Paroxysmal nocturnal dyspnea
Paroxysmal nocturnal dyspnea: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Typically dramatic and terrifying to the patient, this sign refers to an attack of dyspnea that abruptly awakens the patient. Common findings include diaphoresis, coughing, wheezing, and chest discomfort. The attack abates after the patient sits up or stands for several minutes, but may recur every 2 to 3 hours.
Paroxysmal nocturnal dyspnea is a sign of left-sided heart failure. It may result from decreased respiratory drive, impaired left ventricular function, enhanced reabsorption of interstitial fluid, or increased thoracic blood volume. All of these pathophysiologic mechanisms cause dyspnea to worsen when the patient lies down.
History and physical examination
Begin by exploring the patient’s complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?
Next perform a physical examination. Begin by taking the patient’s vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.
Medical causes
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.
Special considerations
Prepare the patient for diagnostic tests, such as a chest X-ray, echocardiography, exercise electrocardiography, and cardiac blood pool imaging. If the hospitalized patient experiences paroxysmal nocturnal dyspnea, assist him to a sitting position or help him walk around the room. If necessary, provide supplemental oxygen. Try to calm him because anxiety can exacerbate dyspnea.
Pediatric pointers
In a child, paroxysmal nocturnal dyspnea usually stems from a congenital heart defect that precipitates heart failure. Help relieve the child’s dyspnea by elevating his head and calming him.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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