MODUL 2

BREATHLESSNESS
PRESENTED BY:
B-3

SCENARIO 2
Seorang laki-laki umur 25 tahun, gizi cukup
datang ke dokter praktek dengan keluhan sesak
napas, demam dengan suhu 38.7 C yang
disertai batuk dengan dahak purulen yang
bercampur darah yang sudah berlangsung
selama satu minggu. Sebelumnya ia mengeluh
bersin-bersin dan sakit dada. Serangan sesak
napas sering kali dialami dengan disertai
keringat yang berlebihan terutama malam hari
dan sembuh walaupun tanpa pengobatan,
namun kali ini walaupun dengan minum obat
sesaknya makin bertambah.

KEY WORDS
25 year-old man
Sufficient intake of nutrition
Breathlessness
Fever 38.7C
Cough with purulent phlegm (+blood)
Sneezing
Chest pain
More sweat at night
Relieved without medication
Breathlessness increased as well as medication was
taken

QUESTIONS
What is the mechanism of productive
cough?
What is the mechanism of
breathlessness/dyspnea?
What is the mechanism of night
sweat+fever?
What are the differential diagnoses?

ANSWERS
Mechanism of productive cough:
Inflammation of airway
Excessive mucus production, epithelial damage
Stimulation of the receptor of airway
Afferent (vagus nerve)
Medullar cough center
Efferent (glossopharyngeal)
Stimulation of laryngeal, ICS muscle, diaphragm

Deep inspiration&clossure of glottis

Contraction of abd muscle
Pushes diaphragm
intrathoracic pressure
Sudden glottis open
Expulsion of mucus&other desquamated cells
PRODUCTIVE COUGH

Mechanism of breathlessness/dyspnea:
Bronchoconstriction

Mucosal secretion
Airway Obstruction

of peripheral airway
caliber

O2 perfussion
Ventilation perfussion

Airway limitation

alveolar ventilation

Prolonged turbulent
airflow during
expiration

CO2, O2 in blood

Wheezing/rhonchi

Stimulation of resp. center

Compensatory
mechanism
heart rate
side effect of drug
-2 agonist

resp. work against limited airways

Tremor
Resp. muscle fatique
Resp. rate
DYSPNEA

Mechanism of night sweat&fever:

MTB @ Strep. Pneumoniae
lungs

Cachectin factors (TNF)

Affecting feeding center

Phagocytosed by macrophage
releasing IL-1,IL-2,IL-6&TNF,
Prostaglandin

Poor appetite

Blood circulation

Loss of body weight

Thermoregulatory center
ant hypothalamus

Stimulate vagal nerve afferent

Loss appetite

Impulse to cough center in brainstem

CAMP
Temp pattern

Deep inspiration
Closure of glottis&vocal cord

Body sweating
in order to body
temp
LOW GRADE FEVER
Superimposed on the usual
diurnal
NIGHT SWEAT

pressure in lungs& abdominal

muscle pressure
Push out against closed glottis
COUGH

DIFFERENTIAL DIAGNOSIS
Chronic Bronchitis
Bronchiectasis
Pulmonary Tuberculosis

CHRONIC BRONCHITIS

DEFINITION
A persistent cough with sputum production
Occurs at least 3 months of the year for 2
consecutive years

ETIOLOGY
Smoking
Recurrent infection
Air pollution SO2
Occupation (low class)

PATHOGENESIS
Cigarrette, pollutants (SO2, NO2) irritants
Hypersecretions of bronchial mucus
glands

Toxic radicle to epithelial lining

the bronchial wall

Hypertrophy&hyperplasia of mucus
glands

Squamous metaplasia with/

without cilia

mucus production

Abnormal ciliary action

Bronchial obstruction

Trapping particles&irritants

Inflammation

susceptibility to bacterial
infection (H. influenza)

Progressive destruction of smooth

muscle of bronchial wall
Replaced by collagen
(healing by fibrosis)
Permanent obstruction

Fever purulent sputum

Chronic mucopurulent bronchitis
(Sputum contain pus)

CLINICAL FEATURES
Productive cough (with hemoptysis)
Expectoration
Breathlessness
Fever
Chest pain

INVESTIGATIONS
Pulmonary function tests
Severity
Mild

Spirometry
FeVi: 60-70% predicted

Symptoms
Smokers cough,
+ exertional breathlessness

Moderate

FeVi: 40-59% predicted

Exertional breathlessness
+ whezze, cough
+ sputum

Severe

FeVi: <40% predicted

Breathlessness, wheeze&
cough prominent, swollen
legs

Imaging
- Chest X-Ray
- lung markings are accentuated
- hilar more prominent
- vasculars are clearly seen > 2/3 of the
lung field
- enlarged ICS

Hematology
- Polycythemia
- Venesection

MANAGEMENT
Non-pharmacology
- Smoking cessation
Phamarcology
- Antibiotics
- Expectorant
- Bronchodilator
- Mucolytic
- Corticosteroids

COMPLICATIONS
Pulmonary bullae are thin-walled
airspaces created by rupture of alveolar
walls
Single/multiple, large/small, &tend to be
situated subpleurally
Pneumothorax
Respiratory failure
Cor pulmonale

PROGNOSIS
Best guide
Better survival
Pulmonary hypertension implies poor
prognosis

BRONCHIECTASIS

DEFINITION
Abnormal & permanent dilatation of bronchi
& bronchioles
Caused by destruction of muscles & elastic
supporting tissue
Asc.ed with/resulting from chronic infection
Not a 1 disease
2 persisting infection/obstruction caused
by variety of condition

ETIOLOGY
Acquired
bronchial obstruction
infection
Congenital
Kartegeners Syndrome
Cystic Fibrosis
Ig deficiency

PATHOGENESIS
Obstruction

Chronic persistent infection

Damage bronchial wall
Accumulating exudate
Further distend airways
Irreversible dilation
Bronchiectasis

CLINICAL FEATURES
Cough
Fever
Malaise
Hemoptysis
Clubbing fingers
Crackles

INVESTIGATIONS
Radiology
High resolution CT
Sputum tests
Test for cystic fibrosis
Lung function spirometry

MANAGEMENT
Antibiotic
Depend on infecting organisms
Staphylococcus aureus flucloxacilin
If no improvement suspect infected
Pseudomonas aeruginosa
ceftazidine aerosol/parentally

Postural drainage
Inhaled/oral steroids
Bronchodilator
Surgery

COMPLICATIONS
Chronic Bronchitis
Pneumonia
Pneumothorax
Empyema
Meningitis
Metastatic abscess (e.g. in brain)
Amyloid formation (e.g. in kidney)

PROGNOSIS
Depends on the exacerbation of the
disease during the first treatment
Without treatment worse

PULMONARY
TUBERCULOSIS

DEFINITION
Chronic granulomatous disease caused
by Mycobacterium tuberculosis
Involves the lung and any organ or tissue
in the body.

CLASSIFICATIONS
Primary tuberculosis (usually child)
Post primary
tuberculosisreinfection(usually adult)

ETIOLOGY
M.tuberculosis hominis(most
cases)transmission direct by inhalation
or exposure to contaminated patient
secretions.
M.Bovis (rarely)drinking milk
contaminated with this bac.
M.avium-intracelullareless virulent
(rarely)
M.africanum

PATHOGENESIS
MTB enter via RT
Enter the lung
Phagocytosed by machrophage

Release IL1,2,6 ,TNF

,PG
Blood circulation
Anterior
hypothalamus

TNF (tumor
necrosing
factor
Cachectin
factor
Affecting
feeding center

IL1,2,6,TNF ,PG
Irritated
epithelium
trachea
Vagal
nervebrain
stem

CAMP

thermoreceptor
Body
temperature
Low grade
fever
Body sweating
in order to
temperature

NIGHT
SWEAT

Poor appetite
Loss of
appetite

WEIGHT
LOSS

Deep inspiration
2.5 liter
Glottis close
Abdomen muscle
contract the
diaphragm
intrathoracic
pressure and
sudden open glottis
Rapid + force
expiration
Chronic dry cough

If MTB cause
erosion of blood
vessel

If immune
respone:mucouse
+pus +cell debri

HAEMOPTYSIS
SPUTUM

CLINICAL FEATURES
Chronic cough often with hemoptysis
Pyrexia
Weigh loss
Night sweat
Malaise
Chest pain
Dyspnea(late symptom)

INVESTIGATIONS
Laboratory examination
-Tuberculin skin test +veErythema nodusom
may be present (10x10)mm
-Tissue biopsyfrom affected site
-StainZiehl Nelson(BTA +ve)
auramine staining(more sensitive)
-Rivalta test +ve
-Blood cultureLED ,leukocyte

Radiology finding
-ACTIVE TBC
- Cavitation
- Consolidation
- Cloudy
- NON ACTIVE TBC
- Calcification
- fibrosis

Treatment
category

MANAGEMENT
Patients

TB treatment
regimens

New cases:
-sputum smear (+)
-sputum smear (-)
w/ro:far-advance
-severe extra pulmo TB

2HRZE (S)/4H3R3
/4HR
/6HE

II

Old cases:
-sputum smear
(+):relaps,failure
treatment

2HRZES1HRZE/5H3R3E3
/5HRE

III

New cases:sputum
smear (-) w/ro:minimal
lession
-less severe extra pulmo
TB

2HRZ/4H3R3
/4HR
/6HE

IV

Old cases:chronic case

REFER TO SPECIALIZE
CENTER

COMPLICATIONS
MASSIVE HAEMOPTYSIS
COR PULMONALE
EMPHYSEMA
LUNG/PLEURAL CALCIFICATION
BRONCHIECTASIS
OBSTRUCTIVE AIRWAYS DISEASE

GROUP MEMBERS
JEFFREY
NADIAH ASMADI
SHEEDA
HAMKA
HILALUDIN
SYUKRI
INDRAWATI
MESSI

HENDRA
IRMA
SHERLY
CITRA A.E.
CITRA IRRYANI
DWI
HAMRIAH

THANKS FOR YOUR

ATTENTION