C2 - Dyspnea

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Curriculum Vitae

Dr. Prayudi Santoso, SpPD-KP, M.Kes,FCCP, FINASIME-mail: [email protected]

Pendidikan:

S1 FK Universitas Padjadjaran Bandung

Sp1 FK Universitas Padjadjaran Bandung

Konsultan Pulmonologi KIPDS2 FK Universitas Padjadjaran Bandung

Pekerjaan:

Staf Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin

Koordinator Tim MDR TB RSUP Dr. Hasan Sadikin Bandung

Organisasi:Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar

Perhimpunan Respirologi Indonesia (PERPARI)

Fellow American College of Chest Physcian (ACCP)

Member European Respiratory Society (ERS)

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Management and Pathogenesisof Dyspnea in Adult

Prayudi Santoso

Division of Respirology and CriticalCare

Department of Internal Medicine

Padjdjaran University/Hasan Sadikin

Hospital Bandung [email protected]

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Dyspnea

Dyspnea, the sensation of breathlessnessor inadequate breathing, is the most

common complaint of patients with

cardiopulmonary diseases.

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Dyspnea - common complaint/symptom

shortness of breath or breathlessness

Defined as abnormal/uncomfortable

breathing

Multiple etiologies -

2/3 of cases - cardiac or pulmonary etiology

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There is no one specific cause of dyspnea and

no single specific treatment

Treatment varies according to patients

condition

chief complaint

history

exam

laboratory & study results

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Differential Diagnosis

Composed of four general categories

Cardiac

Pulmonary

Mixed cardiac or pulmonary

non-cardiac or non-pulmonary

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Mechanisms of dyspnea

Receptors in the respiratory muscles, lungs, upper airways, and face (blue and green boxes) relay information from various stimuli. These are experienced as sense of effort, chest tightness, and

air hunger (orange boxes) and contribute to the sensation of dyspnea. The input from the vagus nerve is complex, because stimuli carried by the vagus can both increase and decrease dyspnea.

Corollary discharge from the motor cortex and medullary respiratory complex (dotted purple line) also contribute to the sensation of dyspnea. Psychological factors (pink box) also influence

symptoms and response to symptoms. Dyspnea causes a decrease in activity that leads to deconditioning and muscle wasting; this results in social isolation and depression, which furtherincreases dyspnea and deconditioning, and a vicious circle is set in progress.

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Differential diagnosis and early

management of acute dyspnea

Thediagnosiswill be respiratory disease,cardiac disease, both, or neither. Themain diagnoses

are shown, with cardinal signs in parentheses. At all stages, resuscitation of the patient is the

goal and may be necessary before a definitive diagnosis has been reached. CHF, Chronic heartfailure.

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Differential Diagnosis of Dyspnea*

*This table shows the differential diagnosis of dyspnea in the approximate order in which they are encountered in the clinic, with the most common causes listed first. Initial consideration of history, physicalexamination, chest X-ray, ECG, and spirometerywith routing blood tests and sputum culture often gives the result. If there is still some doubt, further appropriate studies are organized.

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Differential Diagnosis of Dyspnea*

*This table shows the differential diagnosis of dyspnea in the approximate order in which they are encountered in the clinic, with the most common causes listed first. Initial consideration of history, physicalexamination, chest X-ray, ECG, and spirometerywith routing blood tests and sputum culture often gives the result. If there is still some doubt, further appropriate studies are organized.

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Investigation of Dyspnea*

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable inselected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Level 1 tests

(appropriate for

most patients)

Oximetry

Metabolic screen

Full blood countCXR

ECG

Peak flow

Spirometry

Sputum culture

(Depending on clinical suspicion: brain natriuretic

peptide [BNP], D-dimers)

Oximetry

Metabolic screen

Full blood countCXR

ECG

Peak flow

Spirometry

Sputum culture

(Depending on clinical suspicion: brain natriuretic

peptide [BNP], D-dimers)

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Investigation of Dyspnea*

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable inselected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Level 1 tests

(appropriate for

most patients)

Peak flow chart-serial measurements

PFTs

ABGs

Methacholine or allergen bronchoprovocationchallenge (BPC)

High resolution CT

CT pulmonary angiogram

Ventilation/perfusion scan and/or leg Dopplers

ECHO

Bronchoscopy / bronchoalveolar lavage

Holter recording

Radionuclide cardiac scan

Peak flow chart-serial measurements

PFTs

ABGs

Methacholine or allergen bronchoprovocationchallenge (BPC)

High resolution CT

CT pulmonary angiogram

Ventilation/perfusion scan and/or leg Dopplers

ECHO

Bronchoscopy / bronchoalveolar lavage

Holter recording

Radionuclide cardiac scan

Level 2 tests

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Investigation of Dyspnea*

*Level 1 tests are suitable for all patients, although D-dimer and BNP should be requested on clinical suspicion and according to local protocols. Level 2 tests are suitable inselected patients with a high index of suspicion. Level 3 tests should be arranged after discussion with a specialist.

Level 1 tests

(appropriate for

most patients)

Cardiac catheterization

Cardiopulmonary exercise test

Esophageal pH

Lung biopsy

Cardiac catheterization

Cardiopulmonary exercise test

Esophageal pH

Lung biopsy

Level 2 tests

Level 3 (consulationwith specialist)

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Chest radiograph in the differential

diagnosis of dyspnea

The chest X-ray findings fall into four groups: Normal, abnormal lung fields, abnormal mediastinum, and cardiomegaly with upper lobe blood diversion. This

is a simplified algorithm but illustrates the role of further investigations. The most appropriate investigation is guided by patients presentation and

probable diagnosis; in many patients this will involve further imaging of the chest, usually a CT scan.

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Variability of perception of

breathlessness Huge variation in individual

perception

E.g.: In asthmatics, some patients

have minimal symptoms with 50%

FEV1 bronchoconstriction, some have

significant symptoms with minimal

bronchoconstriction

Symptoms also related to

psychological state and social factors

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CASE

Seorang laki laki berusia 46 tahun, datang ke

UGD dengan keluhan utama: sesak nafas sejak

2 hari ,batuk batuk sudah dirasakan 1

minggu

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Apa yang perlu ditanyakan lagi untuk

kemungkinan differensial diagnosis pada

pasien ini?

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Bunyi mengi : Asma bronchiale, PPOK, Edema

Paru, Tumor Paru

Asma bronchiale vs PPOK ?

Edema paru : tanda tanda CHF/Acute Lung

Edema

Tanda tanda infeksi : demam, batuk purulen

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Pemeriksaan fisik

Respiratory Rate

Ekspirasi memanjang ?

Pursed Lip Breathing? Tanda tanda CHF ?

Pemeriksaan paru: ronkhi ? Ekspirasi

memanjang ?, Wheezing ?

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Laboratorium dan Penunjang

Hematologi rutin:

Hb

Leukosit

Diff count

Ureum

Kreatinin

Pulse oxymetry

Analisis Gas Darah

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Pemeriksaan Penunjang

Foto Toraks

Spirometri

EKG CT Scan

Bronkoskopi

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Global Initiative for Asthma

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HASAN SADIKIN GENERAL HOSPITAL