DYSPNEA

PBL GROUP DR. NICO

DEFINITION
A sense of awareness of increased respiratory effort that is unpleasant that is recognized by the patient as being inappropriate.

Difficult or uncomfortable breathing, usually reported as shortness of breath.

Patients complaint: tightness in the chest.

PATHOPHYSIOLOGY OF DYSPNEA
Heart failure:
Left ventricular failure edema of the pulmonary interstitium and alveoli activates juxtacapillary J receptors, lungs become stiff increasing respiratory effort to ventilate lungs rapid, shallow breathing

Pulmonary causes:

Obstruction: Risk factors + triggers AHR increase in mucous production, mucous edema, and bronchoconstriction limitation of airflow dyspnea; tumor Resistance: formation of fibrosis decreases lungs compliance

Allergic reaction:

Mucous edema obstruction dyspnea

Neuromuscular causes:

Demyelination of nerves Immune complexes and complements deposition at post-synaptic membranes, causing interference with AchRs.

CLASSIFYING DYSPNEA
Based on etiology:
Pulmonary Cardiac Neuromuscular Allergic Anxiety Others

Based on the presence of chest pain:

With chest pain Without chest pain

PULMONARY CAUSES OF DYSPNEA

ARDS Aspiration of foreign bodies Asthma/COPD Athelectasis Blast lung injury Cor pulmonale Emphysema Pneumonia Pneumothorax Pulmonary edema Pulmonary embolism SARS Tuberculosis Avian Influenza Cancer

CARDIAC CAUSES OF DYSPNEA

Heart Failure Myocardial infarct Cardiomyopathy Left Ventricular Hypertrophy Pericarditis

NEUROMUSCULAR CAUSES OF DYSPNEA

Myasthenia gravis Guillian-Barre Syndrome

OTHER CAUSES OF DYSPNEA

Metabolic acidosis Obesity Cystic Fibrosis

DYSPNEA WITH CHEST PAIN

Pneumonia Pleurisy Ischaemic Heart Disease Pulmonary Embolus Pneumothorax

DYSPNEA WITHOUT CHEST PAIN

Congestive heart failure/acute pulmonary edema Silent ischaemic heart disease Pneumonia/lower respiratory tract infection Exacerbation of COPD/asthma Bronchogenic carcinoma

DIAGNOSING DYSPNEA
History Taking Physical examination Additional Examination Differentiating Heart vs. Pulmonary cause

HISTORY TAKING
Sudden or gradual? Occur on activity or rest? Constant or intermittent? Severity? Duration? New symptom or recurrence? Is it worse? Aggravate and alleviate attacks? Associated symptoms: Cough? Chest pain? Orthopnea? Paroxysmal nocturnal dyspnea? Progressive fatigue? Fever? Recent trauma? History of upper respiratory tract infection? Ischemic heart disease? Other disorder? Smoking? Irritants or fumes exposure at work?

PHYSICAL EXAMINATION
Accessory muscle hypertrophy (neck and shoulders) Pursed-lip exhalation Clubbing Peripheral edema Barrel chest Jugular vein distention Edema Abdomen palpation Auscultation of the heart and lungs

DIFFERENTIATING HEART VS. PULMONARY CAUSE

Cardio-pulmonic physical examination. In which at maximum exercise, the following will occur if:
Pulmonary problems:
Maximum ventilation Increase in dead space or hypoxemia (SO2 <90%) Experiencing bronchospasm

Cardiology problems:
Heart rate is 85% above maximum Blood pressure is either very increasing or decreasing Indikator isi sekuncup turun Ischemic changes in ECG

DYSPNEA ALGORITHM

EMERGENCY INTERVENTION
Oxygen administration by nasal cannula, mask, or endotracheal tube Pulmonary edema: apply rotating tourniquets and administer continuous positive airway pressure Pneumothorax: chest tube Monitor:
Cardiac monitoring to detect arrhythmias Oxygen saturation to detect low oxygen saturation