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Dyspnoea & Respiratory Failure

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Dyspnoea & Respiratory Failure

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Dyspnoea & Respiratory Failure

  1. 1. Seminar 1 Dyspnea 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
  2. 2. 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
  3. 3. What are the types ??? • Orthopnea - > breathlessness on lying flat • Paroxysmal nocturnal dyspnea (PND) -> when patient is woken from sleep, fighting for breath.
  4. 4. Etiology Dyspnea Respiratory Cardiac Anaemia Non - cardiorespiratory Psychogenic Acidosis ( compensatory respiratory alkalosis) Hypothalamic lesions
  5. 5. Respiratory Airway disease Parenchymal disease Pulmonary infection Chest wall and pleura Clinical examination ( Talley and O’Connor)
  6. 6. 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
  7. 7. Pathogenesis & Pathophysiology Of Dyspnea
  8. 8. Mechanism Of Dyspnea
  9. 9. Clinical Manifestation Of Dyspnea It’ll Leave You Breathless
  10. 10. • Onset (Minutes, Hours, Days, Months, Years) • Position (Opthopnea, Platypnoea, Trypopnoea) • Associated Symptoms
  11. 11. Differential Diagnosis Modes of Onset, duration and progression DDX 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 Disordes Gradually Onset and Progressed Relentlessly over Months to Years  COPD  Pulmonary Fibrosis  Pulmonary Tuberculosis
  12. 12. Differential Diagnosis Commonly Associated Symptoms (Acute Onset) DDX No Chest Pain  Pulmonary Embolism  Pneumothorax  Metabolic Acidosis  Hypovolemia/shock  Acute left ventricular failure/ pulmonary oedema Pleuritic 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
  13. 13. 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)
  14. 14. Type 1 Respiratory Failure PaO2 = low PaCO2 = Normal or low
  15. 15. Type 2 Respiratory Failure PaO2 = low PaCO2 = high
  16. 16. AetiologyRib cage Severe kyphosis Muscle Dermatomyocitis Brain Trauma to midbrain PNS Guillain Barre Syndrome Spinal Cord Complete transection between cervical 3 - 5 Lungs Asthma Pulmonary Edema Pneumothorax Neuromuscular Junction Myasthenia Gravis
  17. 17. Clinical assesment • Use of accessory muscles of respirations • Intercostal recession • Tachypnoea * • Tachycardia • Sweating • Inability to speak • Asynchronous respiration • Paradoxical respiration
  18. 18. Pathogenesis/Pathophysiology Of Respiratory Failure
  19. 19. 19
  20. 20. Clinical Manifestation Of Respiratory Failure
  21. 21. Convulsion, Mental disorder, Coma Bounding Pulse , Tachycardia, MI, Arrythmias Cyanosis DYSPNOEA, Abnormal Breath Rythm
  22. 22. 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.
  23. 23. INVESTIGATIONS INVESTIGATION EXAMPLE Blood tests Full Blood Count (FBC) Urea & Electrolyte C-Reactive Protein Arterial Blood Gas (ABGs) Radiology chest X-ray Microbiology 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.
  24. 24. 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
  25. 25. Management of Respiratory Failure • Treat underlying illness • Oxygen therapy-CPAP, BPAP MV= RR x TV
  26. 26. 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.
  27. 27. 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
  28. 28. IMMEDIATE TREATMENT High concentration oxygen (>40%) High doses of inhaled β2 agonist via nebuliser Prednisolone tablets 30-60mg. *IV aminophylline 250mg slowly over 20 minutes
  29. 29. 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.
  30. 30. (a) Beta-2 Adrenoreceptor Antagonist  Salbutamol  Salmeterol
  31. 31. Mechanism Of Action bronchial SMC
  32. 32. (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
  33. 33. (c) Methylxanthines  Theophylline  Aminophylline * (Phosphodiesterase inhibitors)
  34. 34. Mechanism Of Action
  35. 35. (d) Corticosteroids Prototype :  Prednisolone (oral)  Hydrocortisone (iv)  Beclomethasone (inhalation)
  36. 36. Mechanism Of Action They do not relax airway smooth muscle directly but reduce bronchial reactivity & frequency of asthma exacerbation
  37. 37. •THANK YOU

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