dyspnoea & respiratory failure
TRANSCRIPT
Seminar 1Dyspnea and Respiratory Failure
• Ahmad Zulhakim B Mokhtar• Muhammad Halmi B Faisal Thena• Wan Nur Aima Nabila Bt Wan Mohd Zuferi• Liyana Bt Roslan• Norhabsah Bt Omar• Noor Alieya Syafikha Bt zakaria• Mahzalena Bt Aziz’s
What is Dyspnea ???
• A subjective sensation of breathlessness Class 1 Disease present but no
dyspnea, or dyspnea only on heavy exertion
Class 2 Dyspnea on moderate exertion
Class 3 Dyspnea on mild exertion
Class 4 Dyspnea at rest
Grade 0 Breathlessness with strenuous exercise
Grade 1 Short of breath when hurrying on level ground or walking up a slight hill
Grade 2 On level ground, walk slower than people of the same age because of breathlessness / have to stop for breath when walking at my own pace on the level
*NYHA *MMRC
What are the types ???
• Orthopnea - > breathlessness on lying flat
• Paroxysmal nocturnal dyspnea (PND) -> when patient is woken from sleep, fighting for breath.
Etiology
Dysp
nea
Respiratory
Cardiac
Anaemia
Non - cardiorespiratory
Psychogenic
Acidosis ( compensatory respiratory alkalosis)
Hypothalamic lesions
Respiratory
Airway disease Parenchymal disease
Pulmonary infection
Chest wall and pleura
Clinical examination ( Talley and O’Connor)
How to differentiate ???Lung disease Heart disease
History of respiratory disease History of hypertension, cardiac ischemia or valvular heart disease
Slow development Rapid development
Present at rest Mainly on exertion
Productive cough is common Cough uncommon and then ‘dry’
Aggravated by respiratory infection
Usually unaffected b respiratory infection
Murtagh’s General Practice
Pathogenesis & Pathophysiology Of Dyspnea
Mechanism Of Dyspnea
Clinical Manifestation Of Dyspnea
It’ll Leave You
Breathless
• Onset (Minutes, Hours, Days, Months, Years)
• Position (Opthopnea, Platypnoea, Trypopnoea)
• Associated Symptoms
Differential DiagnosisModes of Onset, duration and
progressionDDX
Acute Onset and Progressed Rapidly over a few Minutes
Pulmonary Thromboembolism Pneumothorax Left Ventricular Failure Asthma Inhaled Foreign Body
Gradually onset and Progressed Rapidly over Hours to Days
Pneumonia Asthma Exacerbation of COPD
Gradually Onset and Progressed Relentlessly over Weeks to Months
Anaemia Pleural Effusion Respiratory Neuromuscular
DisordesGradually Onset and Progressed Relentlessly over Months to Years
COPD Pulmonary Fibrosis Pulmonary Tuberculosis
Differential DiagnosisCommonly Associated Symptoms
(Acute Onset)DDX
No Chest Pain Pulmonary Embolism Pneumothorax Metabolic Acidosis Hypovolemia/shock Acute left ventricular failure/
pulmonary oedemaPleuritic Chest Pain Pneumonia
Pneumothorax Pulmonary embolism Rib Fracture
Central Chest Pain MI with Left Ventricular Failure Massive Pulmonary
Embolism/Infacrtion Wheeze and Cough Asthma
COPD
What is respiratory failure ???
• Respiratory system ->
• It occurs when pulmonary gas exchange is sufficiently impaired to cause hypoxemia with or without hypercapnia
• In practical terms -> present when ;– PaO2 is < 8 kPa (60 mmHg) or – PaCO2 is > 6.6 kPa (50 mmHg)
Consists of gas – exchanging organ (lungs) and a
ventilatory pump (respiratory muscles / thorax)
Type 1 Respiratory Failure
PaO2 = lowPaCO2 = Normal or low
Type 2 Respiratory Failure
PaO2 = lowPaCO2 = high
AetiologyRib cage Severe kyphosis
Muscle Dermatomyocitis
BrainTrauma to midbrain
PNSGuillain Barre Syndrome
Spinal CordComplete transection between cervical 3 - 5
LungsAsthmaPulmonary EdemaPneumothorax
Neuromuscular Junction Myasthenia Gravis
Clinical assesment
• Use of accessory muscles of respirations
• Intercostal recession • Tachypnoea *• Tachycardia• Sweating • Inability to speak• Asynchronous respiration• Paradoxical respiration
Pathogenesis/Pathophysiology Of Respiratory Failure
19
Clinical Manifestation Of Respiratory Failure
Convulsion, Mental
disorder, Coma
Bounding Pulse , Tachycardia, MI,
Arrythmias
Cyanosis
DYSPNOEA, Abnormal
Breath Rythm
Case Scenario
• A 25-year-old woman presents with shortness of breath. She reported that in high school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.
INVESTIGATIONS
INVESTIGATION EXAMPLE
Blood tests Full Blood Count (FBC)Urea & ElectrolyteC-Reactive ProteinArterial Blood Gas (ABGs)
Radiology chest X-rayMicrobiology Sputum
Blood cultures (if febrile)
Longmore, M., Baldwin, A., B. Wilkinson, I., & Wallin, E. (2014). Respiratory Failure. In Oxford handbook clinical medicine (Ninth ed., p. 180). Oxford.
MONITORING OF RESPIRATORY FAILURE
PULSE OXIMETRY• Lightweight oximeters can be applied to an ear lobe/ finger• Measure the changing amount of light transmitted through the pulsating
arterial blood and provide continuos, non-invasive assessment of arterial oxygen saturation
BLOOD GAS ANALYSIS• Interpretation of the results of blood gas analysis can be considered in
two separate parts:• 1) Disturbances of acid base balance• 2) Alterations in oxygenation
CAPNOGRAPHY• continuous breath by breath analysis of expired dioxide concentration• Used to :• -confirm tracheal intubation• -continuously monitor end-tidal PCO2• -detect apparatus malfunction• -detect acute alterations in cardiorespiratory function
Management of Respiratory Failure
• Treat underlying illness• Oxygen therapy-CPAP, BPAP
MV= RR x TV
TYPE 1 RESPIRATORY FAILURE TYPE 2 RESPIRATORY FAILURE Give oxygen (35-60%) by
facemask to correct hypoxia
Assisted ventilation if PO2<8kPa despite 60% O2
start oxygen therapy at 24% O2
Don’t leave hypoxia untreated-with care
Recheck ABG after 20 minutes.
- If PCO2 is steady or lower, increase O2 concentration to 28%.
- If PCO2 has risen >1.5kPa and patient still hypoxic, consider respiratory stimulant or assisted ventilation (NIPP, rarely respi stimulant (doxapram 1.5-4mg/min))
If this fails, consider intubation and if appropriate.
Guidelines For The Management Of Acute Severe Asthma In Adults
Long term poorly controlled asthma Asthma worsening for some days or weeks.
Features of acute severe asthma :
Too breathless to complete sentences in one breath RR 25 breaths/min PR 110/min PEF £ 50% predicted or best value
IMMEDIATE TREATMENTHigh concentration oxygen (>40%)
High doses of inhaled β2 agonist via nebuliser
Prednisolone tablets 30-60mg.
*IV aminophylline 250mg slowly over 20 minutes
Guidelines For The Management Of Chronic Asthma In Adults
DRUGS TYPES AIM
Bronchodilator drugs
Beta2 agonists
Anticholinergics
Methylxanthines
Relieve bronchospasm.
Improve symptoms.
Anti inflammatory
drugs
Corticosteroids
Sodium cromoglycate (Intal)
Treat airway inflammation.
Treat bronchial hyperresponsiveness.
Prevent recurrent attacks.
(a) Beta-2 Adrenoreceptor Antagonist
Salbutamol Salmeterol
Mechanism Of Action
bronchial SMC
(b) Anticholinergic - Ipratropium Bromide
competitive inhibition of muscarinic receptors (M3-type) on bronchiole smooth muscle
by antagonizing ACh action prevents ↑ in intracellular
calcium concentration
Bronchodilatation
(c) Methylxanthines
Theophylline Aminophylline
* (Phosphodiesterase inhibitors)
Mechanism Of Action
(d) Corticosteroids
Prototype :
Prednisolone (oral) Hydrocortisone (iv) Beclomethasone (inhalation)
Mechanism Of Action
They do not relax airway smooth muscle directly but reduce bronchial reactivity & frequency of asthma exacerbation
•THANK YOU