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

   COPD with PH

   Chronic pulmonary emboli  Deconditioning  Trauma

  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: 

Indonesian Pediatric Society (IDAI)

  Chairman of Respirology Coordination Working Unit, Indonesian Pediatric Society Daily situation

  Classic etiology classification 

  Pulmonary  Asthma, COPD  Pneumonia, bronchiolitis  Restrictive lung disorders  Hereditary lung disease  Pneumothorax

   Cardiac

   Non cardio-pulmonary

   Mix cardio-pulmonary

  Darmawan B Setyanto

Pneumonia! Not that simple !

   Hard to be memorized  need to create

   Metabolic conditions

   Pain  Neuromuscular disorders 

  Otorhinolaryngeal disorders  Functional (anxiety, panic disorders

  Am Fam Phys, Evaluation of Dyspnea, 1998 Breathing

   Congestive heart failure  Coronary artery disease  Myocardial infarction  Cardiomyopathy  Pericarditis  Arrhythmias

A NEW WAY HOW TO SEE dyspnea

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

  Dickenson Richards, 1953 Breathing phenomenon

   automatic  conscious act

   unconscious act

• – healthy persons, especially children generally unaware
• – we can control our own breath

Breathing ≠ respiration Respiratory physiology 

  Breathing : taking air into the lungs and availability of arterial blood send it out again

  (O2,CO2), every time for the Oxford Dictionary tissue of the whole body

   Respiration : the exchange of O 2 & CO

  2 between the atmosphere and the cells of the vital, crucial, can not be postponed body; includes ventilation (inhalation & exhalation), the diffusion of oxygen in the teamwork of 2 main systems: alveoli, & the transport of O 2 & CO 2 and the use of them by the cells respiratory & cardiovascular

  Dorland’s Medical Dictionary Respiration

External respiration

CRUCIAL POINT! Internal respiration

  External External respiration respiration

Ventilation External (V) respiration Diffusion Perfusion (Q)

  ventilation function respiration External respiration - 1 External respiration - 2

• – V a sum VOLUME of ventilation

  air

FLOW in and out L/mnt the respiratory tract

V Diffusion of O2 & CO2 between Diffusion of O2 & CO2 between

  

alveoli & the blood  crucial point alveoli & the blood  crucial point

perfusion – Q a sum VOLUME of blood FLOW through

Q

  Sherwood L, The Respiratory System, 2004 Sherwood L, The Respiratory System, 2004 External respiration - 3 Normal inspiration & expiration

  to take place, gas exchange

  ventilation

  (diffusion) from air to blood in alveolar capillary bed need an

V

  optimal ratio between

  VENTILATION & PERFUSION

  turbulence

V/Q = 4/5 perfusion Q

  V Q

V Q

  Image from:

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

  Medical problem process D iagno symptomatology sis pathophysiology

  & T pathology re at pathogenesis adaptive m e responses nt treatment diagnosis insults Dyspnea 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:

  Symptomatology

   The need to breath more

   Increased muscular effort to breath

   Increased breathing effort

   Unusual awareness of breathing

   Uncomfortable breathing

   Constriction

   Getting winded

   Troubled breathing

   Labored breathing

   Air hunger

   Breath stops

   Chest tightness

   Breathing discomfort

   Breathing difficulties

   Difficult breathing

   Breathlessness

   Shortness of breath

  Dyspnea approach - 1

Symptoms Signs

Symptom, subjective Sign, objective

Sensation

Observable

  Others

Cough

Dyspnea

Dyspnea

  (sudden onset) chronic

  Subjective

  Medical problem process D iagno sis & T re at m e nt pathogenesis

  (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 dyspnea pathophysiology pathology insults adaptive responses

  Dyspnea approach - 2 acute

  Anosmia Nasal blockage

  Patient Dyspnea pathophysiology - 1 Dyspnea pathophysiology - 2 from this crucial point

  difficulties, involvement of additional respiratory muscle  physiologic disturbances

  psychologic disturbances  sign : respiratory distress, patient breathing with

  only could be feel and judge by the patient 

   symptom : sensory experience (sensation), that

  Stridor

  Rhinorrhea

  Chest pain

  Objective

   Dyspnea = the result of V/Q mismatch !!!  a practical approach

V/Q = 4/5

• –  organ system involved in respiration

  to almost all kind of especially respiratory system

• – try to overcome

DYSPNEA

• – the mismatch, by increase the ventilation

  increase Work of Breathing (WoB) CRUCIAL POINT! 

  2 components of ventilation: flow & volume

Clinically

   FLOW disturbance: dyspnea with

DYSPNEA expiratory effort

  

  VOLUME disturbance: dyspnea with

V/Q mis-match V/Q ≠ 4/5

  inspiratory effort not optimal diffusion Dyspnea classification Dyspnea classification

  

EXTRA Obstruction of proximal / EXTRA Obstruction of proximal /

thorax larger airway thorax larger airway FLOW

  FLOW disorders disorders

  INTRA Obstruction of distal /

  INTRA Obstruction of distal / thorax smaller airway thorax smaller airway

  Lung parenchyme disorders Lung parenchyme disorders

  INTRA

  INTRA thorax thorax Extra-pulmonary disorders Extra-pulmonary disorders

  VOLUME

  VOLUME

  disorders disorders

  Lung compliance disorders Lung compliance disorders EXTRA EXTRA thorax thorax Resp center stimulation Resp center stimulation

  Dyspnea classification Extra-thorax FLOW disorders

  Obstruction of proximal / larger airways

  EXTRA Obstruction of proximal / 

  rhinitis with nasal obstruction, nasal polyp

  thorax larger airway FLOW  cranio-facial malformation disorders

  INTRA Obstruction of distal /  OSAS thorax smaller airway

   tonsil-adenoid hypertrophy

  Lung parenchyme disorders

  INTRA

   laryngo-tracheo-malacia

  thorax Extra-pulmonary disorders

  VOLUME

   larynx edema disorders

  Lung compliance disorders EXTRA

  

  larynx papilloma

Inspiratory stridor thorax

  Resp center stimulation

   diphtheria infant

• – underfive

   croup, epiglottitis

Expiratory effort

• – underfive

   pneumothorax, pneumomediastinum  cardiomegaly  enlargement & malposition of large vascular 

  Resp center stimulation Extra-pulmonary disorders Lung compliance disorders Lung parenchyme disorders

  FLOW disorders

  VOLUME

  disorders EXTRA thorax

  INTRA thorax

  EXTRA thorax

  INTRA thorax

  pleural effusion (incl’ empyema, hematothorax)

  Lung parenchyme disorders

  

  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

  Inspiratory effort

  Dyspnea classification Obstruction of proximal / larger airway Obstruction of distal / smaller airway

  Intra-thorax VOLUME disorders

   asthma 

  Obstruction of proximal / larger airway Obstruction of distal / smaller airway

  bronchiolitis

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

  Intra-thorax FLOW disorders

  Obstruction of distal / smaller airways

  infant

  Obstructed airways turbulence & wheezing

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

  Resp center stimulation Extra-pulmonary disorders Lung compliance disorders Lung parenchyme disorders

   left heart failure  near drowning  sepsis

  FLOW disorders

  VOLUME

  disorders EXTRA thorax

  INTRA thorax

  EXTRA thorax

  INTRA thorax

   pneumonia (infection, aspiration)  atelectasis  pulmonary edema

   pulmonary tumor

Inspiratory effort

  Dyspnea classification Extra-thorax VOLUME disorders

  Lung compliance disorders

  EXTRA Obstruction of proximal /  neuromuscular disorders thorax larger airway FLOW

  

  gastritis, peptic ulcer

  disorders

  INTRA Obstruction of distal /  extreme obesity thorax smaller airway

   peritonitis, appendicitis, acute abdomen

  Lung parenchyme disorders

  INTRA  aerophagia, meteorismus thorax Extra-pulmonary disorders

   ascites

  VOLUME

  disorders 

  hepato-splenomegaly Lung compliance disorders EXTRA thorax  abdominal solid tumor

  Resp center stimulation

Inspiratory constraint

  Dyspnea classification Extra-thorax VOLUME disorders

  Respiratory center stimulation

  EXTRA Obstruction of proximal /  anemia thorax larger airway FLOW

   disorders

  high altitude

  INTRA Obstruction of distal /  metabolic acidosis thorax smaller airway

   CNS infections: meningitis, encephalitis

  Lung parenchyme disorders

  INTRA

   encephalopathy (typhoid, DHF, metabolic)

  thorax Extra-pulmonary disorders

  VOLUME

   psychologic (anxiety - usually adolescent) disorders

  Lung compliance disorders  poisoning: salycylate, alcohol

  EXTRA thorax

  

  CNS disease sequelae Resp center stimulation

   trauma capitis

Deep rapid breathing

  clinical approach - 1

  Dyspnea

  clinical approach - 2

  Dyspnea next step : PHYSICAL EXAMINATION first step : ANAMNESIS  identity: age, sex, etc

   inspiratory : nasal flaring, retraction (supra

   dyspnea:

  sternal, intercostal, subcostal, epigastrium),

  o acute, chronic, recurrent chest indrawing (‘retraksi arkus kosta’) o degree of dyspnea o

   how long has been dyspneic expiratory : prolonged expirium, wheezing, o timing of dyspnea: at rest, at activity, day or night

  abdominal muscle contraction

  o triggers, factors make worse / better o response to therapy

   respiratory examination: respiratory rate;  underlying cardiopulmonary / neuromuscular disease

  stridor, symmetry of breath sound &

   associated symptoms: chest pain, cough, wheezing

  percussion; rales; sign of heart failure

   other signs & symptoms

  

  other holistic examination

   80% of cases can be diagnosed clinical approach - 3 clinical approach - 4

  Dyspnea Dyspnea further step SUPPORTING EXAMINATION last step : TREATMENT

  

  Routine blood examination  based on diagnosis

  

  Pulse oximetry

  

  first aid: give O2, before we can identify the

  

  Imaging diagnostic: CXR, ultrasound, … etiology; since most of cases need it

  

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

   Pulmonary function test 

  Electrocardiography, echocardiography

  

  Rhinoscopy, laryngoscopy, bronchoscopy

  Dyspnea classification Summary 

  Dyspnea can be the symptomatology of so many

  EXTRA Obstruction of proximal /

  medical problems

  thorax larger airway FLOW  disorders

  Clinical approach (diagnosis & treatment) should

  INTRA Obstruction of distal /

  be based on the good knowledge of respiratory

  thorax smaller airway physiology and dyspnea pathophysiology

  Lung parenchyme disorders

  

  Alveoly & capillary surround it is the crucial point

  INTRA thorax of the pathophysiology

  Extra-pulmonary disorders

  VOLUME

   Ventilation-perfusion mismatch is the key point disorders

  Lung compliance disorders EXTRA to explain almost all kind of dyspnea thorax Resp center stimulation

  Presented at: Dyspnea

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  

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