Paroxysmal Nocturnal Dyspnea

Paroxysmal Nocturnal Dyspnea: Excerpt from In a Page: Signs and Symptoms

Paroxysmal nocturnal dyspnea is defined as severe difficulty breathing or air hunger that awakens the patient from sleep (usually 1–3 hours after lying down) and forces them to a sitting or standing position. The patient may gasp and proceed to an open window for fresh air. The dyspnea tends to resolve in 10–30 minutes. PND almost always implies heart failure.

Differential Diagnosis

• CHF is the most common cause
  –Etiologies include uncontrolled HTN, pulmonary embolus, endocarditis, hyperthyroidism, pericardial disease, endocardial disease (e.g., valvular stenosis, insufficiency, rupture, endocarditis), and myocardial disease (e.g., MI, ischemia, arrhythmias)
• Mitral stenosis
  –Almost always secondary to rheumatic heart disease (after 15–40 years)
  –Advanced cases result in pulmonary hypertension and right heart failure
  –Dyspnea is the most significant symptom
  –Classic triad: Diastolic rumble, opening snap, and loud first heart sound
• Aortic regurgitation
  –Most commonly due to rheumatic fever
• Cardiomyopathies
  –Abnormal myocardium, resulting in impaired cardiac output and CHF
• Aortic stenosis
  –Due to senile valve degeneration, rheumatic disease, or congenital
  –Associated with angina, syncope, and CHF
• Congenital heart disease
  –May see failure to thrive, progressive CHF symptoms, cyanosis, and/or murmur
  • “Cardiac asthma”
    –Bronchospasm secondary to pulmonary congestion and interstitial edema that compresses small airways
    –Standing decreases lung congestion
  • Anxiety
  • Severe COPD and emphysema
  • Asthma
  • Obstructive sleep apnea
  • Obesity/hypoventilation
  • Tropical pulmonary eosinophilia (filariasis)

  Workup and Diagnosis

  • Complete history and physical exam with special attention to cardiac and respiratory systems
  • Initial laboratory studies may include CBC, pulse oximetry, electrolytes, BUN/creatinine, glucose, and calcium
  • Chest X-ray to evaluate for effusion and heart size
  • Echocardiogram may be used to evaluate valves, chamber size, and ventricular function
  • ECG
  • Consider cardiology consult
  • Cardiac catheterization may be indicated for valvular disease, cardiomyopathies, and congenital heart disease

  Treatment

  • Attention to airway, breathing, and circulation
  • Administer supplemental O₂
  • Many patients feel relief with cold air blowing in face
  • CHF: Mainstay of therapy is to decrease preload (by venodilation) and afterload (by arteriodilation and volume removal) to improve forward blood flow and decrease symptoms; nitrates (sublingual and IV), loop diuretics, IV morphine, ACE inhibitors, and spironolactone; treat refractory respiratory distress with CPAP, BiPAP, or intubation
  • Valvular disease: Blood pressure reduction with an ACE inhibitor or β-blocker is first-line therapy; surgical intervention (balloon valvuloplasty, valve repair, or valve replacement) is needed for severe disease

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Heart failure

• Back to disease: Heart failure: Introduction
• Next Book Extract About Heart failure: Heart Failure (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Heart Failure (In A Page: Pediatric Signs and Symptoms)

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