Respiratory aspects of dyspnea

Dyspnea -1

The sensation of abnormal or uncomfortable breathing in the context of what is normal for a person according to his/her level of fitness and exertional threshold for breathless

Am Fam Phys, Evaluation of Dyspnea, 1998

Other terminologies:

Shortness of breath Breathlessness Difficult breathing Breathing difficulties Breathing discomfort

Chest tightness Breath stops Air hunger

Labored breathing Troubled breathing Getting winded Constriction Uncomfortable breathing Unusual awareness of breathing Increased breathing effort Increased muscular effort to breath The need to breath more

Dyspnea -2
symptom (subjective) VS sign (objective)

symptom: sensory experience (sensation), that only could be feel and judge by the patient psychologic disturbances sign: respiratory distress, patient breath with difficulties, involvement of additional respiratory muscle physiologic disturbances

Dyspnea
an abnormal (pathophysiologic) condition to know it better

breathing phenomenon

respiratory physiology

Breathing respiration
Breathing: taking air into the lungs and

send it out again

Oxford Dictionary

Respiration: the exchange of O2 & CO2

between the atmosphere and the cells of the body; includes ventilation (inhalation & exhalation), the diffusion of oxygen in the alveoli, & the transport of O2 & CO2 and the use of them by the cells
Dorlands Medical Dictionary

Breathing phenomenon
unconscious

act healthy persons, especially children generally unaware automatic

conscious

act we can control our own breath limited

Respiratory physiology
availability of arterial blood (O2, CO2), every time for the tissue of the whole body
vital, crucial, can not be postponed

teamwork of 2 main systems : respiratory & cardiovascular

Respiration

the primary function is to obtain O2 for use by the bodys cells and to eliminate CO2 the cells produce involves the sum of processes that accomplish movement of O2 from the atmosphere to the tissue to support cellular metabolism and removal of CO2 the cells produce to the atmosphere
the respiratory system does not participate in all steps in respiration
Sherwood L, The Respiratory System, 2004

Steps of Respiration - 1
1. Ventilation or gas exchange between atmosphere and alveoli

2. Diffusion of O2 & CO2 between alveoli and the blood

3. Circulation (transport) of O2 & CO2 between the lungs and the tissue

4. Exchange of O2 & CO2 between the blood and the tissues

Sherwood L, The Respiratory System, 2004

Steps of Respiration - 2
producer
Diffusion of O2 & CO2 between alveoli & the blood crucial point

distributor

consumer
Sherwood L, The Respiratory System, 2004

Respiration - 1

The respiratory system only partially participate in external respiration

External respiration
The entire sequence of events involved in the exchange of O2 & CO2 between the atmosphere (external environment) and the alveoli of the lungs

Internal respiration
Intracellular metabolic processes carried out within the mitochondria which use O2 & produce CO2 during the derivation of energy from nutrient molecules

Respiration- 2
ENVIRONMENT

CRUCIAL POINT!

External respiration cardio-vascular system

blood
organ tissue cell mitochondria

respiratory system
respiratory center neuromuscular system

Internal respiration

CRUCIAL POINT!

2000 Lippincott Williams & Wilkins

Fudamentals of Nursing 4th Edition

External respiration - 1
respiratory system

ventilation

Diffusion of O2 & CO2 between alveoli & the blood crucial point

cardiovascular system

perfusion
Sherwood L, The Respiratory System, 2004

External respiration - 2
ventilation

A VOLUME of air FLOW in and out the respiratory tract

L/mnt

Diffusion of O2 & CO2 between alveoli & the blood crucial point

perfusion

A VOLUME of blood FLOW through alveolar capillary

L/mnt

External respiration - 3
ventilation V to take place, gas exchange (diffusion) from air to blood in alveolar capillary bed need an optimal ratio between VENTILATION & PERFUSION

V/Q = 4/5
perfusion

External respiration - 4
V/Q = 4/5 V/Q match optimal diffusion

Clinically DYSPNEA V/Q 4/5

V/Q mismatch not optimal diffusion

Dyspnea
The sensation of abnormal or uncomfortable breathing in the context of what is normal for a person according to his/her level of fitness and exertional threshold for breathless
Am Fam Phys, Evaluation of Dyspnea, 1998

unusual

awareness of breathing the need to breath more whenever the respiratory mechanism can not with ease functionate the body need disproportion : demand supply

Dyspnea mechanism
the mechanisms responsible for dyspnea are still unclear generated centrally or peripherally afferent activation: from many sites

pulmonary stretch receptors rib joint respiratory muscles, including diaphragm others: visceral, neural, emotion

no specific receptor

Dyspnea receptors
respiratory receptors related to cough center dyspnea receptor

chemoreceptor: hypercapnia, hypoxia mechanoreceptors : upper airways, lung receptors (pulmonary stretch receptor, irritant receptor, C fibers chest wall receptors

Dyspnea classification -1

according to severity

normal activity -- patient can not walk without dyspnea

rest vs exercise onset & progressivity

acute, sub acute, chronic cardiac, pulmonary, mix cardio-pulmonary, non cardio-pulmonary

according to etiology

Dyspnea classification -2
Acute VS Chronic (sudden onset) (long standing)

acute: often resolves with treatment of the underlying condition chronic: usually result in progressive dysfunction, severe disability, and eventual death

Dyspnea approach - 1
V/Q = 4/5 from this crucial point we can make a practical approach to almost all kind of DYSPNEA

CRUCIAL POINT!

Clinically DYSPNEA
V/Q 4/5

V/Q mismatch not optimal diffusion

Dyspnea approach - 2

the result of V/Q mismatch

organ system involved in respiration especially respiratory system try to overcome the mismatch, by increase the ventilation

2 components of ventilation: flow & volume FLOW disturbances: dyspnea with expiratory effort VOLUME disturbances: dyspnea with inspiratory effort

Dyspnea approach -3
pathophysiology, anatomic, disorders
EXTRA thorax
INTRA thorax INTRA thorax FLOW disorders

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway Lung parenchyma disorders Extra-pulmonary disorders Lung compliance disorders Respiratory center disorders

VOLUME disorders

EXTRA thorax

Extra-thorax FLOW disorders

cranio-facial malformation

Obstruction of proximal / larger airways

rhinitis with nasal obstruction, nasal polyp OSAS (obstructive sleep apnea syndrome) tonsil-adenoid hypertrophy laringo-tracheo-malacia larynx papilloma diphtheria croup, epiglottitis thymus hypertrophy

clinical: inspiratory stridor

Intra-thorax FLOW disorders

Obstruction of distal / smaller airways

asthma
bronchiolitis

vascular ring
solid foreign body aspiration lymph node enlargement pressure

clinical: expiratory effort

Intra-thorax VOLUME disorders

Lung Parenchyma Disorder pneumonia (infection, aspiration) atelectasis pulmonary edema near drowning sepsis

clinical: inspiratory effort

Extra-thorax VOLUME disorders

Respiratory center disorders anemia
metabolic acidosis CNS infections: meningitis, encephalitis encephalopathy (typhoid, DHF, metabolic) psychologic (anxiety, usually adolescent) poisoning: salycylate, alcohol trauma capitis CNS disease sequelae

clinical: deep rapid breathing