Darmawan B Setyanto, MD Dyspnea · PDF file4/20/2014 1 Darmawan B Setyanto Indonesian Pediatric Society (IDAI) Dyspnea respiratory view Darmawan B Setyanto, MD Born: 11 April 1961

4/20/2014

1

Darmawan B Setyanto Indonesian Pediatric Society

(IDAI)

Dyspnea respiratory view

Darmawan B Setyanto, MD

Born: 11 April 1961

Education: Medical Doctor, Faculty of Medicine, University of Indonesia, 1986

Pediatrician, Faculty of Medicine, University of Indonesia, 1997

Respirology Consultant, 2005

Current position : Head of Respirology Division, Dept of Child Health, Faculty of

Medicine, University of Indonesia

Organization: Chairman of Respirology Coordination Working Unit, Indonesian

Pediatric Society

Daily situation

Pneumonia!

Not that simple !

Classic etiology classification Pulmonary

Asthma, COPD

Pneumonia, bronchiolitis Restrictive lung disorders

Hereditary lung disease Pneumothorax

Cardiac Congestive heart failure Coronary artery disease Myocardial infarction

Cardiomyopathy Pericarditis

Arrhythmias

Hard to be memorized need to create A NEW WAY HOW TO SEE dyspnea

Mix cardio-pulmonary COPD with PH

Chronic pulmonary emboli Deconditioning

Trauma

Non cardio-pulmonary Metabolic conditions Pain Neuromuscular disorders

Otorhinolaryngeal disorders Functional (anxiety, panic

disorders Am Fam Phys, Evaluation of Dyspnea, 1998

Breathing

unconscious act – healthy persons, especially children generally unaware

automatic

conscious act – we can control our own breath

limited

Breathing is truly a strange phenomenon, caught midway between the conscious and the unconscious, and peculiarly sensitive to both

Dickenson Richards, 1953

Breathing phenomenon

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Breathing ≠ respiration

Breathing: taking air into the lungs and

send it out again Oxford Dictionary

Respiration: the exchange of O2 & CO2 between the atmosphere and the cells of the body; includes ventilation (inhalation & exhalation), the diffusion of oxygen in the alveoli, & the transport of O2 & CO2 and the use of them by the cells

Dorland’s Medical Dictionary

availability of arterial blood (O2,CO2), every time for the

tissue of the whole body

vital, crucial, can not be postponed

Respiratory physiology

teamwork of 2 main systems:

respiratory & cardiovascular

Respiration

External respiration

Internal respiration

CRUCIAL

POINT!



Internal respiration

Ventilation (V)

Perfusion (Q)

Diffusion

External

respiration

ventilation Respiratory system

function

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Diffusion of O2 & CO2 between

alveoli & the blood crucial point

Sherwood L, The Respiratory System, 2004

External respiration - 1

ventilation

V

perfusion

Q (circulation)

Diffusion of O2 & CO2 between

alveoli & the blood crucial point

Sherwood L, The Respiratory System, 2004


V – a sum VOLUME of

air FLOW in and out the respiratory tract

Q – a sum VOLUME of

blood FLOW through

alveolar capillary

L/mnt

L/mnt


ventilation

V

perfusion

Q

to take place, gas exchange (diffusion) from air to blood in alveolar capillary bed need an

optimal ratio between VENTILATION & PERFUSION

V/Q = 4/5

V Q Q V

Normal inspiration & expiration

turbulence

Image from: http://www.hadassah.org.il/NR/rdonlyres/5 9B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Medical management sequence

diagnosis treatment

symptomatology

pathophysiology

pathology

insults

adaptive responses

Medical problem process

Dia

gn

osis & Trea

tmen

t

pathogenesis

http://www.hadassah.org.il/NR/rdonlyres/5

http://www.hadassah.org.il/NR/rdonlyres/5

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Dyspnea Dyspnea The sensation of abnormal or uncomfortable

breathing in the context of what is normal for a person according to his/her level of fitness and exertional threshold for breathless

Am Fam Phys, Evaluation of Dyspnea, 1998

Other terminologies:

Shortness of breath

Breathlessness

Difficult breathing

Breathing difficulties

Breathing discomfort

Chest tightness

Breath stops

Air hunger

Labored breathing

Troubled breathing

Getting winded

Constriction

Uncomfortable breathing

Unusual awareness of breathing

Increased breathing effort

Increased muscular effort to breath

The need to breath more

Symptomatology

Symptoms Signs

Subjective Sensation

Patient

Objective Observable

Others

Anosmia Nasal blockage

Chest pain Dyspnea

Rhinorrhea Cough Stridor

Dyspnea

symptom: sensory experience (sensation), that only could be feel and judge by the patient psychologic disturbances

sign: respiratory distress, patient breathing with difficulties, involvement of additional respiratory muscle physiologic disturbances

Dyspnea approach - 1

Symptom, subjective

Sign, objective

Dyspnea approach - 2

acute (sudden onset)

chronic (long-standing)

often resolves with treatment of the

underlying condition

usually result in progressive dysfunction,

severe disability, and eventual death

the lecture focus on acute dyspnea

dyspnea

pathophysiology

pathology

insults

adaptive responses

Medical problem process

Dia

gn

osis & Trea

tmen

t

pathogenesis

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Dyspnea pathophysiology - 1

V/Q = 4/5

V/Q ≠ 4/5

from this crucial point a practical approach

to almost all kind of DYSPNEA

V/Q mis-match not optimal diffusion

Clinically

DYSPNEA

CRUCIAL POINT!

Dyspnea pathophysiology - 2

Dyspnea = the result of V/Q mismatch !!!

organ system involved in respiration – especially respiratory system – try to overcome the mismatch, by increase the ventilation – increase Work of Breathing (WoB)

2 components of ventilation: flow & volume

FLOW disturbance: dyspnea with expiratory effort

VOLUME disturbance: dyspnea with inspiratory effort

Dyspnea classification

Obstruction of proximal /

larger airway

Obstruction of distal /

smaller airway

Resp center stimulation

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyme disorders

FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax



larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

rhinitis with nasal obstruction, nasal polyp

cranio-facial malformation

OSAS

tonsil-adenoid hypertrophy

laryngo-tracheo-malacia

larynx edema

larynx papilloma

diphtheria

croup, epiglottitis

Extra-thorax FLOW disorders Obstruction of proximal / larger airways

Inspiratory stridor

infant – underfive



larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

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asthma

bronchiolitis

thymus hypertrophy

solid foreign body aspiration

lymph node enlargement

vascular ring

Intra-thorax FLOW disorders Obstruction of distal / smaller airways

Expiratory effort

infant – underfive

Obstructed airways

turbulence &

wheezing

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt



larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

pneumonia (infection, aspiration)

atelectasis

pulmonary edema

pulmonary tumor

left heart failure

near drowning

sepsis

Intra-thorax VOLUME disorders Lung parenchyme disorders

Inspiratory effort



larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

pneumothorax, pneumomediastinum

cardiomegaly

enlargement & malposition of large vascular

pleural effusion (incl’ empyema, hematothorax)

hernia diaphragmatica

diaphragmatica eventration, paralysis

intra-thorax mass (non pulmonary)

chest trauma (rib fracture, lung contusion)

thorax deformity

(pectus excavatum, scoliosis, …), scoliosis)

Intra-thorax VOLUME disorders Extra-pulmonary disorders

Inspiratory effort

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larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

neuromuscular disorders

gastritis, peptic ulcer

extreme obesity

peritonitis, appendicitis, acute abdomen

aerophagia, meteorismus

ascites

hepato-splenomegaly

abdominal solid tumor

Extra-thorax VOLUME disorders Lung compliance disorders

Inspiratory constraint



larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

anemia

high altitude

metabolic acidosis

CNS infections: meningitis, encephalitis

encephalopathy (typhoid, DHF, metabolic)

psychologic (anxiety - usually adolescent)

poisoning: salycylate, alcohol

CNS disease sequelae

trauma capitis

Extra-thorax VOLUME disorders Respiratory center stimulation

Deep rapid breathing

first step : ANAMNESIS identity: age, sex, etc

dyspnea: o acute, chronic, recurrent

o degree of dyspnea

o how long has been dyspneic

o timing of dyspnea: at rest, at activity, day or night

o triggers, factors make worse / better

o response to therapy

underlying cardiopulmonary / neuromuscular disease

associated symptoms: chest pain, cough, wheezing

other signs & symptoms

80% of cases can be diagnosed

Dyspnea clinical approach - 1

next step : PHYSICAL EXAMINATION

inspiratory : nasal flaring, retraction (supra sternal, intercostal, subcostal, epigastrium), chest indrawing (‘retraksi arkus kosta’)

expiratory : prolonged expirium, wheezing, abdominal muscle contraction

respiratory examination: respiratory rate; stridor, symmetry of breath sound & percussion; rales; sign of heart failure

other holistic examination


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further stepSUPPORTING EXAMINATION

Routine blood examination

Pulse oximetry

Imaging diagnostic: CXR, ultrasound, …

Blood gas analysis

Pulmonary function test

Electrocardiography, echocardiography

Rhinoscopy, laryngoscopy, bronchoscopy


last step : TREATMENT

based on diagnosis

first aid: give O2, before we can identify the etiology; since most of cases need it

some cases, does not need O2 (see next)




larger airway


smaller airway





FLOW

disorders

VOLUME

disorders

EXTRA

thorax

INTRA

thorax

EXTRA

thorax

INTRA

thorax

Summary Dyspnea can be the symptomatology of so many

medical problems

Clinical approach (diagnosis & treatment) should be based on the good knowledge of respiratory physiology and dyspnea pathophysiology

Alveoly & capillary surround it is the crucial point of the pathophysiology

Ventilation-perfusion mismatch is the key point to explain almost all kind of dyspnea

Dyspnea

Thank you

Presented at:

Pertemuan Ilmiah Tahunan

IDI Kabupaten Bekasi

Meningkatkan profesionalisme & wawasan Dokter Layanan Primer secara komprehensif berbagai layanan disiplin ilmu dalam pelaksanaa SJSN

Ahad, 27 Apr 2014

Hotel Sahid Jaya Lippo Cikarang

Documents

Darmawan B Setyanto, MD Dyspnea · PDF file4/20/2014 1 Darmawan B Setyanto Indonesian Pediatric Society (IDAI) Dyspnea respiratory view Darmawan B Setyanto, MD Born: 11 April 1961