Dyspnoea & Respiratory Failure

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. 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. What are the types ???
• Orthopnea - >
breathlessness on lying flat
• Paroxysmal nocturnal
dyspnea (PND) ->
when patient is woken
from sleep, fighting for
breath.

4. Etiology
Dyspnea Respiratory
Cardiac
Anaemia
Non - cardiorespiratory
Psychogenic
Acidosis ( compensatory
respiratory alkalosis)
Hypothalamic lesions

5. Respiratory
Airway disease
Parenchymal
disease
Pulmonary
infection
Chest wall and
pleura
Clinical examination
( Talley and
O’Connor)

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. Pathogenesis & Pathophysiology
Of Dyspnea

8. Mechanism Of Dyspnea

9. Clinical Manifestation Of Dyspnea
It’ll Leave You
Breathless

10. • Onset (Minutes, Hours, Days, Months,
Years)
• Position (Opthopnea, Platypnoea,
Trypopnoea)
• Associated Symptoms

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. 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. 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. Type 1 Respiratory Failure
PaO2 = low
PaCO2 = Normal or low

15. Type 2 Respiratory Failure
PaO2 = low
PaCO2 = high

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. Clinical assesment
• Use of accessory muscles of
respirations
• Intercostal recession
• Tachypnoea *
• Tachycardia
• Sweating
• Inability to speak
• Asynchronous respiration
• Paradoxical respiration

18. Pathogenesis/Pathophysiology
Of Respiratory Failure

19. 19

20. Clinical Manifestation Of
Respiratory Failure

21. Convulsion,
Mental
disorder, Coma
Bounding Pulse ,
Tachycardia, MI,
Arrythmias
Cyanosis
DYSPNOEA,
Abnormal
Breath Rythm

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. 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. 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. Management of Respiratory Failure
• Treat underlying illness
• Oxygen therapy-CPAP, BPAP
MV= RR x TV

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. 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. 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. 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. (a) Beta-2 Adrenoreceptor Antagonist
 Salbutamol
 Salmeterol

31. Mechanism Of Action
bronchial SMC

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. (c) Methylxanthines
 Theophylline
 Aminophylline
* (Phosphodiesterase inhibitors)

34. Mechanism Of Action

35. (d) Corticosteroids
Prototype :
 Prednisolone (oral)
 Hydrocortisone (iv)
 Beclomethasone (inhalation)

36. Mechanism Of Action
They do not relax airway smooth muscle directly
but reduce bronchial reactivity & frequency
of asthma exacerbation

37. •THANK YOU