DYSPNEABy:

Christian Syukur 2013 - 061 – 114Paulus Aditya B. 2014 - 061 - 045

Advisor: dr. Febie Chriestya, Sp.PD, MSc.

KEPANITERAAN KLINIK DEPARTEMEN ILMU PENYAKIT DALAM FAKULTAS KEDOKTERAN UNIVERSITAS KATOLIK INDONESIA

ATMA JAYAPeriode 21 September 2015 – 28 November 2015

DefinisiPengalaman subyektif dari gangguan bernafas, yang terdiri dari sensasi yang memiliki intensitas yang bervariasi secara kualitatif (American Thoracic Society)

Mechanisms of Dyspnea

Chemoreceptors

Mechanoreceptors

Metaboreceptors

Respiratory centers(Respiratory drive)

Sensory cortex

FeedbackFeed-forwardError Signal

Motor Cortex

Ventilatory muscles

Dispnea intensity and quality

Corollary discharge

Assessing Dyspnea (Quality of Sensation)Descriptor Clinical Examples PathophysiologyChest tightness or constriction

Asthma, CHF Bronchoconstriction, interstitial edema (asthma, myocardial ischemia)

Increased work or effort of breathing

COPD, asthma, neuromuscular disease, chest wall restriction

Airway obstruction, neuromuscular disease (COPD, moderate to severe asthma, myopathy, kyphoscoliosis)

Air hunger, need to breathe, urge to breathe

CHF, COPD, asthma, pulmonary embolism, pulmonary fibrosis

Increased drive to breathe (CHF, pulmonary embolism, moderate to severe airflow obstruction)

Cannot get a deep breath, unsatisfying breath

Asthma, COPD, pulmonary fibrosis, chest wall disease

Hyperinflation (asthma, COPD) and restricted tidal volume (pulmonary fibrosis, chest wall restriction)

Heavy breathing, rapid breathing

Sedentary status in healthy individual / patient with cardiopulmonary disease

Deconditioning

DyspneaRespiraoty Disease

Cardiovascular Disease

Airways

Chest Wall

Lung Parenchym

Left Heart

Pulmonary Vasculature

Pericardium

Respiratory System DyspneaDisease of the Airways• Asthma• COPD

Disease of the Chest Wall• Kyphoscoliosis• Myasthenia Gravis• Guillain-Barre Syndrome

Disease of the Lung Parenchyma• Infections• Autoimmune Disorders

Cardiovascular System DyspneaDisease of the Left Heart• Coronary Artery Disease• Non-ischemic Cardomyopathies

Disease of the Pulmonary Vasculature• Pulmonary Hypertension• Pulmonary Thromboembolic Disease

Disease of the Pericardium• Constrictive Pericarditis• Cardiac Tamponade

Tatalaksana Dispneu

Goal •koreksi penyebab

O2 •saturasi istirahat ≤ 89%•saturasi ↓ saat aktivitas

Edema Paru

Tekanan hidrostatik dan onkotik

Level albumin ↓Kerusakan endotel Akumulasi Cairan

Edema Paru KardiogenikAbnormalitas jantung pe↑ tekanan vena pulmoner pe↑ tekanan hidrostatik cairan keluar dari pembuluh darah edema intersititial / alveolar

Tanda awal : exertional dyspnea dan orthopnea

Efusi Pleura

Ro thoraks: penebalan peribronkial, vaskularisasi yang lebih terlihat pada bagian atas paru, kerley B lines patchy alveolar filling infiltrat difus

Edema Paru Non-Kardiogenikkerusakan lapisan pembuluh darah pulmoner

Berkaitan: disfungsi surfaktan, pe↑ tegangan permukaan, kecenderungan alveoli kolaps

Membran hialin di alveoli, inflamasi fibrosis

Auskultasi: normal

Ro thoraks: infiltrat alveolar difus

CT-scan: edema alveolar heterogen

Bagaimana Membedakan edema paru kardiogenik dan non-kardiogenik ?

Kardiogenik Non-Kardiogenik

Riwayat Penyakit jantung kondisi tertentu

Pemeriksaan Fisik S3 gallop, pe↑ JVP, edema periferRales dan/atau wheezing

Normal pada fase awal

Radiografi Thoraks Perbesaran bayangan jantungRedistribusi vaskularPenebalan intersisialInfiltrat alveolar perihilerEfusi pleura sering

Ukuran jantung normalInfiltrat alveolar di seluruh lapang paruEfusi pleura jarang

Penyebab hipoksemia Mismatch ventilasi/perfusi Shunting intrapulmoner

Respon suplementasi O2 (+) (-)

THANK YOU!