PENDEKATANKHUSUSSESAKNAPAS05

8/3/2019 PENDEKATANKHUSUSSESAKNAPAS05

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PENDEKATAN KHUSUS

SESAK NAPAS

Menaldi Rasmin, Wahju Aniwidyaningsih

Departemen Pulmonologi & Ilmu Kedokteran RespirasiFKUI - RS Persahabatan

Jakarta


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Pengertian dispnea

Suatu istilah yang menggambarkan suatu persepsisubjektif mengenai ketidaknyamanan bernapas yangterdiri dari berbagai sensasi yang berbeda intensitinya

Merupakan hasil interaksi berbagai faktorfisiologi,psikologi, sosial dan lingkungan dan dapat menginduksirespons fisiologi dan perilaku sekunder

Comroe (1996) bukan takipnea, bukan hiperkapnea dan bukan hiperventilasi

tapi pernapasan yang sulit, sejenis pernapasan yang tidakmenyenangkan maupun menyakitkan


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Pengertian awam

Dispnea/breathlessness/sesak napas

Tidak bisa menghirup cukup udara

Udara tidak masuk sempurna

Rasa penuh di dada

Dada terasa berat, sempit

Rasa tercekik Napas pendek

Napas berat


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http://content.nejm.org/content/vol333/issue23/images/large/07t1.jpeg


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Pembagian dispnea

Dispnea akut

Sesak napas yang berlangsung kurang dari 1

bulan

Dispnea kronik

Sesak napas yang berlangsung lebih dari 1bulan


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Mekanisme dispnea

Sensasi dispnea berawal dari aktivasi sistem

sensorik yeng terlibat dalam sistem respirasi.

Informasi sensorik sampai pada pusat

oernapasan di otak dan memproses respiratory-

related signals dan menhasilkan pengaruh

kognitif, kontekstual, dan perilaku sehinggaterjadi sensasi dispnea


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Efferent and Afferent Signals That Contribute to the Sensation of Dyspnea

N Eng Med Journal 1995; 223: 1547-53
http://content.nejm.org/content/vol333/issue23/images/large/07f1.jpeg


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Reseptor pada sistem respirasi

Kemoreseptor Hiperkapnia

Hipoksia

Mekanoreseptor Saluran napas atas

Reseptor di paru

Reseptor di dinding dada

Afferent mismatch


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von Leupoldt, A. et al. Chest 2005;128:345-354

Cortical areas involved in the perception of dyspnea


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http://content.nejm.org/content/vol333/issue23/images/large/07t2.jpeg


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Penilaian terhadap sesak napas

(dispnea)

Kuesioner skala dispnea

Borg Scale

American Thoracic Society Scale

St George Respiratory Questionaire (SGRQ)

Visual Analogue Scale for dyspnea


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Modified Borg Scale

1 Very slight

2 Slight

3 Moderate

4 Somewhat severe

5 Severe

6 Very severe

7

8

9 Very, very severe

10 Maximal


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Skala sesak napas

American Thoracic Society(ATS)

Deskripsi Nilai Derajat

Tak terganggu oleh sesak saat bergegas waktu

jalan atau sedikit mendaki

0 -

Terganggu oleh sesak saat bergegas waktuberjalan atau sedikit mendaki

1 Ringan

Jalan lebih lambat dibanding orang seumur krn

sesak atau harus berhenti utk bernapas saat jalan

biasa

2 Sedang

Berhenti untuk bernapas setelah berjalan 100

yard / setelah berjalan beberapa menit pada

ketinggian tetap

3 Berat

Teralmpau sesak untuk keluar rumah / sesak saat

berpakaian atau melepas pakaian

4 Sangat berat


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Visual analogue scale


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Organ dan sistem organ terkait

dengan dispnea Sistem respirasi

Sistem neuromuskular

Sistem kardiovaskular Sistem hematologi

Sistem ginjal / metabolik

Sistem endokrin

Intoksikasi Psikogenik

Obesiti


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Kategori fisiologik penyakit penyebab

dispnea

1. Gangguan mekanik terhadap proses ventilasi

2. Kelemahan pompa napas (respiratory pump)3. Peningkatan respiratory drive

4. Ventilasi rugi (wasted ventilation)

5. Disfungsi psikologik


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Gangguan mekanik terhadap proses

ventilasi

Obstruksi aliran napas (sentral atau perifer) Asma, PPOK Tumor endobronkial Stenosis trakea / laring

Gangguan pengembangan paru (stiff lung) Interstitial fibrosis Gagal jantung kiri Tumor linfangitik

Gangguan pengembangan dinding dada atau diafragma Penebalan pleura, kifoskoliosis, obesiti, masa intraabdomen,

kehamilan


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Kelemahan pompa napas

(respiratory pump)

Absolut

Riwayat poliomielitis

Penyakit neuromuskular (Sindrom Guillain Barre,muscular dystrophy, SLE, hipertiroidisme)

Relatif

Hiperinflasi

Efusi pleura

Pneumotoraks


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Peningkatan respiratory drive

Hipoksemia

Asidosis metabolik Penyakit ginjal

Anemia, hemoglobinopati

Penurunan curah jantung

Stimulasi reseptor intrapulmoner Infiltrative lung disease, hipertensi pulmoner, edem

paru


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Ventilasi rugi (wasted ventilation)

Destruksi kapiler

Misal pada emfisema, interstitial lung disease

Obstruksi pembuluh darah besar

Misal emboli paru, vaskulitis pulmoner


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Disfungsi psikologik

Somatisasi

Ansietas Depresi


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Pendekatan diagnostik dispnea

Initial Database

History and physical examinationHemogram, electrolytes, creatinineChest radiographSpirometryECG

Extended Work-Up: Special Studies

Pulmonary Function Tests

Peak flow monitoring

Flow-volume loopLung volumesDiffusing capacityMethacholine challengeExercise testing


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Pendekatan diagnostik dispnea

Imaging Studies

Chest CT scanningHigh resolutionPulmonary embolism study

Ventilation-perfusion lung scanningGallium lung scanning

Sinus CT scanningEsophageal Studies

pH monitoring (plus manometry)Barium studiesEndoscopy

Cardiac Evaluation

Exercise testingEchocardiogram (possibly with exercise)Nuclear medicine studyRhythm monitoring (eg, Holter study)

Psychiatric Evaluation


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Diagnosis banding dispnea akut

Cardiac: 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 diseasewith aspiration, restrictive lung disease

Psychogenic: panic attacks, hyperventilation, pain, anxiety

Upper airway obstruction: epiglottitis, foreign body, croup, Epstein-Barrvirus

Endocrine: metabolic acidosis, medications

Central: neuromuscular disorders, pain, aspirin overdose

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


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Cardiac Congestive heart failure Coronary artery disease Cardiac arrhythmias Pericardial disease

Valvular heart disease

Pulmonary Chronic obstructive pulmonary disease Asthma Interstitial lung disease Pleural effusion Malignancy (primary or metastatic) Bronchiectasis

Diagnosis banding dispnea kronik


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Noncardiac or nonpulmonary (less common)

Thromboembolic disease Psychogenic causes (GAD, PTSD, panic disorders) Deconditioning

Pulmonary hypertension Obesity (massive) Severe anemia Gastroesophageal reflux disease Metabolic conditions (acidosis, uremia) Liver cirrhosis Thyroid disease Neuromuscular disorders (myasthenia gravis, amyotrophic lateral sclerosis) Chest wall deformities (kyphoscoliosis) Upper airway obstruction (laryngeal disease,tracheal stenosis)

Diagnosis banding dispnea kronik


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Manajemen dispnea

Hal terpenting adalah mengobati penyakit

dasar serta komplikasinya, misalnya :

Pneumonia antibiotik

Asma bronkodilator dan pengontrol

(kortikosteroid, LABA)

Tatalaksana simptomatis dispnea


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Tatalaksana simptomatik dispnea

Reduce Sense of Effort and Improve Respiratory Muscle

Function Energy conservation (e.g., pacing) Breathing strategies (e.g., pursed-lip breathing) Position (e.g., leaning forward) Correct obesity or malnutrition Inspiratory muscle exercise

Respiratory muscle rest (e.g., cuirass, nasal ventilation, transtrachealoxygen)

Medications (e.g., theophylline)

Decrease Respiratory Drive Oxygen

Opiates and sedatives Exercise conditioning Vagal nerve section Carotid body resection


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Alter Central Nervous System Function Education Psychologic interventions (e.g., coping strategies,

psychotherapy, group support)

Opiates and sedatives

Use Exercise Training Alone or withPulmonary Rehabilitation

Enhance self-esteem Improve efficiency of movement Desensitization to dyspnea (i.e., from repeated

exercise)

Tatalaksana dispnea

Dispnea Akut


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Dispnea Akut

Riwayat EKG

Pem.jasmani

DX : IMA,pneumotoraks

tekan,edema paru,aritmia

jantung,asma

AGDA

AaDO2 Normal AaDO2

tab

DX : DL,pH DX :anemia,

Ro pneumonia as.metab

pneumotoraks,CHF

efusi pleura,ARDS sindr.hiperventilasiobstr.sal.napas atas

Payarperfusi

paru DX : emboli paru

Angiografi

pulmoner Decision Nakin in Pulmonary Medicine 1991 : 3


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Dispnea Kronik

Riwayat pem.jasmani AGDA,DL

singkirkan : anemia

Ro toraks

kemungkinan pem.jantung Peny.paru

Ekokardiografi

singkirkan : infeksi,

neoplasma

Abn Normal

Peny.jantung

Uji faal paru kap.difusi


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Normal AbN

Uji latih

Data sesuai Data sesuai Data sesuai

peny.parenkinal peny.sal.nps peny.vaskuler paru

Normal Abn ILD PPOK Hipertensi pulmoner

Neuplasma

mungkin asma

nonorganik peny.jantung

Decision Making in Respiratory

Medical 1991 : 5


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Tanda Klinis

Sianosis, stridar inspirasi,bradikapnea/takipnea,Kussmaul,Cheyno-Stokes

DJ < 60/m,choe,hypota

Agitasi,stupar,komaTanda Lab

SaO2 < 92%

APE < 150 l/m walaupun inhalasi

berulang 2-agonist

EKG : blok A-V,peny-koroner akut


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Pasien dengan dispnea

yaDarurat

Dispnea akut Dispnea kronikRiw.medik & pem.fisik Penilaian dispnea langsung & tak

Ro.toraks,EKG,AGDA langsung, uji faal paru,EKG,

ekokardia, CT-spiral


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Perkusi & auskultasi

abnormal

Mengi, Mengi Ronki difuse Efusi pleura

inspirasi ekspirasi (edema paru) (infeksi kega-

(laringitis, (serangan lokal nasan I/II,

benda asing, asma,PPOK (pneumonia, pneumotoraks

paralisis pita kambuh, infark paru

suara,lari- gagal

ngeal & jantungtrakeal kiri


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Perkusi & auskultasi dada normal

Emboli paru Ekstratoraks Sinemateria

(anemia, (somatisasi,Perikarditis asidosis,syok ansietas,

septik peny. depresi,

Gagal jantung syaraf litigasikanan

PENDEKATANKHUSUSSESAKNAPAS05

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