, and management of acute decompensated heart failure.Full English text available from: www.revespcardiol.org/en

Biomarkers in Acute Heart Failure

The care of patients with acutely decompensated heart failure is being reshaped by the availability and understanding of several novel and emerging heart failure biomarkers. The gold standard biomarkers in heart failure are B–type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, which play an important role in the diagnosis, prognosis, and management of acute decompensated heart failure. Novel biomarkers that are increasingly involved in the processes of myocardial injury, neurohormonal activation, and ventricular remodeling are showing promise in improving diagnosis and prognosis among patients with acute decompensated heart failure. These include midregional proatrial natriuretic peptide, soluble ST2, galectin–3, highly–sensitive troponin, and midregional proadrenomedullin. There has also been an emergence of biomarkers for evaluation of acute decompensated heart failure that assist in the differential diagnosis of dyspnea, such as procalcitonin (for identification of acute pneumonia), as well as markers that predict complications of acute decompensated heart failure, such as renal injury markers. In this article, we will review the pathophysiology and usefulness of established and emerging biomarkers for the clinical diagnosis, prognosis, and management of acute decompensated heart failure.

NTpro-BNP – diagnostic significance and recommended clinical applications

Brain natriuretic peptides are elevated in circulation in proportion to a decrease in myocardial function. They have been uni-formly shown to have excellent negative predictive value in differential diagnosis of dyspnoea. They can also be used in diag-nosing heart failure and have been recently shown as possible prognostic markers in acute coronary syndrome and pulmonary embolism. It is important to note that brain natriuretic peptide values rise with age and are inversely proportional to body mass index and glomerular filtration rate.

Test with torasemide in the differential diagnosis of dyspnea in patients with cardiovascular diseases

We included into this study 21 patients with a cardiovascular disease and effort dyspnea of at least one month duration. In accordance with result of tissue Doppler echocardiography all patients were divided in 2 groups: 14 patients with confirmed chronic heart failure (CHF) and 7 patients without CHF. All patients performed 6-minute walk test before and one day after receiving 5 mg of torasemide. In the group of patients with CHF 6-minute walk distance after torasemide increased by 52 m, in the group of patients without CHF this distance was reduced by 16 m. Test with torasemide can be used for differential diagnosis of dyspnea in patients with cardiovascular diseases. Increase of 6-minute walk distance one day after 5 mg of torasemide by 15 meters or more evidence in favor of cardiac origin of dyspnea with a sensitivity of 89%. The lack of increment 6-minute walk distance give evidence against heart failure as a cause of dyspnea with a specificity of 82%.

Dyspneic athlete.

Breathing concerns in athletes are common and can be due to a wide variety of pathology. The most common etiologies are exercise-induced bronchoconstriction (EIB) and paradoxic vocal fold movement disorder (PVFMD). Although some patients may have both, PVFMD is often misdiagnosed as EIB, which can lead to unnecessary treatment. The history and physical exam are important to rule out life threatening pulmonary and cardiac causes as well as common conditions such as gastroesophageal reflux disease, sinusitis, and allergic etiologies. The history and physical exam have been shown to be not as vital in diagnosing EIB and PVFMD. Improvement in diagnostic testing with office base spirometry, bronchoprovocation testing, eucapnic voluntary hyperpnea (EVH) and video laryngoscopy are essential in properly diagnosing these conditions. Accurate diagnosis leads to proper management, which is essential to avoid unnecessary testing and save healthcare costs. Also important to the physician treating dyspnea in athletes is knowing regulations on medications, drug testing, and proper documentation needed for certain organizations. The differential diagnosis of dyspnea is broad and is not limited to EIB and PVFMD. Ruling out life threatening cardiac and pulmonary causes with a proper history, physical, and appropriate testing is essential. The purpose of this review is to highlight recent literature on the diagnosis and management of EIB and PVFMD as well as discuss other potential causes for dyspnea in the athlete.