Sesak Napas Kbk 2012
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Transcript of Sesak Napas Kbk 2012
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SESAK NAFAS
Dr. Hj. Asfawati, M.Sc., AIFO
FAKULTAS KEDOKTERAN UISU 2 0 1 2
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Tujuan pembelajaran:
- Mengidentifikasikan proses terjadinya sesak nafas - Menjelaskan alur perjalanan syaraf dan otot timbul sesak nafas - Menjelaskan faktor – faktor yang mempengaruhi proses terjadinya sesak nafas baik faktor endogen maupun eksogen
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DEFINISI
Sesak nafas merupakan suatu istilah yang menggambarkan suatu - persepsi subjektif ( keluhan yang dirasakan pasien ) - mengenai ketidaknyamanan bernapas - terdiri dari berbagai sensasi yang berbeda intensitasnya - selama proses pernafasan Merupakan hasil interaksi berbagai faktor fisiologi, psikologi, sosial dan lingkungan dan dapat menginduksi respons fisiologi dan perilaku sekunder
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Comroe (1996) – “…bukan takipnea, bukan hiperkapnea dan bukan hiperventilasi tapi pernapasan yang sulit, sejenis pernapasan yang tidak menyenangkan maupun menyakitkan “
Istilah : “ Shortness of breath “
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PEMAHAMAN UMUM
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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PATOFISIOLOGI SESAK NAFAS
1. Oksigenasi jaringan berkurang. Penyakit yang menyebabkan kecepatan pengiriman oksigen ke jaringan berkurang seperti perdarahan
2. Kebutuhan oksigen meningkat Peningkatan kebutuhan oksigen secara tiba – tiba akan memerlukan oksigen yang lebih banyak untuk proses metabolisme
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3. Kerja pernafasan meningkat Otot pernafasan dipaksa bekerja lebih kuat karena adanya penyempitan saluran pernafasan
4. Rangsangan pada sistem syaraf pusat Penyakit – penyakit yang menyerang sistem syaraf pusat
5. Penyakit neuromuskuler Penyakit yang menyerang diafragma
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Besarnya tenaga fisik yang dikeluarkan untuk menimbulkan sesak nafas tergantung kepada1. Usia 2. Jenis kelamin3. Ketinggian tempat4. Jenis latihan fisik5. Emosi
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Gejala sesak nafas biasanya memiliki satu atau beberapa keadaan
1. Penyakit kardiovaskuler2. Emboli paru3. Penyakit paru interstitial atau alveolare4. Gangguan dinding dada atau otot dada5. Penyakit obstruksi paru6. Kecemasan
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PEMBAGIAN SESAK NAFAS
Dispnea akut – Sesak napas yang berlangsung kurang dari 1 bulan
Dispnea kronik – Sesak napas yang berlangsung lebih dari 1 bulan
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MEKANISME SESAK NAFAS
Sensasi 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
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Efferent and Afferent Signals That Contribute to the Sensation of Dyspnea
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Kemoreseptor – Hiperkapnia – Hipoksia Mekanoreseptor – Saluran napas atas – Reseptor di paru – Reseptor di dinding dada Afferent mismatch
RESEPTOR PADA SISTEM RESPIRASI
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Cortical areas involved in the perception of dyspnea
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1. Borg Scale 2. American Thoracic Society Scale 3. St George Respiratory Questionaire (SGRQ) 4. Visual Analogue Scale for dyspnea
Penilaian terhadap sesak napas (dispnea)
Kuestioner skala dispnoe
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1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6 Very severe
7
8
9 Very, very severe
10 Maximal
Modified Borg Scale
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Skala sesak napas
American Thoracic Society (ATS)
Deskripsi Nilai Derajat
Tak terganggu oleh sesak saat bergegas waktu 0 -jalan atau sedikit mendaki
Terganggu oleh sesak saat bergegas waktu 1 Ringanberjalan atau sedikit mendaki
Jalan lebih lambat dibanding orang seumur krn 2 Sedangsesak atau harus berhenti utk bernapas saat jalan biasa Berhenti untuk bernapas setelah berjalan 100 3 Beratyard / setelah berjalan beberapa menit pada ketinggian tetap Terlampau sesak untuk keluar rumah / sesak saat 4 Sangat beratberpakaian atau melepas pakaian
Skala sesak nafasAmerican Thoracic Society (ATS)
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Visual analogue scale
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- Sistem respirasi - Sistem endokrine - Sistem neuromuskular - Intoksikasi - Sistem kardiovaskular - Psikogenik - Sistem hematologi - Obesiti - Sistem ginjal / metabolik
Organ dan sistem organ terkait dengan dispnea
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- Gangguan mekanik terhadap proses ventilasi
- Kelemahan pompa napas (respiratory pump) - Peningkatan respiratory drive - Ventilasi rugi (wasted ventilation) - Disfungsi psikologik
Kategori fisiologik penyakit penyebab dispnea
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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 limfangitik Gangguan pengembangan dinding dada atau diafragma – Penebalan pleura, kifoskoliosis, obesiti, masa intraabdomen, kehamilan
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Absolut – Riwayat poliomielitis – Penyakit neuromuskular (Sindrom Guillain Barre, muscular dystrophy, SLE, hipertiroidisme) Relatif – Hiperinflasi – Efusi pleura – Pneumotoraks
Kelemahan pompa napas (respiratory pump)
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-- Hipoksemia -- Asidosis metabolik – Penyakit ginjal – Anemia, hemoglobinopati – Penurunan curah jantung -- Stimulasi reseptor intrapulmoner – Infiltrative lung disease, hipertensi pulmoner, edem paru
Peningkatan respiratory drive
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Destruksi kapiler – Misal pada emfisema, interstitial lung disease Obstruksi pembuluh darah besar – Misal emboli paru, vaskulitis pulmoner
Ventilasi rugi (wasted ventilation)
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- Somatisasi - Ansietas - Depresi
Disfungsi psikologik
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Initial Database - History and physical examination - Hemogram, electrolytes, creatinine - Chest radiograph - Spirometry - ECG Extended Work-Up: Special Studies - Pulmonary Function Tests - Peak flow monitoring - Flow- volume loop - Lung volumes Diffusing - capacity Methacholine - challenge Exercise - testing
Pendekatan diagnostik dispnea
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Imaging Studies - Chest CT scanning - High resolution - Pulmonary embolism study - Ventilation-perfusion lung - scanning Gallium lung scanning - Sinus CT scanning
Esophageal Studies - pH monitoring (plus manometry) - Barium studies - Endoscopy
Pendekatan diagnostik dispnea
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Cardiac Evaluation - Exercise testing - Echocardiogram (possibly with exercise) - Nuclear medicine study - Rhythm monitoring (eg, Holter study)
Psychiatric Evaluation
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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 disease with aspiration, restrictive lung disease
Psychogenic: panic attacks, hyperventilation, pain, anxiety
Diagnosis banding dispnea akut
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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
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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)
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– Liver cirrhosis – Thyroid disease – Neuromuscular disorders ( myasthenia gravis, amyotrophic lateral sclerosis ) – Chest wall deformities ( kyphoscoliosis ) – Upper airway obstruction ( laryngeal disease,tracheal stenosis )
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Manajemen sesak nafas
Hal terpenting adalah mengobati penyakit dasar serta komplikasinya, misalnya
- Pneumonia ----> antibiotik- Asma ------ > bronkodilator dan pengontrol (kortikosteroid, LABA)
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Tatalaksana simptomatis sesak nafas
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, transtracheal oxygen) – Medications (e.g., theophylline)
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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 with Pulmonary Rehabilitation – Enhance self-esteem – Improve efficiency of movement – Desensitization to dyspnea (i.e., from repeated exercise)
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Tanda klinis
Sianosis, stridar inspirasi, bradikapnea / takipnea, Kussmaul,Cheyno-Stokes DJ < 60/menit Agitasi, stupar, koma Tanda Lab - SaO2 < 92% - APE < 150 l/m walaupun inhalasi berulang b2-agonist EKG : blok A-V, peny-koroner akut
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Beda sesak nafas - nyeri dada
Sesak nafasSaat hendak menarik nafas dada terasa berat. Pada awalnya tidak terasa sakit, lama –lama timbul terasa sakit karena lelahnya otot pernafasan didada baik sisi kanan atau sisi kiri
Nyeri dadaRasa nyeri didada seperti ditindih dan ditusuk benda tajam, menyerap kelengan kiri bahkan sampai keujung tangan kiri. Pada awalnya nyyeri dada masih bisa bernafas, tidak ada hambatan berarti . Lama - lama nyeri dada membuat pernafasan terganggu
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Sampai jumpa lagi
Salam manis …