Curriculum Vitae

Dr. Prayudi Santoso, SpPD-KP, M.Kes,FCCP, FINASIM

E-mail: prayudimartha@yahoo.com

Pendidikan:
S1
FK Universitas Padjadjaran Bandung
Sp1
FK Universitas Padjadjaran Bandung
Konsultan Pulmonologi
KIPD
S2
FK Universitas Padjadjaran Bandung
Pekerjaan:
Staf Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin
Koordinator Tim MDR TB RSUP Dr. Hasan Sadikin Bandung
Organisasi:
Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar
Perhimpunan Respirologi Indonesia (PERPARI)
Fellow American College of Chest Physcian (ACCP)
Member European Respiratory Society (ERS)

Management and Pathogenesis

of Dyspnea in Adult
Prayudi Santoso
Division of Respirology and Critical
Care
Department of Internal Medicine
Padjdjaran University/Hasan Sadikin
Hospital Bandung 2016
prayudimartha@yahoo.com

Dyspnea
Dyspnea, the sensation of breathlessness
or inadequate breathing, is the most
common complaint of patients with
cardiopulmonary diseases.

 Dyspnea - common complaint/symptom

shortness of breath or breathlessness

Defined as abnormal/uncomfortable
breathing
Multiple etiologies 2/3 of cases - cardiac or pulmonary etiology

 There is no one specific cause of dyspnea and

no single specific treatment
Treatment varies according to patients
condition

chief complaint
history
exam
laboratory & study results

Differential Diagnosis
Composed of four general categories
Cardiac
Pulmonary
Mixed cardiac or pulmonary
non-cardiac or non-pulmonary

Mechanisms of dyspnea

Receptors in the respiratory muscles, lungs, upper airways, and face (blue and green boxes) relay information from various stimuli. These are experienced as sense of effort, chest tightness, and
air hunger (orange boxes) and contribute to the sensation of dyspnea. The input from the vagus nerve is complex, because stimuli carried by the vagus can both increase and decrease dyspnea.
Corollary discharge from the motor cortex and medullary respiratory complex (dotted purple line) also contribute to the sensation of dyspnea. Psychological factors (pink box) also influence
symptoms and response to symptoms. Dyspnea causes a decrease in activity that leads to deconditioning and muscle wasting; this results in social isolation and depression, which further
increases dyspnea and deconditioning, and a vicious circle is set in progress.

Differential diagnosis and early

management of acute dyspnea

The diagnosis will be respiratory disease, cardiac disease, both, or neither. The main diagnoses
are shown, with cardinal signs in parentheses. At all stages, resuscitation of the patient is the
goal and may be necessary before a definitive diagnosis has been reached. CHF, Chronic heart
failure.

Differential Diagnosis of Dyspnea*

*This table shows the differential diagnosis of dyspnea in the approximate order in which they are encountered in the clinic, with the most common causes listed first. Initial consideration of history, physical
examination, chest X-ray, ECG, and spirometery with routing blood tests and sputum culture often gives the result. If there is still some doubt, further appropriate studies are organized.

Differential Diagnosis of Dyspnea*

*This table shows the differential diagnosis of dyspnea in the approximate order in which they are encountered in the clinic, with the most common causes listed first. Initial consideration of history, physical
examination, chest X-ray, ECG, and spirometery with routing blood tests and sputum culture often gives the result. If there is still some doubt, further appropriate studies are organized.

Investigation of Dyspnea*
Level 1 tests
(appropriate for
most patients)

Oximetry
Metabolic screen
Full blood count
CXR
ECG
Peak flow
Spirometry
Sputum culture
(Depending on clinical suspicion: brain natriuretic
peptide [BNP], D-dimers)

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable in
selected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Investigation of Dyspnea*
Level 1 tests
(appropriate for
Level 2 tests
most patients)

Peak flow chart-serial measurements

PFTs
ABGs
Methacholine or allergen bronchoprovocation
challenge (BPC)
High resolution CT
CT pulmonary angiogram
Ventilation/perfusion scan and/or leg Dopplers
ECHO
Bronchoscopy / bronchoalveolar lavage
Holter recording
Radionuclide cardiac scan

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable in
selected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Investigation of Dyspnea*
Level 1 tests
(appropriate for
Level 2 tests
most patients)
Level 3 (consulation
with specialist)

Cardiac catheterization
Cardiopulmonary exercise test
Esophageal pH
Lung biopsy

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable in
selected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Chest radiograph in the differential

diagnosis of dyspnea

The chest X-ray findings fall into four groups: Normal, abnormal lung fields, abnormal mediastinum, and cardiomegaly with upper lobe blood diversion. This
is a simplified algorithm but illustrates the role of further investigations. The most appropriate investigation is guided by patients presentation and
probable diagnosis; in many patients this will involve further imaging of the chest, usually a CT scan.

Variability of perception of
breathlessness

Huge variation in individual

perception
E.g.: In asthmatics, some patients
have minimal symptoms with 50%
FEV1 bronchoconstriction, some have
significant symptoms with minimal
bronchoconstriction
Symptoms also related to
psychological state and social factors

CASE
Seorang laki laki berusia 46 tahun, datang ke
UGD dengan keluhan utama: sesak nafas sejak
2 hari ,batuk batuk sudah dirasakan 1
minggu

 Apa yang perlu ditanyakan lagi untuk

kemungkinan differensial diagnosis pada
pasien ini?

 Bunyi mengi : Asma bronchiale, PPOK, Edema

Paru, Tumor Paru
Asma bronchiale vs PPOK ?
Edema paru : tanda tanda CHF/Acute Lung
Edema
Tanda tanda infeksi : demam, batuk purulen

Pemeriksaan fisik

Respiratory Rate
Ekspirasi memanjang ?
Pursed Lip Breathing?
Tanda tanda CHF ?
Pemeriksaan paru: ronkhi ? Ekspirasi
memanjang ?, Wheezing ?

Laboratorium dan Penunjang

Hematologi rutin:
Hb
Leukosit
Diff count
Ureum
Kreatinin
Pulse oxymetry
Analisis Gas Darah

Pemeriksaan Penunjang

Foto Toraks
Spirometri
EKG
CT Scan
Bronkoskopi

 Global Initiative for Asthma

HASAN SADIKIN GENERAL HOSPITAL