Dyspnea : Is it Pulmonary or extra

Pulmonary Problem ?

Dr Anna Uyainah ZN SpPD,KP,MARS

 Definition
• Subjective experience perceived and reported by an
affected patient
• Many definitions of dyspnea :
 “difficult, labored, uncomfortable breathing”
 “awareness of respiratory distress”
 “the sensation of feeling breathless or experiencing air hunger”
 “an uncomfortable sensation of breathing”

• These definitions have sometimes mixed the true symptom:

 what patients say they are feeling with physical signs
 what the physician observes about the patient
 Anamnesis
• Do you have any difficulty breathing ?
• When did it begin ?
• Has the onset been sudden or insidious ?
• Frequency and duration of attacks ?
• Response to activity, emotional state, change of
body position, should be noted
• Risc factor ?
• Underlying disease ?
• Family history ?
 Physical examination Findings

Fever Pneumonia, other infection

Chest pain Myocardial ischemia, PE, Pneumonia, Trauma
Cough Pneumonia, COPD/Asthma, PE, Heart Failure
Wheezing Asthma, COPD, Cardiac ischemia, Heart failure,
Anaphylaxis
Fremitus Pulmonary disorder
Sonor/Hypersonor/dullness Pulmonary disorder
Ronchi Pulmonary disorder
Tachycardia / Bradycardia Cardiac disorder, infection, sepsis
Leg edema Heart failure, PE, Myocardial Ischemia
Increase JVP Heart failure
Breathing Pattern ?
 Abnormal breathing patterns

Tachypnea Increased respiratory rate >20 bpm, regular

rhythm e g. anxiety ,asthmatic, atelectasis, brain
lesions, drugs (aspirin), exercise, fever,
hypercapnia, hypoxemia, metabolic acidosis, pain
Bradypnea Slow respiratory rate  <12 bpm.
e g. normal during sleep, brain tumors,
diabetic coma, drugs (alcohol, narcotics),
increased intracranial pressure, metabolic
acidosis, uremia, hypothyroidism

Hyperpnea Increased depth of breathing

Increased volume with or without and increased
frequency (RR), normal blood gases present.
 Abnormal breathing patterns
Hyperventilation = Overbreathing : the breathing faster or deeper than normal,
(hyperpnoea)[causing falling Paco2 below normal (35–45 mmHg).
e.g. Stress or anxiety ( psychogenic)

Hypoventilation = respiratory depression: occurs when ventilation is inadequate

to perform needed gas exchange
It causes an increased concentration of carbon dioxide
(hypercapnia) and respiratory acidosis
Kussmaull breathing is a deep and labored breathing pattern
often associated with severe metabolic acidosis . Ex: diabetic
ketoacidosis , acidosis metabolic e.c.renal failure.
 Abnormal breathing patterns
Paroxismal Nocturnal dyspnea The sensation of shortness of breath that awakens
the patient, often after 1 or 2 hours of sleep, and is
usually relieved in the upright position
Orthopnea The sensation of breathlessness in the recumbent
position relieved by sitting or standing
Dyspnea d’effort Dyspnea on exertion, occurs at level of activity that
is usually well tolerated
Trepopnea Dyspnea that occurs in one lateral decubitus
position as opposed to the other
Platypnea Breastlessness that occurs in the upright position
and is relieved with recumbency
 Abnormal breathing patterns
Cheyne-Stokes respirations Also called as “periodic breathing”
(CSR) Characterized by alternate periods of tachypnea
and apnea
 Is the dyspnea
A new problem ? An exacerbation of A combination of a
chronic problem ? new and chronic
problem ?
• Myocardial Ischemia • Asthma • Recurrent Disease
• Pneumonia • Emphysema / Chronic  Myocardial Ischemia
• Pulmonary embolism bronchitis  Pulmonary Embolism
• Anaphylaxis • Congestive Hart Failure  Arrhytmia
• Arrhytmia • Intersitial Lung Disease • Multiple disease
• Trauma • Cardiac Arrhytmia conspiring together
• Pleural or pericardial  Infection exacerbating
efusion Heart Failure
• Neuromuscular disorder  Arrhytmia exacerbating
• Anemia Cardiac Ischemia
 COPD complicated by
pneumonia
 Differential Diagnosis of Dyspnea

Pulmonary Kardio pulmonary Systemic

• COPD • CHF/pulmonary edema • Anemia
• Asthma • Acute coronary Syndrome • Acute Renal Failure
• Pneumonia • Pericardial Disease/ • Metabolic Acidosis
• Tuberkulosis • cardiac tamponade • Thyrotoxicosis
• Bronchiectasis • Valvular Heart Disease • GERD
• ILD • Arrhytmia • Cirrhosis
• Lung Cancer • Intracardiac shunt • Anaphylaxis
• Pleura Effusion • Etc… • Sepsis
• Lung Emboli • Etc…
• Pneumothorax
Neuromuscular
• Etc …
• Rib fracture/ Chest trauma Psychogenic
• Flail chest • Hyperventilation syndrome
• CNS disorders • Psychogenic dyspnea
• Phrenic Nerve Paralysis • Vocal cord Dysfunction
• Myophathy Syndrome
• Neuropathy • Foreign body aspiration
• Etc … • Etc …
 Pathologic Progression of CV Disease
Sudden
Coronary artery Death
disease

Hypertension Myocardial Pathologic Low ejection

injury remodeling fraction Death
Diabetes

Cardiomyopathy
Pump
Valvular disease failure

Symptoms:
• Neurohormonal Chronic
Dyspnea
heart
stimulation Fatigue
failure
• Myocardial Edema
toxicity

Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.

 Clinical Presentation of Heart Failure
• Due to excess fluid accumulation:
– Dyspnea d’effort
– Orthopnea
– Paroxysmal Nocturnal Dyspnea (PND)
– Peripheral edema
– Hepatic congestion
– Ascites
– Pleural effusion
– Pulmonary Edema due to
Pulmonary edema
Heart Failure
– Cardiomegaly
– Jugular venous distension
• Due to reduction in cardiac ouput:
– Fatigue
– Weakness
 COR PULMONALE
(Right sided heart failure)

Is an enlargement of the right ventricle due to

high blood pressure in the lungs usually caused
by chronic lung disease
 Metabolic acidosis
• A condition that occurs when the body produces excessive
quantities of acid or when the kidneys are not removing
enough acid from the body.
• Metabolic acidosis leads to acidemia , i.e., blood PH is low
(less than 7.35) due to increased production of hydrogen
ions by the body or the inability of the body to form
bicarbonate (HCO3−) in the kidney.
• Its causes are diverse, and its consequences can be serious,
including coma and death . Together with respiratory
acidosis , it is one of the two general causes of acidemia.
There are several types of metabolic acidosis:

• Diabetic acidosisis (also called diabetic ketoacidosis and

DKA) develops when substances called ketone bodies
(which are acidic) build up during uncontrolled diabetes
• Hyperchloremic acidosis is caused by the loss of too much
sodium bicarbonate from the body, which can happen with
severe diarrhea.
• Kidney disease (distal renal tubular acidosis and proximal
renal tubular acidosis
• Poisoning by aspirin, ethylene glycol (found in antifreeze),
or methanol
• Severe dehydration
 Acid Reflux and Shortness of Breath
Written by Robin Madell and Tricia Kinman
Medically Reviewed by Steven Kim, MD on June 15, 2015

• Breathing difficulties such as bronchospasm and aspiration

• These difficulties can sometimes lead to life-threatening
respiratory complications
• Because stomach acid that creeps into the esophagus can
cause it to narrow
• When gastric acid reaches the vocal folds, airways, and
lungs, it can cause a swelling of the passages.
• This can lead to atypical asthma reactions
• Such airway damage can affect breathing by causing
coughing or wheezing and making swallowing solid foods
more difficult
 Aspiration Pneumonia
• Chronically ill people with compromised lung function who may be
bedridden for long periods may be susceptible to a form of
pneumonia known as aspiration pneumonia.
• Preexisting GERD increases the risk for this condition. Inhaling large
amounts of stomach contents can infect the lungs and cause a
chemical burn of the airways, leading to obstructed airflow and
fluid retention in the lungs.
• Aspiration pneumonia, which is unlikely to strike otherwise healthy
people, comes on suddenly in a matter of hours. It is treated with
antibiotics and other drugs, and breathing support is often needed.
• Symptoms include fever, shortness of breath and a cough
producing a bad-tasting sputum.
2014 Nov;70(2):1385-91. doi: 10.1007/s12013-014-0068-4.
Type 1 diabetes mellitus is an independent risk factor for
pulmonary fibrosis.
Hu Y1, Ma Z, Guo Z, Zhao F, Wang Y, Cai L, Yang J.

This study examined clinical pulmonary function parameters and

transbronchial lung biopsies to assess associated histopathological
changes in 12 type 1 diabetic patients presenting with dyspnea.
Pulmonary function parameters (FVC, FEV1, TLC, and DLco/VA) were
significantly reduced in diabetic patients with dyspnea and without
dyspnea, compared to controls.
 Case 1
• Pasien wanita 53 tahun, datang ke IGD dengan keluhan
sesak napas sejak 2 hari, sesak bersifat cepat dan dalam.
Sesak seperti ini baru dirasa saat ini, OS belum pernah
dirawat dengan sesak spt ini. Riwayat DM sejak 12 tahun
yl, berobat tidak teratur kadang menggunakan obat
herbal kadang ke puskesmas.
o Jenis sesak yang ada pada pasien ini ?
o Differensial diagnosis ? (DM dg Acidosis metabolik, CKD dg
asidosis metabolik)
o Rencana pemeriksaan penunjang untuk diagnosis ?
o Penatalaksanaan selanjutnya ?
 Case 2
• Pasien laki2 Tn 57 tahun sedang dirawat di ruang rawat
inap dengan keluhan sesak napas terutama bila jalan
jauh dan naik tangga. Pasien mempunyai kebiasaan
merokok sejak SMA minimal 10 batang setiap hari. Saat
ini sering terbangun malam hari karena sesak napas, dan
pasien lebih nyaman tidur dengan 2 bantal.
o Jenis sesak yang ada pada pasien ini ?
o Differensial diagnosis ? (CHF)
o Pemeriksaan fisik apa yang ditemukan ?
o Rencana pemeriksaan penunjang untuk diagnosis ?
o Penatalaksanaan selanjutnya ?
 Case 3
• Pasien wanita 55 tahun, datang ke UGD jam 12
malam dengan sesak napas tiba2, sesak bersifat
tachipnoe, kesadaran compos mentis, kedua tagan
agak kaku. Pasien tidak mempunyai riwayat sakit
jantung, DM, asma ataupun paru.
o Jenis sesak yang ada pada pasien ini ?
o Differensial diagnosis ? (Hiperventilasi psikogenik)
o Pendekatan pemeriksaan anamnesis dan PF apa yang perlu
dilakukan ?
o Rencana pemeriksaan penunjang yang diperlukan ?
o Penatalaksanaan selanjutnya ?
Dyspnea
…….

Hystory Physical Exam Lab Diagn

……. ……. …….

Differential diagnosis

Pulmonary Non Pulmonary

……. …….

Cardiac Systemic Psychogenic Neuromuscular

……. ……. ……. …….
TERIMA KASIH