dyspnea

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