DYSPNEA

Allen Widysanto

MAJOR SYMPTOMS OF PULMONARY DISEASE

DEFINITION
DYSPNEA
Difficult, laboured, uncomfortable breathing. Subjective feeling which may be associated with mild anxiety or extreme fear

HYPERVENTILATION

Rapid-deep breathing

TACHYPNEA BREATHLESSNESS

Rapid-shallow breathing

Sensation of not being able to get enough air

PROBLEM
?????
Pulmonary dyspnea Cardiac dyspnea

EVALUATION OF A PATIENT WITH DYSPNEA ARE ITS DURATION, CONSTANCY OR INTERMITTENCY

ETIOLOGY
LUNG HEART MUSCULOSCELET AL

DYSPNEA

METABOLIC

KIDNEY

BRAIN

PULMONARY DYSPNEA
OBSTRUCTION

VENTILATIO N IMPAIRMEN T

RESTRICTION IMPAIRMENT OF OXYGEN TRANSFER SHUNTING PERFUSION ANEMIA

INADEQUATE CARDIAC OUTPUT

DIFFUSION

3 MAJOR CATEGORIES
DYSPNEA

ACUTE DYSPNEA

CHRONIC PROGRESSIVE DYSPNEA

RECURRENT PAROXYSMAL DYSPNEA

Acute dyspnea
LOWER RESPIRATORY TRACT

ACUTE PULMONARY EDEMA PULMONARY THROMBOEMBOLISM

ACUTE LARYNGEAL EDEMA INHALED FOREIGN BODY

PNEUMONIA SPONTANEOUS PNEUMOTHORAX ATELECTASIS

TRACHEA OBSTRUCTION/COMPRESSION

UPPER RESPIRATORY TRACT

NEOPLASMA

INFECTIOUS CROUP

SIGNS AND SYMPTOMS

Depend on the causa
UPPER AIRWAY OBSTRUCTIONS ARE CHARACTERIZED BY STRIKING INSPIRATORY STRIDOR, INSPIRATORY WHEEZING

LARYNGEAL OR TRACHEAL OBSTRUCTION

Chronic progressive dyspnea

CONGESTIVE HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE INTERSTITIAL DISEASE (Occupational Lung Diseases)

ASTHMA

HYPERSENSITIVITY PNEUMONIAS

GRANULOMATOUS DISEASE

SARCOIDOSIS COLLAGEN DISEASES (scleroderma, SLE, Polyarteritis nodosa, Wageners granulomatosis, rhematoid lung )

RECURRENT PAROXYSMAL DYSPNEA ASTHMA

Allergen Viral Bacterial Parasit Fungi

LVH MS

ONSET of BREATHLESSNESS
SUDDEN ONSET
Pulmonary embolus Pneumotoraks Inhalation of a foreign body

A few hour
Asthma Pulmonary edema

Over days or weeks

Accumulation of PE Partial/complete airway occlusion due to growth of lung cancer GRADUAL ONSET OVER MONTHS OR YEARS

COPD Lung fibrosis Non-respiratory causes (anemia, hyperthyroidism)

RISK FACTORS FOR RESPIRATORY DISEASE

Childhood respiratory illness Tobacco smoking (pack year smoking) Family history ( asthma and atopy, emphysema, thromboembolic disease) Occupational and home environment Exposure to animals and birds Infectious contacts Immunosupression (HIV, immunosuppresant drugs, DM)

DIAGNOSIS
Presenting complaint-breathlessness
Consider

Respiratory causes

Cardiovascular causes

Other causes

Differentiate between main groups of causes

Exacerbating and relieving factors Associated features Risk factors

Identify likely organ system involved

Consider specific differential diagnosis eg. respiratory

COPD

Asthma

Pulmonary embolus

Pulmonary fibrosis

Pleural effusion

Further history + examination

Differentiate between specific causes

MANAGEMENT STRATEGIES FOR ACUTE DYSPNEA

Several validated and more sensitive one-dimensional instruments can be used to measure the patients level of dyspnea such as : The modified Borg Scale The most important : Elicit underlying diseases Using Medical Research Council (MRC) dyspnea score
Gets breathless with strenuous exercise Gets short of breath when hurrying on the level or walking up a slight hill Walks slower than people of the same age on the level because of breathlessness, or has to stop for breath when walking at own pace on the level Stops for breath after walking about 100 yards or after a few minutes on the level Too breathless to leave the house or breathless when dressing or undressing

1. 2. 3.

4. 5.

FOUR KEY QUESTIONS HAVE BEEN SUGGESTED TO ELICIT UNDERLYING DISEASE

Are you short of breath? Do you have any chest pain? What were you doing before and at the onset of

breathlessness? Do you have any major medical or surgical conditions?

THE BORG SCALE

The Borg Scale is used to measure your

sensation of breathlessness during various activities. Monitoring your breathlessness can help you safely adjust your activity by speeding up or slowing down your movements. It can also provide important information to your health care provider.

0 0.5 1 2 3 4 5

No breathlessness at all Very very slight ( just noticable) Very slight Slight breathlessness Moderate Somewhat severe Severe breathlessness

6 7
8 9 10 Very very severe (almost maximum) Maximum

Very severe breathlessness

MANAGEMENT STRATEGIES
Decreasing the central drive to breathe

Reducing the sense of effort or improve respiratory muscle function

Altering the central perception of dyspnea

Decreasing central drive to breathe

Oxygen
Opiates Anxiolytics

Reduce the sense of effort and improve respiratory muscle function

Hyperinflation as a primary mechanism of dyspnea :

breathing techniques and changing breathing paterns for reducing dyspnea. The patient should be allowed to get the most convenient position until she/he experiences the least shortness of breath NISV Pursed lip breathing
Help the patient to maintain a slow, rhythmic and deep pattern of breathing

Alter the central perception of dyspnea

When acute dyspnea persists despite optimal

treatment, care focuses on the symptom rather than the disease. Breathing-relaxation training Counseling and support Distraction with music Acupunture /acupressure Chest wall vibration Neuro-electrical muscle stimulation

COMPLICATION
RESPIRATORY FAILURE

Inability of the respiratory system to maintain a normal state of gas exchange from the atmosphere to the cells as required by the body = To maintain normal arterial blood PO2, PCO2 and pH

 Respiratory failure is present if:

PaO2 is < 60 mmHg or 2. PaCO2 is > 45 mmHg, except when elevation in PCO2 is compensation for metabolic alkalosis
1.

PaO2 < 60 mmHg : Hypoxemic respiratory failure PaCO2 > 45 mm Hg: Hypercapnic respiratory failure

TREATMENT
Supplemental oxygen

Bronchodilators
Diuretics Antibiotics Mechanical ventilation
THE UNDERLYING DISEASE LEADING TO RESPIRATORY FAILURE MUST BE ADDRESSED

DEVICE
Nasal cannula

Flow rate 2-6 L/min

Low flow delivery device

Simple mask Venturi mask

Flow rate 4-8 L/min

High flow delivery device

NRM

OTHER DRUGS
Corticosteroids

Leucotriene antagonists and inhibitors

Expectorant Sedative ( Lorazepam )and muscle relaxant (

Propofol) particularly for the patients who are receiving mechanical ventilator. In patients not receiving MV, sedative drugs ( barbiturates, benzodiapines, opioids) are contraindicated. Chest physiotherapy

MECHANICAL VENTILATION
Indications for intubation and MV:

Physiologic
Hypoxemia persists after O2 administration PCO2 > 55 mmHg with pH < 7.25 Vital capacity < 15 mL/kg with neuromuscular disease

Clinical
Altered mental status with impaired airway protection Respiratory distress with hemodynamic instability

Upper airway obstruction High volume of secretions not cleared by patient, requiring suctioning

4 take home messages

Dyspnea = Shortness of breath is one of the

major symptoms of pulmonary disease which is giving sensation such as uncomfortable breathing . There are many etiologies of shortness of breath either from the lung or the other organs. Management of dyspnea is depend on the underlying disease, however supplemental oxygen is a must. Respiratory failure ( type 1 or type 2 ) is the complication of unmanaged shortness of breath.

THE MEDULLARY RESPIRATORY CNTRE

Dorsal respiratory centre Nucleus of the tractus solitarius Consists mainly inspiratory neurons

Ventral respiratory centre

Retrofacial nucleus, nucleus ambiguus and nucleus retroambiguus Consists of Inspiratory and Expiratory cells

REFLEX MECHANISMS OF RESPIRATORY CONTROL

HERING-BREUER INFLATION REFLEX HERING-BREUER DEFLATION REFLEX

PARADOXICAL REFLEX OF HEAD

HERING-BREUER INFLATION REFLEX

Stimulus : Lung inflation

Receptor : Stretch receptor within smooth muscle of

large and small airways Afferent pathway : Vagus Effect : Respiratory : Cessation of inspiratory effort, apnea, or decreased breathing frequency, bronchodilation Cardiovascular : increased heart rate, slight vasoconstriction

HERING-BREUER DEFLATION REFLEX

Stimulus : Lung deflation

Receptor : possibly J receptors, irritant receptors in

lungs or stretch receptors in airways Afferent : Vagus Effect : Hyperpnea

PARADOXICAL REFLEX OF HEAD

Stimulus : Lung inflation Receptor : Stretch receptors in lungs Afferent : Vagus Effects: inspiration