dyspnea
DESCRIPTION
PPT..TRANSCRIPT
Allen Widysanto
DYSPNEA
MAJOR SYMPTOMS OF PULMONARY DISEASE
DEFINITION
DYSPNEA
HYPERVENTILATION
TACHYPNEA
BREATHLESSNESS
Difficult, laboured, uncomfortable breathing. Subjective feeling which may
be associated with mild anxiety or extreme fear
Rapid-deep breathing
Rapid-shallow breathing
Sensation of not being able to get enough air
PROBLEM
EVALUATION OF A PATIENT WITH DYSPNEA ARE ITS DURATION, CONSTANCY OR INTERMITTENCY
Pulmonarydyspnea
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Cardiacdyspnea
ETIOLOGY
LUNG HEARTMUSCULOSCELET
AL
METABOLIC BRAINKIDNEY
DYSPNEA
PULMONARY DYSPNEA
IMPAIRMENT OF OXYGEN
TRANSFER
SHUNTING
ANEMIA
INADEQUATE CARDIAC OUTPUT
3 MAJOR CATEGORIES
DYSPNEA
ACUTE DYSPNEA
CHRONIC PROGRESSIVE
DYSPNEA
RECURRENTPAROXYSMAL
DYSPNEA
Acute dyspnea
ACUTE PULMONARY EDEMA
PULMONARY THROMBOEMBOLISM
PNEUMONIA
SPONTANEOUSPNEUMOTHORAX
UPPERRESPIRATORYTRACT
LOWERRESPIRATORYTRACT
ATELECTASIS
ACUTE LARYNGEAL EDEMA
INHALED FOREIGN BODY
NEOPLASMA
TRACHEA OBSTRUCTION/COMPRESSION
INFECTIOUS CROUP
SIGNS AND SYMPTOMS
Depend on the causaUPPER AIRWAY OBSTRUCTIONS ARE
CHARACTERIZED BY STRIKING INSPIRATORY STRIDOR, INSPIRATORY WHEEZING
LARYNGEAL OR TRACHEAL
OBSTRUCTION
Chronic progressive dyspnea
CONGESTIVE HEART
FAILURE
CHRONIC OBSTRUCTIVEPULMONARY
DISEASE
ASTHMA
HYPERSENSITIVITY PNEUMONIAS
GRANULOMATOUSDISEASE
SARCOIDOSISCOLLAGEN DISEASES (scleroderma, SLE, Polyarteritis nodosa, Wagener’s granulomatosis, rhematoid lung )
INTERSTITIAL DISEASE(Occupational Lung Diseases)
RECURRENT PAROXYSMAL DYSPNEA
Allergen
Viral
Bacterial
Parasit
Fungi
LVH
MS
ONSET of BREATHLESSNESS
SUDDENONSET
A few hour
Over days or weeks
GRADUAL ONSET OVER
MONTHS OR YEARS
Pulmonary embolusPneumotoraksInhalation of a foreign body
AsthmaPulmonary edema
Accumulation of PEPartial/complete airway occlusiondue to growth of lung cancer
COPDLung fibrosisNon-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)
DIAGNOSISPresenting complaint-breathlessness
Consider
Respiratorycauses
Cardiovascularcauses
Othercauses
Differentiate between main groups of causesExacerbating and relieving factorsAssociated featuresRisk factors
Identify likely organ system involved
Consider specific differential diagnosiseg. 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 patient’s level of dyspnea such as : The modified Borg Scale
The most important : Elicit underlying diseases
Using Medical Research Council (MRC) dyspnea score1. Gets breathless with strenuous exercise
2. Gets short of breath when hurrying on the level or walking up a slight hill
3. 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
4. Stops for breath after walking about 100 yards or after a few minutes on the level
5. Too breathless to leave the house or breathless when dressing or undressing
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?
FOUR KEY QUESTIONS HAVE BEEN SUGGESTED TO ELICIT
UNDERLYING DISEASE
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 No breathlessness at all
0.5 Very very slight ( just noticable)
1 Very slight
2 Slight breathlessness
3 Moderate
4 Somewhat severe
5 Severe breathlessness
6
7 Very severe breathlessness
8
9 Very very severe (almost maximum)
10 Maximum
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
OxygenOpiatesAnxiolytics
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
NISVPursed lip breathing
Help the patient to maintain a slow, rhythmic and deep pattern of breathing
Alter the central perception of dyspneaWhen acute dyspnea persists despite
optimal treatment, care focuses on the symptom rather than the disease.
Breathing-relaxation trainingCounseling and supportDistraction with musicAcupunture /acupressureChest wall vibrationNeuro-electrical muscle stimulation
COMPLICATION
RESPIRATORYFAILURE
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:1.PaO2 is < 60 mmHg or2.PaCO2 is > 45 mmHg, except when
elevation in PCO2 is compensation for metabolic alkalosis
PaO2 < 60 mmHg : Hypoxemic respiratory failure
PaCO2 > 45 mm Hg: Hypercapnic respiratory failure
TREATMENT Supplemental oxygenBronchodilatorsDiureticsAntibioticsMechanical ventilation
THE UNDERLYING DISEASE LEADING TO RESPIRATORY FAILURE MUST BE ADDRESSED
DEVICE
Low flow delivery device
High flow delivery device
Nasal cannula
Simple mask
Venturi mask
NRM
Flow rate 2-6 L/min
Flow rate 4-8 L/min
Flow rate 2-12 L/min
Flow rate 6-15 L/min
OTHER DRUGSCorticosteroidsLeucotriene antagonists and inhibitorsExpectorantSedative ( 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 VENTILATIONIndications for intubation and MV:
Hypoxemia persists after O2 administration
PCO2 > 55 mmHg with pH < 7.25
Vital capacity < 15 mL/kg with neuromuscular
disease
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 messagesDyspnea = 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
Ventral respiratory centre
Nucleus of the tractus solitariusConsists mainly inspiratory neurons
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 inflationReceptor : Stretch receptor within smooth muscle of
large and small airwaysAfferent pathway : VagusEffect : Respiratory : Cessation of inspiratory effort, apnea, or
decreased breathing frequency, bronchodilationCardiovascular : increased heart rate, slight
vasoconstriction
HERING-BREUER DEFLATION REFLEX
Stimulus : Lung deflationReceptor : possibly J receptors, irritant receptors in
lungs or stretch receptors in airwaysAfferent : VagusEffect : Hyperpnea
PARADOXICAL REFLEX OF HEAD
Stimulus : Lung inflationReceptor : Stretch receptors in lungsAfferent : VagusEffects: inspiration