DYSPNEA Menaldi Rasmin Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia Persahabatan Hospital, Jakarta

INTRODUCTION Dyspnea: Discomfort feeling in breathing Subjective and difficult to measure Etiology : lung, heart, endocrine, kidney, neurology, hematology, rheumatology and psichology Prevalence of dyspnea → no accurate data 1

VENTILATORY REGULATION Ventilatory Central Centre located in the medulla of the brainstem composed of several subcenters, that interact to produce rhytmical breathing output is transmitted to phrenic nerves to diaphragm and respiratory muscles affected by Higher cortical centers Mechanical Chemical stimuli

Cortical Centers Mechanical reflexes input to the ventilatory center result; breathing partially under voluntary control Mechanical reflexes emanate from skeletal muscle spindle pulmonary vessels and tissue

Dyspnea breathlessness shortness of breath uncomfortable or unpleasant respiratory-related sensation not tachypnea, not hyperpnea and not hyperventilation but; difficult, labored, uncomfortable breathing; it is unpleasant type of breathing though not painful in the usual sense of the word. It is subjective and, like pain, it involves both perception of the sensation by the patient and his reaction to the sensation Comroe (1966)

“ an uncomfortable awareness of breathing or an increased respiratory effort that is unpleasant and regarded as in appropriate” (Mahler et al 1984)

DEFINITION OF DYSPNEA The American Thoracic Society (ATS): the term of discomfort perception subjective in breathing that consist of sensation with different intensity as a results of interaction of various physiologic, social and environtmental factors. 3

MECHANISM OF DYSPNEA Interaction between signal and receptor in otonomic nerve system, motoric cortex,airway receptor, lung and thoracic cage →dyspnea 4

MECHANISM OF DYSPNEA Dyspnea Emosi Komplek pernapasan Dispnea Komplek pernapasan Paru & dinding dada kognitif perilaku Emosi Stimulasi kemoreseptor latihan Kortek motorik primer Kortek sensorik primer MECHANISM OF DYSPNEA Dyspnea Complex of breathing Lung and thoracic cage Cognitive Behavior Emotion Chemoreceptor stimulation Exercise Primary motoric cortex Primary sensoric corte

MECHANISM OF DYSPNEA

MEASUREMENT OF DYSPNEA Aim : to differentiate the severity and to evaluate the nature of dyspnea Technique of measurement : visual analogue scale Borg scale Medical Research Council (MRC) Dyspnea Scale American Thoracic Sosiety (ATS) Dyspnea Scale Baseline Dyspnea Index (BDI) Transitional Dyspnea Index (TDI)

ATS dyspnea index Grade 1 : No dyspnea except severe exercise activity Grade 2 : Dyspnea when climb the step in hurry or climb a small hill Grade 3 : Walk slower compared to common people Grade 4 : Must stop for breathing after 100 yard walk Grade 5 : Dyspnea while put on / off the clothes

pulmonary non-pulmonary Dyspnea pulmonary non-pulmonary (cardiac) *pulm edema *arrhythmias *asthma/COPD *acute MI *PE *myocardial ischemia *pneumonia *pneumothorax

DYSPNEA IN PULMONARY DISEASE Abnormality of breathing mechanism, lung become more stiff, weakness of ventilation muscles. Restrictive lung diseases. Obstructive lung diseases. Disturbance of lung diffusion. Disturbance of lung perfusion.

RESTRICTIVE LUNG DISEASE Lung : - atelectasis - fibrosis - lung tumour - bullae - lung abscess Mediastinum : - mediastinal tumour - cardiomegali - pericardial effusion

ATELECTASIS

PANCOAST TUMOR

LUNG ABSCESS

DESTROYED LUNG

BULLAE

BULLAE

RESTRICTIVE LUNG DISEASE Pleura : - pleural effusion - pleural tumour - pneumothorax Diaphragm : - hernia of diaphragm - paralize of diaphragm Bone : - rib fracture - pectus excavatum - scoliosis, kyphosis Muscle : - myasthenia gravis

PLEURAL EFUSSION

PNEUMOTHORAX

HYDROPNEUMOTHORAX

OBSTRUCTIVE LUNG DISEASE Asthma COPD : - Chronic bronchitis - Emphysema Bronchiectasis Lung tumour Foreign body

BRONCHIECTASIS

LUNG TUMOR

DISTURBANCE OF DIFFUSION Alveolar wall Interstitial space Arterial wall Plasma Red blood cell wall

PNEUMONIA

ARDS

DISTURBANCE OF PERFUSSION Pulmonary emboli Congestive heart failure

LUNG NODULES

MILLIARY TB

CONCLUSION Dyspnea is a subjective symptom Various abnormalities may cause dyspnea Severity of dyspnea can be measured

Thank You