DYSPNEADYSPNEA

Faisal Yunus

Department of Pulmonology and Respiratory Medicine, Faculty of Medicine,

University of Indonesia-Persahabatan Hospital, Jakarta

Dyspnea: • Discomfort feeling in breathing

• Subjective and difficult to measure

• Etiology : lung, heart, endocrine, kidney, neurology, hematology, rheumatology and psychology

• Prevalens of dyspnea → no accurate data

INTODUCTIONINTODUCTION

1

DEFINITION OF DYSPNEADEFINITION OF DYSPNEA

The American Thoracic Society (ATS):

the term of discomfort perception subjective in breathing that consist of sensation with different intensity as a results of interaction of various physiologic, social and environtmental factors.

3

MECHANISM OF DYSPNEAMECHANISM OF DYSPNEA

• Interaction between signal and receptor in otonomic nerve system, motoric cortex,airway receptor, lung and thoracic cage → dyspnea

4

MECHANISM OF DYSPNEAMECHANISM OF DYSPNEA

MECHANISM OF DYSPNEAMECHANISM OF DYSPNEA

Dyspnea

Complex of breathing

Lung and thoracic cage

CognitiveBehavior

Emotion

Chemoreceptor stimulation

Exercise

Primary motoric cortex

Primary sensoric corte

MEASURE OF DYSPNEAMEASURE OF DYSPNEA• Aim : to differentiate the severity and to

evaluate the nature of dyspnea • Technique of measuring :

– visual analogue scale– Borg scale– Medical research council (MRC) dyspnea

scale– American thoracic sosiety (ATS) dyspnea

scale – Baseline dyspnea index (BDI) – Transitional dyspnea index (TDI)

ATS dyspnea indexATS dyspnea index• Grade 1 : No dyspnea except severe exercise activity

• Grade 2 : Dyspnea when climb the step in hurry or climb a small hill • Grade 3 : Walk slower compared to common people• Grade 4 : Must stop for breathing after 100 yard walk• Grade 5 : Dyspnea while put on / off the clothes

DYSPNEA pulmonary non-pulmonary (cardiac) *pulm edema *arrhythmias *asthma/COPD *acute MI *pleural effusion * myocardial ischemia

*pneumonia *pneumothorax

DYSPNEA IN PULMONARY DYSPNEA IN PULMONARY DISEASEDISEASE

• Abnormality of breathing mechanism, lung become more stiff, weakness of ventilation muscles.

• Restrictive lung diseases.• Obstructive lung diseases.• Disturbance of lung diffusion.• Disturbance of lung perfusion.

RESTRICTIVE LUNG DISEASERESTRICTIVE LUNG DISEASE

• Lung : - atelectasis - fibrosis - lung tumour - bullae - lung abscess

• Mediastinum : - mediastinal tumour - cardiomegali - pericardial effusion

LUNG TUMORLUNG TUMOR

PANCOAST TUMORPANCOAST TUMOR

PNEUMONIAPNEUMONIA

ATELECTASISATELECTASIS

DESTROYED LUNGDESTROYED LUNG

RESTRICTIVE LUNG DISEASERESTRICTIVE LUNG DISEASE

• Pleura : - pleural effusion - pleural tumour - pneumothorax • Diaphragm : - hernia of diaphragm - paralize of diaphragm• Bone : - rib fracture - pectus excavatum - scoliosis, kyphosis• Muscle : - miasthenia gravis

PLEURAL EFUSSIONPLEURAL EFUSSION

PNEUMOTHORAXPNEUMOTHORAX

HYDROPNEUMOTHORAXHYDROPNEUMOTHORAX

OBSTRUCTIVE LUNG DISEASEOBSTRUCTIVE LUNG DISEASE

• Asthma• COPD : - Chronic bronchitis - Emphysema• Bronchiectasis• Lung tumour• Foreign body

DISTURBANCE OF DIFFUSIONDISTURBANCE OF DIFFUSION

• Alveolar wall• Interstitial space• Arterial wall• Plasma• Red blood cell wall

DISTURBANCE OF DISTURBANCE OF PERFUSSIONPERFUSSION

• Pulmonary emboli• Congestive heart failure

HYPERVENTILATION SYNDROMEHYPERVENTILATION SYNDROME

• Response to stress, anxiety• Patient exhales CO2 faster than

metabolism produces it• Blood vessels in brain constrict• Anxiety, dizziness, lightheadedness• Seizures, unconsciousness

HYPERVENTILATION SYNDROMEHYPERVENTILATION SYNDROME

• Chest pain, dyspnea• Numbness, tingling of fingers, toes, area

around mouth, nose • Carpopedal spasms of hands, feet

UPPER AIRWAYUPPER AIRWAY

• Foreign Body Obstruction• Pharyngeal Edema• Croup• Epiglottitis

FOREIGN BODY OBSTRUCTIONFOREIGN BODY OBSTRUCTION

• Partial or complete• Most common cause of pediatric airway

obstruction

FOREIGN BODY OBSTRUCTIONFOREIGN BODY OBSTRUCTION

• Suspect in any child with – Sudden onset of dyspnea– Decreased Loss of conciousness

• Suspect in any adult who develops dyspnea or loses consciousness while eating

PHARYNGEAL EDEMAPHARYNGEAL EDEMA

• Swelling of soft tissues of throat• Allergic reactions, upper airway burns• Hoarseness, stridor, drooling

EPIGLOTIDISEPIGLOTIDIS

• Bacterial infection • Causes edema of epiglottis• Children age 4-7 years • Increasingly common in adults• Rapid onset, high fever, stridor, sore

throat, drooling

CROUPCROUP

• Laryngotracheobronchitis• Viral infection• Causes edema of larynx/trachea• Children ages 6 months to 4 years

CROUPCROUP

• Slow onset, hoarseness, brassy cough, nightime stridor, dyspnea

• When in doubt, manage as epiglottitis

LOWER AIRWAYLOWER AIRWAY

• Asthma• Chronic Obstructive Pulmonary Disease

– Chronic bronchitis– Emphysema

ASTHMAASTHMA

• Reversible obstructive pulmonary disease

• Younger person’s disease (80% have first episode before age 30)

• Lower airway hypersensitive to allergens, emotional stress, irritants, infection

ASTHMAASTHMA

• Bronchospasm• Bronchial edema• Increased mucus production, plugging

Resistance to airflow, work of breathing increase

ASTHMAASTHMA

• Airway narrowing interferes with exhalation

• Air trapped in chest interferes with gas exchange

• Wheezing, coughing, respiratory distress

ASTHMAASTHMA

• All that wheezes is not asthma• Other possibilities

– Pulmonary edema– Pulmonary embolism– Anaphalaxis (severe allergic reaction)– Foreign body aspiration– Pneumonia

AsthmaAsthmaNormalNormal

COPDCOPD

• Prone to periods of “decompensation”• Triggered by respiratory infections, chest

trauma• Signs/Symptoms

– Respiratory distress– Tachypnea– Cough productive of green, yellow sputum

CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE PULMONARY DISEASEPULMONARY DISEASE

• Chronic Bronchitis• Emphysema

CHRONIC BRONCHITISCHRONIC BRONCHITIS

• Chronic lower airway inflammation– Increased bronchial mucus production– Productive cough

• Urban male smokers > 30 years old

CHRONIC BRONCHITISCHRONIC BRONCHITIS

• Mucus, swelling interfere with ventilation• Increased CO2, decreased 02

• Cyanosis occurs early in disease• Lung disease overworks right ventricle• Right heart failure occurs• RHF produces peripheral edema

Blue Bloater

EMPHYSEMAEMPHYSEMA

• Loss of elasticity in small airways• Destruction of alveolar walls• Urban male smokers > 40-50 years old

EMPHYSEMAEMPHYSEMA

• Lungs lose elastic recoil • Retain CO2, maintain near normal O2

• Cyanosis occurs late in disease• Barrel chest (increased AP diameter) • Thin, wasted• Prolonged exhalation through pursed lips

Pink Puffer

Alveolar Function ProblemsAlveolar Function Problems

PULMONARY EDEMAPULMONARY EDEMA

• Fluid in/around alveoli, small airways• Causes

– Left heart failure– Toxic inhalants– Aspiration– Drowning– Trauma

ARDSARDS

PULMONARY EDEMAPULMONARY EDEMA

• Signs/Symptoms– Labored breathing– Coughing– Rales, rhonchi– Wheezes– Pink, frothy sputum

PULMONARY EDEMAPULMONARY EDEMA

• Signs/Symptoms– Sit up– High concentration O2

– Assist ventilation

PULMONARY EDEMAPULMONARY EDEMA

• Clot from venous circulation • Passes through right heart• Lodges in pulmonary circulation• Shuts off blood flow past part of alveoli

PULMONARY EDEMAPULMONARY EDEMA

• Associated with:– Prolonged bed rest or immobilization– Casts or orthopedic traction– Pelvic or lower extremity surgery– Phlebitis

PULMONARY EDEMAPULMONARY EDEMA

• Signs/Symptoms– Dyspnea– Chest pain– Tachycardia– Tachypnea– Hemoptysis

Sudden Dyspnea + No Readily Identifiable Cause = Pulmonary Embolism

CONCLUSIONCONCLUSION

• Dyspnea is subjective symptom• Various abnormalities may cause dyspnea• Severity of dyspnea can be measured

LUNG ABSCESSLUNG ABSCESS

BULLAEBULLAE

BULLAEBULLAE

MILLIARY TBMILLIARY TB

LUNG NODULESLUNG NODULES

PANCOAST TUMORPANCOAST TUMOR

BRONCHIECTASISBRONCHIECTASIS

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