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DyspneaFina Herlinda NurI11111053Pengertian dispneaSuatu istilah yang menggambarkan suatu persepsi subjektif mengenai ketidaknyamanan bernapas yang terdiri dari berbagai sensasi yang berbeda intensitasnya

Merupakan hasil interaksi berbagai faktor fisiologi, psikologi, sosial dan lingkungan dan dapat menginduksi respons fisiologi dan perilaku sekunder

Comroe (1996)bukan takipnea, bukan hiperkapnea dan bukan hiperventilasi tapi pernapasan yang sulit, sejenis pernapasan yang tidak menyenangkan maupun menyakitkan

Pembagian dispneaDispnea akutSesak napas yang berlangsung kurang dari 1 bulan

Dispnea kronik Sesak napas yang berlangsung lebih dari 1 bulanMekanisme dispneaSensasi dispnea berawal dari aktivasi sistem sensorik yang terlibat dalam sistem respirasi.

Informasi sensorik sampai pada pusat pernapasan di otak dan memproses respiratory-related signals dan menghasilkan pengaruh kognitif, kontekstual, dan perilaku sehingga terjadi sensasi dispnea

Efferent and Afferent Signals That Contribute to the Sensation of DyspneaN Eng Med Journal 1995; 223: 1547-53

von Leupoldt, A. et al. Chest 2005;128:345-354Cortical areas involved in the perception of dyspnea6Penilaian terhadap sesak napas (dispnea)

Kuesioner skala dispneaBorg ScaleAmerican Thoracic Society ScaleVisual Analogue Scale for dyspnea

Skala sesak napasAmerican Thoracic Society (ATS)DeskripsiNilaiDerajatTak terganggu oleh sesak saat bergegas waktu jalan atau sedikit mendaki0 -Terganggu oleh sesak saat bergegas waktu berjalan atau sedikit mendaki1RinganJalan lebih lambat dibanding orang seumur krn sesak atau harus berhenti utk bernapas saat jalan biasa2SedangBerhenti untuk bernapas setelah berjalan 100 yard / setelah berjalan beberapa menit pada ketinggian tetap3BeratTeralmpau sesak untuk keluar rumah / sesak saat berpakaian atau melepas pakaian4Sangat beratVisual analogue Scale

Organ dan sistem organ terkait dengan dispneaSistem respirasiSistem neuromuskularSistem kardiovaskularSistem hematologiSistem ginjal / metabolikSistem endokrinIntoksikasiPsikogenikObesitiKategori fisiologik penyakit penyebab dispneaGangguan mekanik terhadap proses ventilasiKelemahan pompa napas (respiratory pump)Peningkatan respiratory driveVentilasi rugi (wasted ventilation)Disfungsi psikologikGangguan mekanik terhadap proses ventilasiObstruksi aliran napas (sentral atau perifer)Asma, PPOKTumor endobronkialStenosis trakea / laring

Gangguan pengembangan paru (stiff lung)Interstitial fibrosisGagal jantung kiriTumor linfangitik

Gangguan pengembangan dinding dada atau diafragmaPenebalan pleura, kifoskoliosis, obesiti, masa intraabdomen, kehamilanKelemahan pompa napas (respiratory pump)

Absolut Riwayat poliomielitisPenyakit neuromuskular (Sindrom Guillain Barre, muscular dystrophy, SLE, hipertiroidisme)

RelatifHiperinflasiEfusi pleuraPneumotoraksPeningkatan respiratory driveHipoksemia

Asidosis metabolikPenyakit ginjalAnemia, hemoglobinopatiPenurunan curah jantung

Stimulasi reseptor intrapulmonerInfiltrative lung disease, hipertensi pulmoner, edem paru

Ventilasi rugi (wasted ventilation)Destruksi kapiler Misal pada emfisema, interstitial lung disease

Obstruksi pembuluh darahMisal emboli paru, vaskulitis pulmonerDisfungsi psikologikSomatisasiAnsietasDepresi

Pendekatan diagnostik dispneaInitial DatabaseHistory and physical examinationLaboratoriumChest radiographSpirometryPulse oxymeter saturasi oksigen darahECGAnamnesisDo you have any difficulty breathing?When did it begin?Has the onset been sudden or insidious?Inquire about the frequency and duration of attacks. The conditions in which dyspnea occurs should be ascertained.Response to activity, emotional state, and change of body position should be notedAsk about associated symptoms: chest pain, palpitations, wheezing, or coughingWhat other significant medical problems does the patient have, and what medications has he been taking? How much has he smoked?ask if he has noticed any recent or progressive limitation in his ability to conduct specific tasks that he was able to perform without difficulty in the pastAdditional questions should be aimed at ascertaining whether the patient has orthopnea or paroxysmal nocturnal dyspneanumber of pillows he uses under his head at night and whether he has ever had to sleep sitting upDoes he develop coughing or wheezing in the recumbent position? Did he ever wake up at night with shortness of breath? How long after lying down did the episode occur, and what did he do to relieve his distress?Occupation?Family disease?

History Examination Clues to Conditions That Cause Dyspnea

FINDINGSCONDITIONHistoryDyspnea on exertionCardiac or pulmonary disease, deconditioningDyspnea during restSevere cardiopulmonary disease or noncardiopulmonary disease (e.g., acidosis)Orthopnea, paroxysmal nocturnal dyspnea, edemaCongestive heart failure, chronic obstructive pulmonary diseaseMedicationsBeta blockers may exacerbate bronchospasm or limit exercise tolerance. Pulmonary fibrosis is a rare side effect of some medicationsSmokingEmphysema, chronic bronchitis, asthmaAllergies, wheezing, family history of asthmaAsthmaCoronary artery diseaseDyspnea as anginal equivalentHigh blood pressureLeft ventricular hypertrophy, congestive heart failureAnxietyHyperventilation, panic attackLightheadedness, tingling in fingers and perioral areaHyperventilationRecent traumaPneumothorax, chest-wall pain limiting respirationOccupational exposure to dust, asbestos or volatile chemicalsInterstitial lung diseasePhysical Examination Clues to Conditions That Cause DyspneaPhysical examinationAnxietyAnxiety disorderNasal polyp, septal deviationDyspnea due to nasal obstructionPostnasal dischargeAllergies/asthmaJugular vein distentionCongestive heart failureDecreased pulse or bruitsPeripheral vascular disease with concomitant coronary artery diseaseIncreased anteroposterior chest diameterEmphysemaWheezingAsthma, pulmonary edemaRalesAlveolar fluid (edema, infection, etc.)TachycardiaAnemia, hypoxia, heart failure, hyperthyroidismS3Congestive heart failureMurmurValvular dysfunctionHepatomegaly, hepatojugular reflux, edemaCongestive heart failureCyanosis, clubbingChronic severe hypoxemiaDiagnosis banding dispnea akutCardiac: congestive heart failure, coronary artery disease, arrhythmia,pericarditis, acute myocardial infarction, anemia

Pulmonary: chronic obstructive pulmonary disease, asthma, pneumonia,pneumothorax, pulmonary embolism, pleural effusion, metastatic disease, pulmonary edema, gastroesophageal reflux disease with aspiration, restrictive lung disease

Psychogenic: panic attacks, hyperventilation, pain, anxiety

Upper airway obstruction: epiglottitis, foreign body, croup, Epstein-Barr virus

Endocrine: metabolic acidosis, medications

Central: neuromuscular disorders, pain, aspirin overdose

Pediatric: bronchiolitis, croup, epiglottitis, foreign body aspiration, myocarditis

CardiacCongestive heart failureCoronary artery diseaseCardiac arrhythmiasPericardial diseaseValvular heart disease

PulmonaryChronic obstructive pulmonary diseaseAsthmaInterstitial lung diseasePleural effusionMalignancy (primary or metastatic)Bronchiectasis

Diagnosis banding dispnea kronikNoncardiac or nonpulmonary (less common)

Thromboembolic diseasePsychogenic causes (GAD, PTSD, panicdisorders)DeconditioningPulmonary hypertensionObesity (massive)Severe anemiaGastroesophageal reflux diseaseMetabolic conditions (acidosis, uremia)Liver cirrhosisThyroid diseaseNeuromuscular disorders (myasthenia gravis, amyotrophic lateral sclerosis)Chest wall deformities (kyphoscoliosis)Upper airway obstruction (laryngeal disease,tracheal stenosis)

Diagnosis banding dispnea kronikManajemen dispneaABCMengobati penyakit dasar serta komplikasinya, misalnya : Pneumonia -> antibiotik Asma ->bronkodilator dan pengontrol

Daftar PustakaWalter C. Morgan, Heidi L. Diagnostic Evaluation of Dyspnea. Am Fam Physician. 1998 Feb15;57 (4):711-716.Vaskar Mukerji. Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. 1990.BMJ. Assessment of dyspnoea. 2014. http://bestpractice.bmj.com/best-practice/monograph/862/diagnosis.htmlAmerican Thoracic Society. Dyspnea Mechanisms, Assessment, and Management: A Consensus Statement. Am J Respir Crit Care Med Vol159. pp 321-340,1999 .