7/26/2019 C2 - Dyspnea
1/23
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)
7/26/2019 C2 - Dyspnea
2/23
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]
7/26/2019 C2 - Dyspnea
3/23
Dyspnea
Dyspnea, the sensation of breathlessnessor inadequate breathing, is the most
common complaint of patients with
cardiopulmonary diseases.
7/26/2019 C2 - Dyspnea
4/23
Dyspnea - common complaint/symptom
shortness of breath or breathlessness
Defined as abnormal/uncomfortable
breathing
Multiple etiologies -
2/3 of cases - cardiac or pulmonary etiology
7/26/2019 C2 - Dyspnea
5/23
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
7/26/2019 C2 - Dyspnea
6/23
Differential Diagnosis
Composed of four general categories
Cardiac
Pulmonary
Mixed cardiac or pulmonary
non-cardiac or non-pulmonary
7/26/2019 C2 - Dyspnea
7/23
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.
7/26/2019 C2 - Dyspnea
8/23
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.
7/26/2019 C2 - Dyspnea
9/23
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.
7/26/2019 C2 - Dyspnea
10/23
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.
7/26/2019 C2 - Dyspnea
11/23
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)
7/26/2019 C2 - Dyspnea
12/23
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
7/26/2019 C2 - Dyspnea
13/23
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)
7/26/2019 C2 - Dyspnea
14/23
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.
7/26/2019 C2 - Dyspnea
15/23
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
7/26/2019 C2 - Dyspnea
16/23
CASE
Seorang laki laki berusia 46 tahun, datang ke
UGD dengan keluhan utama: sesak nafas sejak
2 hari ,batuk batuk sudah dirasakan 1
minggu
7/26/2019 C2 - Dyspnea
17/23
Apa yang perlu ditanyakan lagi untuk
kemungkinan differensial diagnosis pada
pasien ini?
7/26/2019 C2 - Dyspnea
18/23
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
7/26/2019 C2 - Dyspnea
19/23
Pemeriksaan fisik
Respiratory Rate
Ekspirasi memanjang ?
Pursed Lip Breathing? Tanda tanda CHF ?
Pemeriksaan paru: ronkhi ? Ekspirasi
memanjang ?, Wheezing ?
7/26/2019 C2 - Dyspnea
20/23
Laboratorium dan Penunjang
Hematologi rutin:
Hb
Leukosit
Diff count
Ureum
Kreatinin
Pulse oxymetry
Analisis Gas Darah
7/26/2019 C2 - Dyspnea
21/23
Pemeriksaan Penunjang
Foto Toraks
Spirometri
EKG CT Scan
Bronkoskopi
7/26/2019 C2 - Dyspnea
22/23
Global Initiative for Asthma
7/26/2019 C2 - Dyspnea
23/23
HASAN SADIKIN GENERAL HOSPITAL