Causes of Asphyxia

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Source: Handbook of Diseases, 2003

Apnea: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Airway obstruction

Brain stem dysfunction

Neuromuscular failure

Parenchymatous lung disease

Pleural pressure gradient disruption

Pulmonary capillary perfusion decrease

Other causes

Drugs

Neuromuscular blockers

Sleep-related apnea

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Bradypnea: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Diabetic ketoacidosis

Hepatic failure

Increased intracranial pressure (ICP)

Renal failure

Respiratory failure

Other causes

Drugs

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Dyspnea: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

See Dyspnea: Causes and associated findings, pages 122 to 125.

Acute respiratory distress syndrome (ARDS)

ARDS is a life-threatening form of noncardiogenic pulmonary edema that usually produces acute dyspnea as the first complaint. Progressive respiratory distress then develops with restlessness, anxiety, decreased mental acuity, tachycardia, and crackles and rhonchi in both lung fields. Other findings include cyanosis, tachypnea, motor dysfunction, and intercostal and suprasternal retractions. Severe ARDS can produce signs of shock, such as hypotension and cool, clammy skin.

Amyotrophic lateral sclerosis (ALS).

Anemia

Dyspnea usually develops gradually with anemia. Anemia commonly causes fatigue, weakness, and syncope; if severe, it may also cause tachycardia, tachypnea, restlessness, anxiety, and thirst.

Anthrax (inhalation).

Aspiration of a foreign body.

Asthma

Acute dyspneic attacks occur with this asthma — a chronic disorder — along with audible wheezing, dry cough, accessory muscle use, nasal flaring, intercostal and supraclavicular retractions, tachypnea, tachycardia, diaphoresis, prolonged expiration, flushing or cyanosis, and apprehension. Medications that block beta receptors can exacerbate asthma attacks.

Cardiac arrhythmia

In a patient with arrhythmias, acute or gradual dyspnea can result from decreased cardiac output. The pulse rate may be rapid, slow, or irregular, with frequent premature or escape beats. Alternating pulse may be present. Other symptoms include palpitations, chest pain, diaphoresis, light-headedness, weakness, or vertigo.

Cor pulmonale

Chronic dyspnea begins gradually with exertion and progressively worsens until it occurs even at rest. Underlying cardiac or pulmonary disease is usually present. The patient may have a chronic productive cough, wheezing, tachypnea, jugular vein distention, dependent edema, and hepatomegaly. He may also experience increasing fatigue, weakness, and light-headedness.

Emphysema

Flail chest

Sudden dyspnea results from multiple rib fractures and is accompanied by paradoxical chest movement, severe chest pain, hypotension, tachypnea, tachycardia, and cyanosis. Bruising and decreased or absent breath sounds occur over the affected side.

Guillain-Barré syndrome

Usually following a fever and upper respiratory tract infection, Guillain-Barré syndrome causes slowly worsening dyspnea along with fatigue, ascending muscle weakness and, eventually, paralysis.

Heart failure

Inhalation injury

Dyspnea may develop suddenly or gradually over several hours after inhalation of chemicals or hot gases. Increasing hoarseness, persistent cough, sooty or bloody sputum, and oropharyngeal edema may also be present. The patient may also exhibit thermal burns, singed nasal hairs, and orofacial burns as well as crackles, rhonchi, wheezing, and signs of respiratory distress.

Interstitial fibrosis.

Lung cancer

Dyspnea that develops slowly and progressively worsens occurs with late-stage lung cancer. Other findings include fever, hemoptysis, productive cough, wheezing, clubbing, chest pain, and pleural friction rub.

Myasthenia gravis

Myasthenia gravis is a neuromuscular disorder that causes bouts of dyspnea as the respiratory muscles weaken. With myasthenic crisis, acute respiratory distress may occur, with shallow respirations and tachypnea.

Myocardial infarction

Sudden dyspnea occurs with crushing substernal chest pain that may radiate to the back, neck, jaw, and arms. Other signs and symptoms include nausea, vomiting, diaphoresis, vertigo, hypertension or hypotension, tachycardia, anxiety, and pale, cool, clammy skin.

Plague

Pleural effusion

Dyspnea develops slowly and becomes progressively worse with pleural effusion. Initial findings include a pleural friction rub accompanied by pleuritic pain that worsens with coughing or deep breathing. Other findings include dry cough; dullness on percussion; egophony, bronchophony, and whispered pectoriloquy; tachycardia; tachypnea; weight loss; and decreased chest motion, tactile fremitus, and decreased breath sounds. With infection, fever may occur.

Pneumonia

Dyspnea occurs suddenly, usually accompanied by fever, shaking chills, pleuritic chest pain that worsens with deep inspiration, and a productive cough. Fatigue, headache, myalgia, anorexia, abdominal pain, crackles, rhonchi, tachycardia, tachypnea, cyanosis, decreased breath sounds, and diaphoresis may also occur.

Pneumothorax

Pneumothorax is a life-threatening disorder that causes acute dyspnea unrelated to the severity of pain. Sudden, stabbing chest pain may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, dry cough, cyanosis, decreased vocal fremitus, tachypnea, tympany, decreased or absent breath sounds on the affected side, asymmetrical chest expansion, splinting, and accessory muscle use. In patients with tension pneumothorax, tracheal deviation occurs in addition to these typical findings. Decreased blood pressure and tachycardia may also occur.

Poliomyelitis (bulbar)

Dyspnea develops gradually and progressively worsens. Additional signs and symptoms include fever, facial weakness, dysphasia, hypoactive deep tendon reflexes, decreased mental acuity, dysphagia, nasal regurgitation, and hypopnea.

Pulmonary edema.

Pulmonary embolism

Acute dyspnea that’s usually accompanied by sudden pleuritic chest pain characterizes pulmonary embolism — a life-threatening disorder. Related findings include tachycardia, low-grade fever, tachypnea, nonproductive or productive cough with blood-tinged sputum, pleural friction rub, crackles, diffuse wheezing, dullness on percussion, decreased breath sounds, diaphoresis, restlessness, and acute anxiety. A massive embolism may cause signs of shock, such as hypotension and cool, clammy skin.

Sepsis

Sepsis is a potentially fatal disorder that gradually causes dyspnea along with chills and sudden fever. As dyspnea worsens, it may be accompanied by tachycardia, tachypnea, restlessness, anxiety, decreased mental acuity, and warm, flushed, dry skin. Late findings include hypotension; oliguria; cool, clammy skin; and rapid, thready pulse.

Severe acute respiratory syndrome (SARS).

Shock

Dyspnea arises suddenly and worsens progressively in shock — a life-threatening disorder. Related findings include severe hypotension, tachypnea, tachycardia, decreased peripheral pulses, decreased mental acuity, restlessness, anxiety, and cool, clammy skin,

Tuberculosis

Dyspnea commonly occurs with chest pain, crackles, and productive cough. Other findings are night sweats, fever, anorexia and weight loss, vague dyspepsia, palpitations on mild exertion, and dullness on percussion.

Tularemia

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hyperpnea: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Head injury

Signs of increased ICP include decreased response to painful stimulation, loss of pupillary reaction, bradycardia, increased systolic pressure, and widening pulse pressure.

Hyperventilation syndrome

Acute anxiety triggers episodic hyperpnea, resulting in respiratory alkalosis. Other findings may include agitation, vertigo, syncope, pallor, circumoral and peripheral paresthesia, muscle twitching, carpopedal spasm, weakness, and arrhythmias.

Hypoxemia

Many pulmonary disorders that cause hypoxemia — for example, pneumonia, pulmonary edema, chronic obstructive pulmonary disease, and pneumotho-
rax — may cause hyperpnea and episodes of hyperventilation with chest pain, dizziness, and paresthesia. Other effects include dyspnea, cough, crackles, rhonchi, wheezing, and decreased breath sounds.

Ketoacidosis

Alcoholic ketoacidosis (occurring most commonly in females with a history of alcohol abuse) typically follows cessation of drinking after a marked increase in alcohol consumption has caused severe vomiting. Kussmaul’s respirations begin abruptly and are accompanied by vomiting for several days, fruity breath odor, slight dehydration, abdominal pain and distention, and absent bowel sounds. The patient is alert and has a normal blood glucose level, unlike the patient with diabetic ketoacidosis.

Diabetic ketoacidosis is potentially life-threatening and typically produces Kussmaul’s respirations. The patient usually experiences polydipsia, polyphagia, and polyuria before the onset of acidosis; he may or may not have a history of diabetes mellitus. Other clinical features include fruity breath odor; orthostatic hypotension; rapid, thready pulse; generalized weakness; decreased LOC (lethargy to coma); nausea; vomiting; anorexia; and abdominal pain.

Starvation ketoacidosis is also potentially life-threatening and can cause Kussmaul’s respirations. Its onset is gradual; typical findings include signs of cachexia and dehydration, decreased LOC, bradycardia, and a history of severely limited food intake.

Renal failure

Acute or chronic renal failure can cause life-threatening acidosis with Kussmaul’s respirations. Signs and symptoms of severe renal failure include oliguria or anuria, uremic fetor, and yellow, dry, scaly skin. Other cutaneous signs include severe pruritus, uremic frost, purpura, and ecchymoses. The patient may complain of nausea and vomiting, weakness, burning pain in the legs and feet, and diarrhea or constipation.

As acidosis progresses, corresponding clinical features include frothy sputum, pleuritic chest pain, and signs of heart failure and pleural or pericardial effusion. Neurologic signs include altered LOC (lethargy to coma), twitching, and seizures. Hyperkalemia and hypertension, if present, require rapid intervention to prevent cardiovascular collapse.

Sepsis

A severe infection may cause lactic acidosis, resulting in Kussmaul’s respirations. Other findings include tachycardia, fever or a low temperature, chills, headache, lethargy, profuse diaphoresis, anorexia, cough, wound drainage, burning on urination, confusion or change in mental status, and other signs of local infection.

Shock

Potentially life-threatening metabolic acidosis produces Kussmaul’s respirations, hypotension, tachycardia, narrowed pulse pressure, weak pulse, dyspnea, oliguria, anxiety, restlessness, stupor that can progress to coma, and cool, clammy skin. Other clinical features may include external or internal bleeding (in hypovolemic shock); chest pain or arrhythmias and signs of heart failure (in cardiogenic shock); high fever, chills and, rarely, hypothermia (in septic shock); or stridor due to laryngeal edema (in anaphylactic shock). Onset is usually acute in hypovolemic, cardiogenic, or anaphylactic shock, but it may be gradual in septic shock.

Other causes

Drugs

Toxic levels of salicylates, ammonium chloride, acetazolamide, and other carbonic anhydrase inhibitors can cause Kussmaul’s respirations. So can ingestion of methanol and ethylene glycol, found in antifreeze solutions.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Stridor: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress — nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation)

Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aspiration of a foreign body

Sudden stridor is characteristic in this life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

Epiglottiditis

With epiglottiditis, an inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.

Hypocalcemia

With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Laryngeal tumor

Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

Laryngitis (acute)

Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

Mediastinal tumor

Commonly producing no symptoms at first, this type of tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, jugular vein distention, face and neck swelling, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid

An anatomic abnormality, retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Thoracic aortic aneurysm

If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Medical treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Bradypnea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Diabetic ketoacidosis

Bradypnea occurs late in patients with severe, uncontrolled diabetes. Patients with severe ketoacidosis may experience Kussmaul’s respirations. Associated signs and symptoms include decreased LOC, fatigue, weakness, fruity breath odor, and oliguria.

Increased intracranial pressure

A late sign of increased intracranial pressure (ICP) and a life-threatening condition, bradypnea is preceded by decreased LOC, deteriorating motor function, and fixed, dilated pupils. The triad of bradypnea, bradycardia, and hypertension is a classic sign of late medullary strangulation.

Respiratory failure

Bradypnea occurs with end-stage respiratory failure along with cyanosis, diminished breath sounds, tachycardia, and mildly increased blood pressure. The patient may also be restless, confused, irritable, or have a decreased LOC.

Other causes

Drugs

Overdose with an opioid analgesic or, less commonly, a sedative, barbiturate, phenothiazine, or other CNS depressant can cause bradypnea. Use of any of these drugs with alcohol can also cause bradypnea.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Dyspnea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a life-threatening form of noncardiogenic pulmonary edema that usually produces acute dyspnea as the first complaint. Progressive respiratory distress then develops with restlessness, anxiety, decreased mental acuity, tachycardia, and crackles and rhonchi in both lung fields. Other findings include cyanosis, tachypnea, motor dysfunction, and intercostal and suprasternal retractions. Severe ARDS can produce signs of shock, such as hypotension and cool, clammy skin.

Amyotrophic lateral sclerosis

Also known as Lou Gehrig disease, amyotrophic lateral sclerosis (ALS) causes slow onset of dyspnea that worsens with time. Other features include dysphagia, dysarthria, muscle weakness and atrophy, fasciculations, shallow respirations, tachypnea, and emotional lability.

Anemia

Dyspnea usually develops gradually with anemia. Anemia commonly causes fatigue, weakness, and syncope; in severe cases, it may also cause tachycardia, tachypnea, restlessness, anxiety, and thirst. In advanced stages, the patient may develop pallor, inability to concentrate, and irritability. With chronic iron deficiency, nails become spoon-shaped and brittle, the corners of the mouth crack, the tongue becomes smooth, and dysphagia may develop.

Anthrax (inhalation)

Dyspnea is a symptom of the second stage of anthrax inhalation; it’s accompanied by fever, stridor and hypotension (the patient usually dies within 24 hours). Initial symptoms of anthrax inhalation, which are caused by the inhalation of aerosolized spores (from infected animals or a result of bioterrorism) from the bacterium Bacillus anthracis, are flulike and include fever, chills, weakness, cough, and chest pain.

Aspiration of a foreign body

Aspiration of a foreign body is a life-threatening condition characterized by acute dyspnea and paroxysmal intercostal, suprasternal, and substernal retractions. The patient may also display accessory muscle use, inspiratory stridor, tachypnea, decreased or absent breath sounds, possibly asymmetrical chest expansion, anxiety, cyanosis, diaphoresis, and hypotension.

Asthma

In asthma, a chronic disorder, acute dyspneic attacks occur along with audible wheezing, dry cough, accessory muscle use, nasal flaring, intercostal and supraclavicular retractions, tachypnea, tachycardia, diaphoresis, prolonged expiration, flushing or cyanosis, and apprehension. Medications that block beta receptors can exacerbate asthma attacks.

Cardiac arrhythmia

In a patient with an arrhythmia, acute or gradual dyspnea can result from decreased cardiac output. The patient’s pulse rate may be rapid, slow, or irregular, with frequent premature or escape beats. Alternating pulse may be present. Other symptoms include palpitations, chest pain, diaphoresis, light-headedness, weakness, or vertigo.

Cor pulmonale

Chronic dyspnea begins gradually with exertion and progressively worsens until it occurs even at rest. Underlying cardiac or pulmonary disease is usually present. The patient may also have a chronic productive cough, wheezing, tachypnea, jugular vein distention, dependent edema, and hepatomegaly. He may experience increasing fatigue, weakness, and light-headedness.

Emphysema

Emphysema is a chronic disorder that gradually causes progressive exertional dyspnea. The patient may exhibit barrel chest, accessory muscle hypertrophy, diminished breath sounds, anorexia, weight loss, malaise, peripheral cyanosis, tachypnea, pursed-lip breathing, prolonged expiration and, possibly, a chronic productive cough. Clubbing is a late sign.

Flail chest

With flail chest, sudden dyspnea results from multiple rib fractures and is accompanied by paradoxical chest movement, severe chest pain, hypotension, tachypnea, tachycardia, and cyanosis. Bruising and decreased or absent breath sounds occur over the affected side.

Guillain-Barré syndrome

Usually following a fever and upper respiratory tract infection, Guillain-Barré syndrome causes slowly worsening dyspnea along with fatigue, ascending muscle weakness and, eventually, paralysis. Other clinical features include facial diplegia, dysphagia or dysarthria and, less commonly, weakness of the muscles supplied by cranial nerve XI.

Heart failure

Dyspnea usually develops gradually in patients with heart failure. Chronic paroxysmal nocturnal dyspnea, orthopnea, tachypnea, tachycardia, palpitations, ventricular gallop, fatigue, dependent peripheral edema, hepatomegaly, dry cough, weight gain, and loss of mental acuity may occur. With acute onset, heart failure may produce jugular vein distention, bibasilar rates, oliguria, and hypotension.

Inhalation injury

Dyspnea may develop suddenly or gradually over several hours after inhalation of chemicals or hot gases. Increasing hoarseness, persistent cough, sooty or bloody sputum, and oropharyngeal edema may also be present. The patient may also exhibit thermal burns, singed nasal hairs, and orofacial burns as well as crackles, rhonchi, wheezing, and signs of respiratory distress.

Lung cancer

Dyspnea that develops slowly and progressively worsens occurs with late-stage lung cancer. Other findings include fever, hemoptysis, productive cough, wheezing, clubbing, chest pain, and pleural friction rub. The patient may also report weight loss and anorexia.

CULTURAL CUE:Among indigenous Arctic populations, the incidence of lung cancer is growing faster than any other cancer. This may be a result of high smoking rates in Native Alaskan adults and children.

Myasthenia gravis

Myasthenia gravis is a neuromuscular disorder that causes bouts of dyspnea as the respiratory muscles weaken. The patient may have difficulty chewing and swallowing, which may lead to aspiration. With myasthenic crisis, acute respiratory distress may occur, with shallow respirations and tachypnea.

Myocardial infarction

With myocardial infarction, sudden dyspnea occurs with crushing substernal chest pain that may radiate to the back, neck, jaw, and arms. Other signs and symptoms include nausea, vomiting, diaphoresis, vertigo, hypertension or hypotension, tachycardia, anxiety, and pale, cool, clammy skin.

Plague

The pneumonic form of plague, caused by the bacterium Yersinia pestis, is characterized by dyspnea, a productive cough, chest pain, tachypnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency. The onset of this virulent infection is usually sudden and includes such signs and symptoms as chills, fever, headache, and myalgias. If untreated, plague is one of the most potentially lethal diseases known.

Pleural effusion

Dyspnea develops slowly and becomes progressively worse with pleural effusion. Initial findings include a pleural friction rub accompanied by pleuritic pain that worsens with coughing or deep breathing. Other findings include dry cough; dullness on percussion; egophony, bronchophony, and whispered pectoriloquy; tachycardia; tachypnea; weight loss; and decreased chest motion, tactile fremitus, and decreased breath sounds. With infection, fever may occur.

Pneumonia

With pneumonia, dyspnea occurs suddenly and is usually accompanied by fever, shaking chills, pleuritic chest pain that worsens with deep inspiration, and a productive cough. Fatigue, headache, myalgia, anorexia, abdominal pain, crackles, rhonchi, tachycardia, tachypnea, cyanosis, decreased breath sounds, and diaphoresis may also occur.

Pneumothorax

Pneumothorax is a life-threatening disorder that causes acute dyspnea unrelated to the severity of pain. Sudden, stabbing chest pain may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, dry cough, cyanosis, decreased vocal fremitus, tachypnea, tympany, decreased or absent breath sounds on the affected side, asymmetrical chest expansion, splinting, and accessory muscle use. In patients with tension pneumothorax, tracheal deviation occurs in addition to these typical findings. Decreased blood pressure and tachycardia may also occur.

Pulmonary edema

Commonly preceded by signs of heart failure, such as jugular vein distention and orthopnea, pulmonary edema causes acute dyspnea. Other features include tachycardia, tachypnea, crackles in both lung fields, a third heart sound (S₃ gallop), oliguria, thready pulse, hypotension, diaphoresis, cyanosis, and marked anxiety. The patient’s cough may be dry or may produce copious amounts of pink, frothy sputum.

Pulmonary embolism

Acute dyspnea that’s usually accompanied by sudden pleuritic chest pain characterizes pulmonary embolism — a life-threatening disorder. Related findings include tachycardia, low-grade fever, tachypnea, nonproductive or productive cough with blood-tinged sputum, pleural friction rub, crackles, diffuse wheezing, dullness on percussion, decreased breath sounds, diaphoresis, restlessness, and acute anxiety. A massive embolism may cause signs of shock, such as hypotension and cool, clammy skin.

Sepsis

Sepsis, a potentially fatal disorder, gradually causes dyspnea along with chills and sudden fever. As dyspnea worsens, it may be accompanied by tachycardia, tachypnea, restlessness, anxiety, decreased mental acuity, and warm, flushed, dry skin. Late findings include hypotension; oliguria; cool, clammy skin; and rapid, thready pulse.

Severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is an infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

CULTURAL CUE:Although most reported SARS cases have been in Asia (particularly China, Vietnam, Singapore, and Thailand), some people in Europe and North America have also been diagnosed with SARS.

Shock

Dyspnea arises suddenly and worsens progressively in a patient with shock, a life-threatening disorder. Related findings include severe hypotension, tachypnea, tachycardia, decreased peripheral pulses, decreased mental acuity, restlessness, anxiety, and cool, clammy skin.

Tuberculosis

In a patient with tuberculosis, dyspnea is commonly accompanied by chest pain, crackles, and productive cough. Other findings include night sweats, fever, anorexia and weight loss, vague dyspepsia, palpitations on mild exertion, and dullness on percussion.

Tularemia

Also known as rabbit fever, tularemia is an infectious disease that causes dyspnea along with fever, chills, headache, generalized myalgia, a nonproductive cough, pleuritic chest pain, and empyema. Other signs and symptoms include diaphoresis, weight loss, and a red spot on the skin that ultimately enlarges to an ulcer.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Hyperpnea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Head injury

Hyperpnea can occur with severe head injury. Other clinical manifestations depend on the site and extent of injury and can include loss of consciousness; soft-tissue injury or bony deformity of the face, head, or neck; facial edema; clear or bloody drainage from the mouth, nose, or ears; raccoon eyes; Battle’s sign; an absent doll’s eye sign; and motor and sensory disturbances.

Signs of increased intracranial pressure include decreased response to painful stimulation, loss of pupillary reaction, bradycardia, increased systolic pressure, and widening pulse pressure.

Hyperventilation syndrome

Acute anxiety triggers episodic hyperpnea, resulting in respiratory alkalosis. Other findings may include agitation, vertigo, syncope, pallor, circumoral and peripheral paresthesia, muscle twitching, carpopedal spasm, weakness, and arrhythmias.

Hypoxemia

Many pulmonary disorders that cause hypoxemia — for example, pneumonia, pulmonary edema, chronic obstructive pulmonary disease, and pneumothorax — may cause hyperpnea and episodes of hyperventilation with chest pain, dizziness, and paresthesia. Other effects include dyspnea, cough, crackles, rhonchi, wheezing, and decreased breath sounds.

Ketoacidosis

Alcoholic ketoacidosis typically follows cessation of drinking after a marked increase in alcohol consumption has caused severe vomiting. Kussmaul’s respirations begin abruptly and are accompanied by vomiting for several days, fruity breath odor, slight dehydration, abdominal pain and distention, and absent bowel sounds. The patient is alert and has a normal blood glucose level, unlike the patient with diabetic ketoacidosis.

Diabetic ketoacidosis is potentially life-threatening and typically produces Kussmaul’s respirations. The patient usually experiences polydipsia, polyphagia, and polyuria before the onset of acidosis; he may or may not have a history of diabetes mellitus. Other clinical features include fruity breath odor; orthostatic hypotension; rapid, thready pulse; generalized weakness; decreased LOC (lethargy to coma); nausea; vomiting; anorexia; and abdominal pain.

Starvation ketoacidosis is also potentially life-threatening and can cause Kussmaul’s respirations. Its onset is gradual; typical findings include signs of cachexia and dehydration, decreased LOC, bradycardia, and a history of severely limited food intake.

Renal failure

Acute or chronic renal failure can cause life-threatening acidosis with Kussmaul’s respirations. Signs and symptoms of severe renal failure include oliguria or anuria, uremic fetor, and yellow, dry, scaly skin. Other cutaneous signs include severe pruritus, uremic frost, purpura, and ecchymoses. The patient may complain of nausea and vomiting, weakness, burning pain in the legs and feet, and diarrhea or constipation.

As acidosis progresses, corresponding clinical features include frothy sputum, pleuritic chest pain, and signs of heart failure and pleural or pericardial effusion. Neurologic signs include altered LOC (lethargy to coma), twitching, and seizures. Hyperkalemia and hypertension, if present, require rapid intervention to prevent cardiovascular collapse.

Sepsis

A severe infection may cause lactic acidosis, resulting in Kussmaul’s respirations. Other findings in sepsis include tachycardia, fever or a low temperature, chills, headache, lethargy, profuse diaphoresis, anorexia, cough, wound drainage, burning on urination, confusion or change in mental status, and other signs of local infection.

Shock

Potentially life-threatening metabolic acidosis produces Kussmaul’s respirations, hypotension, tachycardia, narrowed pulse pressure, weak pulse, dyspnea, oliguria, anxiety, restlessness, stupor that can progress to coma, and cool, clammy skin. Other clinical features may include external or internal bleeding (in hypovolemic shock); chest pain or arrhythmias and signs of heart failure (in cardiogenic shock); high fever, chills and, rarely, hypothermia (in septic shock); or stridor due to laryngeal edema (in anaphylactic shock). Onset is usually acute in hypovolemic, cardiogenic, or anaphylactic shock, but it may be gradual in septic shock.

Other causes

Drugs

Toxic levels of salicylates, ammonium chloride, acetazolamide, and other carbonic anhydrase inhibitors can cause Kussmaul’s respirations. So can ingestion of methanol and ethylene glycol, found in antifreeze solutions.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Orthopnea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) typically produces orthopnea and other dyspneic complaints, accompanied by accessory muscle use, tachypnea, tachycardia, and paradoxical pulse. Auscultation may reveal diminished breath sounds, rhonchi, crackles, and wheezing. The patient may also exhibit a dry or productive cough with copious sputum. Other features include anorexia, weight loss, and edema. Barrel chest, cyanosis, and clubbing are usually late signs.

Left-sided heart failure

Orthopnea occurs late in left-sided heart failure. If heart failure is acute, orthopnea may begin suddenly; if chronic, it may become constant. The earliest symptom of left-sided heart failure is progressively severe dyspnea. Other common early symptoms include Cheyne-Stokes respirations, paroxysmal nocturnal dyspnea, fatigue, weakness, and a cough that may occasionally produce clear or blood-tinged sputum. Tachycardia, tachypnea, and crackles may also occur.

Other late findings include cyanosis, clubbing, ventricular gallop, and hemoptysis. Left-sided heart failure may also lead to such signs of shock as hypotension, thready pulse, and cold, clammy skin.

Mediastinal tumor

Orthopnea is an early sign of a mediastinal tumor, resulting from pressure of the tumor against the trachea, bronchus, or lung when the patient lies down. However, many patients are asymptomatic until the tumor enlarges. Then it produces retrosternal chest pain, dry cough, hoarseness, dysphagia, stertorous respirations, palpitations, and cyanosis. Examination reveals suprasternal retractions on inspiration, bulging of the chest wall, tracheal deviation, dilated jugular and superficial chest veins, and edema of the face, neck, and arms.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Stridor: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Airway trauma

Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis

With a severe allergic reaction (anaphylaxis), upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings of anaphylaxis include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation)

Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours.

Aspiration of a foreign body

Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

Epiglottiditis

With epiglottiditis, a life-threatening inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia.

Hypocalcemia

With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, hyperactive deep tendon reflexes, muscle twitching and cramping, and positive Chvostek’s and Trousseau’s signs.

Inhalation injury

Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms  of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Laryngeal tumor

Stridor is a late sign of laryngeal tumor and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

Laryngitis (acute)

Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

Mediastinal tumor

Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Thoracic aortic aneurysm

If a thoracic aortic aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

Other causes

Diagnostic tests

Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Treatments

After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Respiratory Distress and Apnea: Principal Causes of Respiratory Distress (Neonatal)
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Upperrespiratory tract obstruction
2. Lower respiratory tract disorders
   1. Transienttachypnea of the newborn
   2. Respiratory distress syndrome (hyalinemembrane disease)
   3. Meconium aspiration and other aspirationsyndromes
   4. Pneumonia
   5. Pulmonary air leaks
   6. Pulmonary hemorrhage
   7. Bronchopulmonary dysplasia
   8. Congenital malformations of the lungs,bronchi, diaphragm, and rib cage
      1. Lung agenesis and aplasia
      2. Pulmonary hypoplasia
      3. Pulmonary sequestration
      4. Lobar emphysema
      5. Cystic lung lesions
         1. Bronchogeniccyst
         2. Congenital cystic adenomatoid malformation
         3. Intrapulmonary cysts
         4. Congenital pulmonary lymphangiectasia
      6. Chylothorax
      7. Bronchial malformations
      8. Diaphragm lesions
         1. Congenitaldiaphragmatic hernia
         2. Diaphragmatic eventration
         3. Diaphragmatic paralysis or paresis
      9. Rib cage anomalies
   9. Persistent fetal circulation
3. Cardiac disorders
4. Hematologic disorders
   1. Anemia
   2. Polycythemia
5. Metabolic disorders
   1. Hypothermia
   2. Hypoglycemia
   3. Metabolic acidosis
6. Neurologic and muscle disorders
   1. Braindisorders
   2. Spinal cord injury
   3. Neuromuscular disorders
7. Drugs

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Stertor, Stridor, and Airway Obstruction: Principal Causes of Airway Obstruction
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Noseand nasopharynx
   1. Congenital
      1. Choanal atresia
      2. Craniofacial anomalies
      3. Midline masses
   2. Infection/inflammation
      1. Rhinitis
      2. Adenoid hypertrophy
      3. Polyps
   3. Trauma
   4. Neoplasm
2. Oropharynx and hypopharynx
   1. Congenital
      1. Micrognathiaand other skull base abnormalities
      2. Macroglossia
      3. Decreased pharyngeal muscle tone
   2. Infection/inflammation
      1. Tonsillarhypertrophy
      2. Abscess
   3. Foreign body
   4. Trauma
   5. Neoplasm
3. Supraglottic
   1. Congenital
      1. Laryngomalacia
      2. Laryngeal cyst and laryngocele
   2. Infection/inflammation
      1. Supraglottitis
      2. Gastroesophageal reflux
      3. Hereditary angioedema
   3. Trauma
   4. Neoplasm
4. Glottic
   1. Congenital
      1. Laryngeal web
      2. Laryngeal cleft
      3. Vocal cord paralysis
   2. Infection/inflammation
      1. Laryngitis
      2. Laryngeal spasm
   3. Foreign body
   4. Trauma
   5. Neoplasm
5. Subglottic
   1. Congenital
      1. Subglottic stenosis
      2. Cysts
   2. Infection/inflammation
      1. Croup
      2. Bacterial tracheitis
   3. Trauma
   4. Neoplasm
6. Tracheobronchial
   1. Congenital
      1. Tracheomalacia
      2. Tracheal web
      3. Tracheal cysts
      4. Tracheal stenosis
      5. Vascular anomalies
   2. Infection/inflammation
   3. Foreign body
   4. Trauma
   5. Neoplasm
      1. Tracheal
      2. Thyroid
      3. Mediastinal masses
7. Psychogenic

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Apnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Airway obstruction.Occlusion or compression of the trachea, central airways, or smaller airways can cause sudden apnea by blocking the patient's airflow and producing acute respiratory failure.

Brain stem dysfunction.Primary or secondary brain stem dysfunction can cause apnea by destroying the brain stem's ability to initiate respirations. Apnea may arise suddenly (as in trauma, hemorrhage, or infarction) or gradually (as in degenerative disease or tumor). Apnea may be preceded by a decreased LOC and by various motor and sensory deficits.

Neuromuscular failure.Trauma or disease can disrupt the mechanics of respiration, causing sudden or gradual apnea. Associated findings include diaphragmatic or intercostal muscle paralysis from injury or respiratory weakness or paralysis from acute or degenerative disease.

Parenchymatous lung disease.An accumulation of fluid within the alveoli produces apnea by interfering with pulmonary gas exchange and producing acute respiratory failure. Apnea may arise suddenly, as in near drowning and acute pulmonary edema, or gradually, as in emphysema. Apnea may be preceded by crackles and labored respirations with accessory muscle use.

Pleural pressure gradient disruption.Conversion of normal negative pleural air pressure to positive pressure by chest wall injuries (such as flail chest) causes lung collapse, producing respiratory distress and, if untreated, apnea. Associated signs include an asymmetrical chest wall and asymmetrical or paradoxical respirations.

Pulmonary capillary perfusion
decrease.Apnea can stem from obstructed pulmonary circulation, most commonly due to heart failure or lack of circulatory patency. It occurs suddenly in cardiac arrest, massive pulmonary embolism, and most cases of severe shock. In contrast, it occurs progressively in septic shock and pulmonary hypertension. Related findings include hypotension, tachycardia, and edema.

Other causes

Drugs.Central nervous system (CNS) depressants may cause hypoventilation and apnea. Benzodiazepines may cause respiratory depression and apnea when given I.V. along with other CNS depressants to elderly or acutely ill patients. Drug overdose can lead to respiratory depression and apnea.

Neuromuscular blockers—such as curariform drugs and anticholinesterases—may produce sudden apnea because of respiratory muscle paralysis.

Sleep-related apneas.These repetitive apneas occur during sleep from airflow obstruction or brain stem dysfunction.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Bradypnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Diabetic ketoacidosis.Bradypnea occurs late in patients with severe, uncontrolled diabetes. Patients with severe ketoacidosis may experience Kussmaul's respirations. Associated signs and symptoms include a decreased LOC, fatigue, weakness, a fruity breath odor, and oliguria.

Hepatic failure.Occurring with end-stage hepatic failure, bradypnea may be accompanied by coma, hyperactive reflexes, asterixis, a positive Babinski's sign, fetor hepaticus, and other signs.

Increased intracranial pressure (ICP).A late sign of increased ICP, a life-threatening condition, bradypnea is preceded by a decreased LOC, deteriorating motor function, and fixed, dilated pupils. The triad of bradypnea, bradycardia, and hypertension is a classic sign of late medullary strangulation.

Renal failure.Occurring with end-stage renal failure, bradypnea may be accompanied by convulsions, a decreased LOC, GI bleeding, hypotension or hypertension, uremic frost, and diverse other signs.

Respiratory failure.Bradypnea occurs with end-stage respiratory failure along with cyanosis, diminished breath sounds, tachycardia, mildly increased blood pressure, and a decreased LOC.

Other causes

Drugs.Overdose with an opioid analgesic or, less commonly, a sedative, barbiturate, phenothiazine, or other CNS depressant can cause bradypnea. The use of any of these drugs with alcohol can also cause bradypnea.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Dyspnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute respiratory distress syndrome (ARDS).ARDS is a life-threatening form of noncardiogenic pulmonary edema that usually produces acute dyspnea as the first complaint. Progressive respiratory distress then develops with restlessness, anxiety, decreased mental acuity, tachycardia, and crackles and rhonchi in both lung fields. Other findings include cyanosis, tachypnea, motor dysfunction, and intercostal and suprasternal retractions. Severe ARDS can produce signs of shock, such as hypotension and cool, clammy skin.

Amyotrophic lateral sclerosis (ALS).ALS causes the slow onset of dyspnea that worsens with time. Other features include dysphagia, dysarthria, muscle weakness and atrophy, fasciculations, shallow respirations, tachypnea, and emotional lability.

Anthrax (inhalation).Dyspnea is a symptom of the second stage of anthrax, along with a fever, stridor, and hypotension (the patient usually dies within 24 hours). Initial symptoms of this disorder, which are due to the inhalation of aerosolized spores (from infected animals or as a result of bioterrorism) from the bacterium Bacillus anthracis, are flulike and include a fever, chills, weakness, a cough, and chest pain.

Aspiration of a foreign body.Acute dyspnea marks this life-threatening condition, along with paroxysmal intercostal, suprasternal, and substernal retractions. The patient may also display accessory muscle use, inspiratory stridor, tachypnea, decreased or absent breath sounds, possibly asymmetrical chest expansion, anxiety, cyanosis, diaphoresis, and hypotension.

Asthma.Acute dyspneic attacks occur with asthma, along with audible wheezing, a dry cough, accessory muscle use, nasal flaring, intercostal and supraclavicular retractions, tachypnea, tachycardia, diaphoresis, prolonged expiration, flushing or cyanosis, and apprehension. Medications that block beta receptors can exacerbate asthma attacks.

Avian influenza.These potentially life-threatening viruses are spread to humans through contact with infected poultry or surfaces contaminated with infected bird excretions. Within 1 to 5 days of exposure to avian influenza, the patient typically develops flulike symptoms, such as fever, sore throat, cough, and muscle aches. Those with severe forms of the virus may develop dyspnea caused by acute respiratory distress or pneumonia.

Blast lung injury.The result of a forceful percussive wave following an explosive detonation, blast lung injury is commonly characterized by dyspnea and hypoxia. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause cyanosis, chest pain, wheezing, and hemoptysis. Chest X-ray, the primary diagnostic tool, reveals a characteristic “butterfly” pattern. Many of these patients suffer concomitant injuries and require complex management, usually in an intensive care setting.

Cor pulmonale.With cor pulmonale, chronic dyspnea begins gradually with exertion and progressively worsens until it occurs even at rest. Underlying cardiac or pulmonary disease is usually present. The patient may have a chronic productive cough, wheezing, tachypnea, jugular vein distention, dependent edema, and hepatomegaly. He may also experience increasing fatigue, weakness, and light-headedness.

Emphysema.Emphysema is a chronic disorder that gradually causes progressive exertional dyspnea. A history of smoking, an alpha1-antitrypsin deficiency, or exposure to an occupational or environmental irritant usually accompanies barrel chest, accessory muscle hypertrophy, diminished breath sounds, anorexia, weight loss, malaise, peripheral cyanosis, tachypnea, pursed-lip breathing, prolonged expiration and, possibly, a chronic productive cough. Clubbing is a late sign.

Flail chest.Sudden dyspnea results from multiple rib fractures and is accompanied by paradoxical chest movement, severe chest pain, hypotension, tachypnea, tachycardia, and cyanosis. Bruising and decreased or absent breath sounds occur over the affected side.

Heart failure.Dyspnea usually develops gradually in patients with heart failure. Chronic paroxysmal nocturnal dyspnea, orthopnea, tachypnea, tachycardia, palpitations, a ventricular gallop, fatigue, dependent peripheral edema, hepatomegaly, a dry cough, weight gain, and loss of mental acuity may occur. With acute onset, heart failure may produce jugular vein distention, bibasilar rates, oliguria, and hypotension.

Inhalation injury.Dyspnea may develop suddenly or gradually over several hours after the inhalation of chemicals or hot gases. Increasing hoarseness, a persistent cough, sooty or bloody sputum, and oropharyngeal edema may also be present. The patient may also exhibit thermal burns, singed nasal hairs, and orofacial burns as well as crackles, rhonchi, wheezing, and signs of respiratory distress.

Monkeypox.Dyspnea is one of the less common symptoms of this rare viral disease. Infected individuals may also experience fever, muscle aches, sore throat, chills, and lymphadenopathy. A papular rash appears 1 to 3 days after the fever begins. The virus is similar to smallpox; however, the symptoms are milder and the disease is rarely fatal in developed countries.

Myasthenia gravis.Myasthenia gravis causes bouts of dyspnea as the respiratory muscles weaken. With myasthenic crisis, acute respiratory distress may occur, with shallow respirations and tachypnea.

Myocardial infarction.Sudden dyspnea occurs with crushing substernal chest pain that may radiate to the back, neck, jaw, and arms. Other signs and symptoms include nausea, vomiting, diaphoresis, vertigo, hypertension or hypotension, tachycardia, anxiety, and pale, cool, clammy skin.

Plague(Yersinia pestis).Among the symptoms of the pneumonic form of plague are dyspnea, a productive cough, chest pain, tachypnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency. The onset of this virulent infection is usually sudden and includes such signs and symptoms as chills, fever, headache, and myalgia. If untreated, plague is one of the most potentially lethal diseases known.

Pleural effusion.With pneumonia, yspnea develops slowly and becomes progressively worse with pleural effusion. Initial findings include a pleural friction rub accompanied by pleuritic pain that worsens with coughing or deep breathing. Other findings include a dry cough; dullness on percussion; egophony, bronchophony, and whispered pectoriloquy; tachycardia; tachypnea; weight loss; and decreased chest motion, tactile fremitus, and decreased breath sounds. With infection, a fever may occur.

Pneumonia.With pneumonia, dyspnea occurs suddenly, usually accompanied by a fever, shaking chills, pleuritic chest pain that worsens with deep inspiration, and a productive cough. Fatigue, a headache, myalgia, anorexia, abdominal pain, crackles, rhonchi, tachycardia, tachypnea, cyanosis, decreased breath sounds, and diaphoresis may also occur.

Pneumothorax.Pneumothorax is a life-threatening disorder that causes acute dyspnea unrelated to the severity of the pain. Sudden, stabbing chest pain may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, a dry cough, cyanosis, decreased vocal fremitus, tachypnea, tympany, decreased or absent breath sounds on the affected side, asymmetrical chest expansion, splinting, and accessory muscle use. In patients with tension pneumothorax, tracheal deviation occurs in addition to these typical findings. Decreased blood pressure and tachycardia may also occur.

Poliomyelitis (bulbar).Dyspnea develops gradually and progressively worsens. Additional signs and symptoms include a fever, facial weakness, dysphasia, hypoactive deep tendon reflexes, decreased mental acuity, dysphagia, nasal regurgitation, and hypopnea.

Pulmonary edema.Commonly preceded by signs of heart failure, such as jugular vein distention and orthopnea, pulmonary edema—a life-threatening disorder—causes acute dyspnea. Other features include tachycardia, tachypnea, crackles in both lung fields, a third heart sound (S₃ gallop), oliguria, a thready pulse, hypotension, diaphoresis, cyanosis, and marked anxiety. The patient's cough may be dry or may produce copious amounts of pink, frothy sputum.

Pulmonary embolism.Acute dyspnea that's usually accompanied by sudden pleuritic chest pain characterizes pulmonary embolism, a life-threatening disorder. Related findings include tachycardia, a low-grade fever, tachypnea, a nonproductive or productive cough with blood-tinged sputum, a pleural friction rub, crackles, diffuse wheezing, dullness on percussion, decreased breath sounds, diaphoresis, restlessness, and acute anxiety. A massive embolism may cause signs of shock, such as hypotension and cool, clammy skin.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Shock.Dyspnea arises suddenly and worsens progressively with shock, a life-threatening disorder. Related findings include severe hypotension, tachypnea, tachycardia, decreased peripheral pulses, decreased mental acuity, restlessness, anxiety, and cool, clammy skin.

Tuberculosis.Dyspnea commonly occurs with chest pain, crackles, and a productive cough. Other findings are night sweats, a fever, anorexia and weight loss, vague dyspepsia, palpitations on mild exertion, and dullness on percussion.

Tularemia.Also known as rabbit fever, tularemia causes dyspnea along with a fever, chills, a headache, generalized myalgia, a nonproductive cough, pleuritic chest pain, and empyema.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Hyperpnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Head injury.Hyperpnea that results from a severe head injury is called central neurogenic hyperventilation. Whether its onset is acute or gradual, this type of hyperpnea indicates damage to the lower midbrain or upper pons. Accompanying signs reflect the site and extent of injury and can include loss of consciousness; soft-tissue injury or bony deformity of the face, head, or neck; facial edema; clear or bloody drainage from the mouth, nose, or ears; raccoon eyes; Battle's sign; an absent doll's eye sign; and motor and sensory disturbances.

Signs of increased intracranial pressure include decreased response to painful stimulation, loss of pupillary reaction, bradycardia, increased systolic pressure, and a widening pulse pressure.

Hyperventilation syndrome.Acute anxiety triggers episodic hyperpnea, resulting in respiratory alkalosis. Other findings may include agitation, vertigo, syncope, pallor, circumoral and peripheral paresthesia, muscle twitching, carpopedal spasm, weakness, and arrhythmias.

Hypoxemia.Many pulmonary disorders that cause hypoxemia—for example, pneumonia, pulmonary edema, chronic obstructive pulmonary disease, and pneumothorax—may cause hyperpnea and episodes of hyperventilation with chest pain, dizziness, and paresthesia. Other effects include dyspnea, a cough, crackles, rhonchi, wheezing, and decreased breath sounds.

Ketoacidosis.Alcoholic ketoacidosis (occurring most commonly in females with a history of alcohol abuse) typically follows cessation of drinking after a marked increase in alcohol consumption has caused severe vomiting. Kussmaul's respirations begin abruptly and are accompanied by vomiting for several days, a fruity breath odor, slight dehydration, abdominal pain and distention, and absent bowel sounds. The patient is alert and has a normal blood glucose level, unlike the patient with diabetic ketoacidosis.

Diabetic ketoacidosis is potentially life-threatening and typically produces Kussmaul's respirations. The patient usually experiences polydipsia, polyphagia, and polyuria before the onset of acidosis; he may have a history of diabetes mellitus. Other clinical features include a fruity breath odor; orthostatic hypotension; a rapid, thready pulse; generalized weakness; a decreased LOC (lethargy to coma); nausea; vomiting; anorexia; and abdominal pain.

Starvation ketoacidosis is also potentially life-threatening and can cause Kussmaul's respirations. Its onset is gradual; typical findings include signs of cachexia and dehydration, a decreased LOC, bradycardia, and a history of severely limited food intake.

Renal failure.Acute or chronic renal failure can cause life-threatening acidosis with Kussmaul's respirations. Signs and symptoms of severe renal failure include oliguria or anuria, uremic fetor, and yellow, dry, scaly skin. Other cutaneous signs include severe pruritus, uremic frost, purpura, and ecchymoses. The patient may complain of nausea and vomiting, weakness, burning pain in the legs and feet, and diarrhea or constipation.

As acidosis progresses, corresponding clinical features include frothy sputum, pleuritic chest pain, and signs of heart failure and pleural or pericardial effusion. Neurologic signs include an altered LOC (lethargy to coma), twitching, and seizures. Hyperkalemia and hypertension, if present, require rapid intervention to prevent cardiovascular collapse.

Sepsis.A severe infection may cause lactic acidosis, resulting in Kussmaul's respirations. Other findings include tachycardia, a fever or a low temperature, chills, a headache, lethargy, profuse diaphoresis, anorexia, a cough, wound drainage, burning on urination, confusion or a change in mental status, and other signs of local infection.

Shock.Potentially life-threatening metabolic acidosis produces Kussmaul's respirations, hypotension, tachycardia, narrowed pulse pressure, a weak pulse, dyspnea, oliguria, anxiety, restlessness, stupor that can progress to coma, and cool, clammy skin. Other clinical features may include external or internal bleeding (in hypovolemic shock); chest pain or arrhythmias and signs of heart failure (in cardiogenic shock); a high fever, chills and, rarely, hypothermia (in septic shock); or stridor due to laryngeal edema (in anaphylactic shock). The onset is usually acute in hypovolemic, cardiogenic, or anaphylactic shock, but it may be gradual in septic shock.

Other causes

Drugs.Toxic levels of salicylates, ammonium chloride, acetazolamide, and other carbonic anhydrase inhibitors can cause Kussmaul's respirations. So can ingestion of methanol and ethylene glycol, found in antifreeze solutions.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Orthopnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Chronic obstructive pulmonary disease (COPD).COPD typically produces orthopnea and other dyspneic complaints, accompanied by accessory muscle use, tachypnea, tachycardia, and paradoxical pulse. Auscultation may reveal diminished breath sounds, rhonchi, crackles, and wheezing. The patient may also exhibit a dry or productive cough with copious sputum. Other features include anorexia, weight loss, and edema. Barrel chest, cyanosis, and clubbing are usually late signs.

Left-sided heart failure.Orthopnea occurs late in left-sided heart failure. If heart failure is acute, orthopnea may begin suddenly; if chronic, it may become constant. The earliest symptom of this disorder is progressively severe dyspnea. Other common early symptoms include Cheyne-Stokes respirations, paroxysmal nocturnal dyspnea, fatigue, weakness, and cough that may occasionally produce clear or blood-tinged sputum. Tachycardia, tachypnea, and crackles may also occur.

Other late findings include cyanosis, clubbing, a ventricular gallop, and hemoptysis. Left-sided heart failure may also lead to signs of shock, such as hypotension, a thready pulse, and cold, clammy skin.

Mediastinal tumor.Orthopnea is an early sign of a mediastinal tumor, resulting from pressure of the tumor against the trachea, bronchus, or lung when the patient lies down. However, he may be asymptomatic until the tumor enlarges. Then it produces retrosternal chest pain, a dry cough, hoarseness, dysphagia, stertorous respirations, palpitations, and cyanosis. Examination reveals suprasternal retractions on inspiration, bulging of the chest wall, tracheal deviation, dilated jugular and superficial chest veins, and face, neck, and arm edema.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Stridor: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Airway trauma.Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

Anaphylaxis.With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

Anthrax (inhalation).Initial signs and symptoms of anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Hypocalcemia.With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek's and Trousseau's signs.

Inhalation injury.Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

Mediastinal tumor.Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, a brassy cough, a tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

Retrosternal thyroid.Retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

Other causes

Diagnostic tests.Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

Foreign body aspiration.Sudden stridor is characteristic in foreign body aspiration, a life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing; gagging or choking; hoarseness; tachycardia; wheezing; dyspnea; tachypnea; intercostal muscle retractions; diminished breath sounds; cyanosis; and shallow respirations. The patient typically appears anxious and distressed.

Treatments.After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Paroxysmal nocturnal dyspnea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Left-sided heart failure.Dyspnea—on exertion, during sleep, and eventually even at rest—is an early sign of left-sided heart failure. This sign is characteristically accompanied by Cheyne-Stokes respirations, diaphoresis, weakness, wheezing, and a persistent, nonproductive cough or a cough that produces clear or blood-tinged sputum. As the patient's condition worsens, he develops tachycardia, tachypnea, alternating pulse (commonly initiated by a premature beat), a ventricular gallop, crackles, and peripheral edema.

With advanced left-sided heart failure, the patient may also exhibit severe orthopnea, cyanosis, clubbing, hemoptysis, and cardiac arrhythmias as well as signs and symptoms of shock, such as hypotension, a weak pulse, and cold, clammy skin.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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