Breathing is truly a strange phenomenon, caught midway between the conscious and the unconscious, and peculiarly sensitive to both

(1)

Darmawan B Setyanto

Indonesian Pediatric Society

(IDAI)

Dyspnea

respiratory view

Darmawan B Setyanto, MD

Born: 11 April 1961

Education:

 Medical Doctor, Faculty of Medicine, University of Indonesia, 1986  Pediatrician, Faculty of Medicine, University of Indonesia, 1997  Respirology Consultant, 2005

Current position :

 Head of Respirology Division, Dept of Child Health, Faculty of Medicine, University of Indonesia

Organization:

 Chairman of Respirology Coordination Working Unit, Indonesian Pediatric Society

Daily situation

Pneumonia!

Not that simple !

Classic etiology classification

 Pulmonary

 Asthma, COPD

 Pneumonia, bronchiolitis

 Restrictive lung disorders

 Hereditary lung disease

 Pneumothorax

 Cardiac

 Congestive heart failure

 Coronary artery disease

 Myocardial infarction

 Cardiomyopathy

 Pericarditis

 Arrhythmias

 Hard to be memorized  need to create

A NEW WAY HOW TO SEE dyspnea

Mix cardio-pulmonary

COPD with PH

Chronic pulmonary emboli

Deconditioning

Trauma

Non cardio-pulmonary

Metabolic conditions

Pain

Neuromuscular disorders

Otorhinolaryngeal disorders

Functional (anxiety, panic disorders

Am Fam Phys, Evaluation of Dyspnea, 1998

Breathing



unconscious act

–

healthy persons,

especially children generally unaware



automatic



conscious act

–

we can control our own

breath



limited

Breathing is truly a strange

phenomenon, caught midway

between the conscious and the

unconscious, and peculiarly

sensitive to both

(2)

Breathing ≠ respiration



Breathing

: taking air into the lungs and

send it out again

Oxford Dictionary



Respiration: the exchange of O

2 & CO2

between the atmosphere and the cells of the body; includes ventilation (inhalation & exhalation), the diffusion of oxygen in the alveoli, & the transport of O2 & CO2 and the use of them by the cells

Dorland’s Medical Dictionary

availability of

arterial blood

(O2



,CO2



),

every time

for

the

tissue of the whole body

vital,

crucial

, can not be postponed

Respiratory physiology

teamwork of 2 main systems:

respiratory & cardiovascular

Respiration

External

respiration

Internal

respiration

CRUCIAL POINT!

External respiration

External

respiration

Internal

respiration

Ventilation

(V)

Perfusion

(Q)

Diffusion

External

respiration

ventilation

(3)

Diffusionof O2 & CO2 between alveoli & the blood crucial point

Sherwood L, The Respiratory System, 2004

External respiration - 1

ventilation

V

perfusion

Q

(circulation)

Diffusionof O2 & CO2 between alveoli & the blood crucial point

Sherwood L, The Respiratory System, 2004

External respiration - 2

V –a sumVOLUME of

air FLOW in and out the respiratory tract

Q –a sum VOLUME of

blood FLOW through alveolar capillary

L/mnt

External respiration - 3

ventilation

V

perfusion

Q

to take place, gas exchange (diffusion) from air to blood in

alveolar capillary bed need an optimal ratio between VENTILATION & PERFUSION

V/Q = 4/5

V

Q

V

Normal inspiration & expiration

turbulence

Image from: http://www.hadassah.org.il/NR/rdonlyres/5

9B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Medical management sequence

diagnosis

treatment

symptomatology

pathophysiology

pathology

insults

adaptive

responses

Medical problem process

D

iagno

sis

&

T

re

at

m

e

nt

(4)

Dyspnea

The sensation of abnormal or uncomfortable breathing in the context of what is normal for a person according to his/her level of fitness and exertional threshold for breathless

Am Fam Phys, Evaluation of Dyspnea, 1998 Other terminologies:

 Shortness of breath  Breathlessness  Difficult breathing  Breathing difficulties  Breathing discomfort  Chest tightness  Breath stops  Air hunger

 Labored breathing  Troubled breathing  Getting winded  Constriction  Uncomfortable breathing  Unusual awareness of breathing  Increased breathing effort  Increased muscular effort to breath  The need to breath more

Symptomatology

Symptoms

Signs

Subjective

Sensation

Patient

Objective

Observable

Others

Anosmia Nasal blockage

Chest pain Dyspnea

Rhinorrhea

Cough

Stridor Dyspnea

symptom: sensory experience (sensation), that only could be feel and judge by the patient 

psychologic disturbances

sign: respiratory distress, patient breathing with difficulties, involvement of additional respiratory muscle  physiologic disturbances

Dyspnea approach - 1

Symptom,

subjective

Sign,

objective

Dyspnea approach - 2

acute

(sudden onset)

chronic

(long-standing)

often resolves with treatment of the underlying condition

usually result in progressive dysfunction,

severe disability, and eventual death

the lecture focus on

acute

dyspnea

pathophysiology

pathology

insults

adaptive

responses

Medical problem process

D

iagno

sis

&

T

re

at

m

e

nt

(5)

Dyspnea pathophysiology - 1

V/Q = 4/5

V/Q

≠

4/5

from this crucial point



a practical approach

to almost all kind of

DYSPNEA

V/Q mis-match

not optimal diffusion

Clinically

DYSPNEA

CRUCIAL POINT!

Dyspnea pathophysiology - 2

Dyspnea = the result of V/Q mismatch !!! organ system involved in respiration –

especially respiratory system – try to overcome the mismatch, by increase the ventilation – increase Work of Breathing (WoB)

2 components of ventilation: flow & volume

FLOW disturbance: dyspnea with expiratory effort

VOLUME disturbance: dyspnea with

inspiratory effort

Dyspnea classification

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Resp center stimulation Extra-pulmonary disorders

Lung compliance disorders Lung parenchyme disorders

FLOW disorders

VOLUME

disorders

EXTRA thorax

INTRA thorax

EXTRA thorax INTRA thorax

Dyspnea classification

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

 rhinitis with nasal obstruction, nasal polyp  cranio-facial malformation

 OSAS

tonsil-adenoid hypertrophy  laryngo-tracheo-malacia larynx edema

larynx papilloma  diphtheria  croup, epiglottitis

Extra-thorax FLOW disorders

Obstruction of proximal / larger airways

Inspiratory stridor

infant

–

underfive

Dyspnea classification

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

(6)

 asthma  bronchiolitis  thymus hypertrophy  solid foreign body aspiration  lymph node enlargement vascular ring

Intra-thorax FLOW disorders

Obstruction of distal / smaller airways

Expiratory effort

infant

–

underfive

Obstructed airways

turbulence & wheezing

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax



pneumonia (infection, aspiration)



atelectasis



pulmonary edema



pulmonary tumor



left heart failure



near drowning



sepsis

Intra-thorax VOLUME disorders

Lung parenchyme disorders

Inspiratory effort

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

pneumothorax, pneumomediastinum  cardiomegaly

 enlargement & malposition of large vascular  pleural effusion (incl’ empyema, hematothorax)  hernia diaphragmatica

 diaphragmatica eventration, paralysis  intra-thorax mass (non pulmonary)  chest trauma (rib fracture, lung contusion)

 thorax deformity

(pectus excavatum, scoliosis, …), scoliosis)

Intra-thorax VOLUME disorders

Extra-pulmonary disorders

(7)

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

neuromuscular disorders  gastritis, peptic ulcer  extreme obesity

 peritonitis, appendicitis, acute abdomen  aerophagia, meteorismus

 ascites

 hepato-splenomegaly  abdominal solid tumor

Extra-thorax VOLUME disorders

Lung compliance disorders

Inspiratory constraint

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

anemia high altitude metabolic acidosis

CNS infections: meningitis, encephalitis encephalopathy (typhoid, DHF, metabolic) psychologic (anxiety - usually adolescent) poisoning: salycylate, alcohol

CNS disease sequelae trauma capitis

Extra-thorax VOLUME disorders

Respiratory center stimulation

Deep rapid breathing

first step :ANAMNESIS

 identity: age, sex, etc  dyspnea:

oacute, chronic, recurrent

odegree of dyspnea

ohow long has been dyspneic

otiming of dyspnea: at rest, at activity, day or night

otriggers, factors make worse / better

oresponse to therapy

 underlying cardiopulmonary / neuromuscular disease  associated symptoms: chest pain, cough, wheezing  other signs & symptoms

 80% of cases can be diagnosed

Dyspnea

clinical approach - 1

next step : PHYSICAL EXAMINATION

inspiratory

:

nasal flaring, retraction (supra sternal, intercostal, subcostal, epigastrium),

chest indrawing(‘retraksi arkus kosta’)

expiratory

:

prolonged expirium, wheezing, abdominal muscle contraction

respiratory examination: respiratory rate; stridor, symmetry of breath sound & percussion; rales; sign of heart failure

(8)

further stepSUPPORTING EXAMINATION

Routine blood examination

Pulse oximetry

Imaging diagnostic: CXR, ultrasound, … Blood gas analysis

Pulmonary function test

Electrocardiography, echocardiography

Rhinoscopy, laryngoscopy, bronchoscopy

Dyspnea

last step : TREATMENT

based on diagnosis

first aid: give O2, before we can identify the etiology; since most of cases need it

some cases, does not need O2 (see next)

Dyspnea

Obstruction of proximal / larger airway

FLOW disorders

VOLUME

disorders

EXTRA thorax

Summary

Dyspnea can be the symptomatology of so many medical problems

Clinical approach (diagnosis & treatment) should be based on the good knowledge of respiratory physiology and dyspnea pathophysiology

Alveoly & capillary surround it is the crucial point

of the pathophysiology

Ventilation-perfusion mismatch is the key point to explain almost all kind of dyspnea

Dyspnea

Thank you

Presented at:

Pertemuan Ilmiah Tahunan

IDI Kabupaten Bekasi

Meningkatkan profesionalisme & wawasan Dokter Layanan Primer secara komprehensif berbagai layanan disiplin ilmu dalam pelaksanaa SJSN

Ahad, 27 Apr 2014