Escolar Documentos
Profissional Documentos
Cultura Documentos
, SpPD
Tempat/Tanggal Lahir : Bandung, 24 November 1977
Email : hendarsyahsuryadinata@gmail.com
Pekerjaan : Departemen Ilmu Penyakit Dalam Divisi
Respirologi dan Respirasi Kritis
Jabatan : Staff Departemen Ilmu Penyakit
Dalam RSHS Bandung
Management of Dyspnea
Hendarsyah Suryadinata
Orthopnea
Recumbent-induced SOB
ABC’s
Mental status
Presence of cyanosis
Dyspnea
Initial Interventions
IV assess
Cardiac monitor
What Are the Indications for Airway
Management?
80% 75%
70%
60%
50%
40%
30%
20% 10% 15%
10%
0%
Respiratory Cardiac Other
Dyspnea
Pneumonia
Pulmonary embolism
Pneumothorax
Dyspnea
CHF
Dysrhythmias
Metabolic acidemias
Severe Anemia
Pregnancy
Hyperventilation Syndrome
Pulmonary Diseases & Disorders
Mental status
Altered MS - Hypoxemia/Hypercapnia
Dyspnea
Physical Examination
Pulmonary
Signs of severe
Use of accessory muscles respiratory
distress
Intercostal retractions
Abdominal-thoracic discoordination
Presence of stridor
Cardiac
Check neck for presence of JVD
Dyspnea
Inspection
Use of accessory muscles
Splinting
Intercostal retractions
Percussion
Hyper-resonance vs. dullness
Unilateral vs. bilateral
Dyspnea
Auscultation
Abnormal S2 splitting
Present of S3 and/or S4
Rubs
Murmurs
What does
clubbing suggest?
Chronic Hypoxemia
Pneumonia
Viral
Bacterial
Fungi
Protozoa (pneumocystis)
Aspiration
Management of Pneumonia
Lethargy, confusion,
suprasternal retractions
RESPIRATORY FAILURE
Asthma : Signs and Symptoms
WHY?
Asthma : Signs and Symptoms
IMPENDING
RESPIRATORY
FAILURE
Asthma : Signs and Symptoms
RESPIRATORY
FAILURE
Asthma : Management
Airway
Breathing
Sitting position or position of comfort
Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs
Encourage coughing
Consider intubation, assisted ventilation
Impending respiratory failure
Avoid if at all possible
Asthma : Management
Circulation
IV TKO
Assess for dehydration
Titrate fluid administration to severity of dehydration
Trial bolus of 250 cc
Monitor ECG, Pulse Oximetry
Obtain medication history
Consider
Overdose
Dysrhythmias
Asthma : Management
Rarely used
Questionable efficacy, Potential Complications
Magnesium Sulfate (IV)
Methylxanthines
Aminophylline (IV)
COPD : Management
Causes of Decompensation
Respiratory infection (increased mucus
production)
Chest trauma (pain discourages coughing or deep
breathing)
Sedation (depression of respirations and
coughing)
Spontaneous Pneumothorax
Dehydration (causes mucus to dry out)
COPD: Management
Ventilation
Avoid intubation unless absolutely necessary
Near respiratory failure
Exhaustion
Circulation
IV TKO
Titrate fluid to degree of dehydration
250 cc trial bolus
Excessive fluid may precipitate CHF
Monitor ECG
COPD : Management
Drug Therapy
Obtain thorough medication history
Nebulized Beta 2 agonists
Albuterol
Terbutaline
Metaproterenol
Isoetharine
COPD : Management
Drug Therapy
Ipratropium (anticholinergic) by SVN
(Beta-2 agonist) by MDI, SQ or IV
Corticosteroids (Anti-inflammatory agent) by IV
Pneumothorax
Toxic Inhalation
Near Drowning
Liver Disease
Nutritional Deficiencies
Lymphomas
High Altitude Pulmonary Edema
Acute Respiratory Distress Syndrome
Dyspnea on Exertion
Paroxysmal Nocturnal Dyspnea
Orthopnea
Noisy, Labored Breathing
Restlessness, Anxiety
Productive Cough (Frothy Sputum)
Rales, Wheezing
Tachypnea
Tachycardia
Management of Non-Cardiogenic Pulmonary Edema
Position
Oxygen
PPV / Intubation
CPAP
PEEP
IV Access; Minimal fluid administration
Treat the underlying cause
Diuretics usually not helpful; May be harmful
Transport
Acute Respiratory Distress Syndrome
A disorder of perfusion
Combination of factors increase probability of
occurrence
Hypercoagulability
Platelet aggregation
Deep vein stasis
Embolus usually originates in lower
extremities or pelvis
Pulmonary Embolism
Risk factors
Venostasis or DVT
Recent surgery or trauma
Long bone fractures (lower)
Oral contraceptives
Pregnancy
Smoking
Cancer
Pulmonary Embolism: Management
Thrombolytics
Aspirin & Heparin
Rapid transport to appropriate facility
Embolectomy or thrombolytics at hospital (rarely
effective in severe cases due to time delay)
Poor prognosis when cardiac arrest follows
Pulmonary Embolism: Management
Management
Based upon severity of presentation
Mostly supportive
Laryngotracheobronchitis (Croup)
Common syndrome of
infectious upper airway
obstruction
Viral Infection
Parainfluenza Virus
Subglottic Edema
Larynx, Trachea,
mainstem bronchi
Usually 3 months to 4
years of age
Croup: Management
Bacterial infection
(Hemophilus
influenza )
Edema of epiglottis
(supraglottic)
partial upper
airway obstruction
Typically affects 3-7
year olds
Epiglottitis: Management
Common illness
Rarely life-threatening
Often exacerbates underlying pulmonary
conditions
May become more significant in some
patients
Immunosuppressed
Elderly
Chronic pulmonary disease
Management of URI
Hyperventilation Syndrome
Hyperventilation Syndrome
A diagnosis of EXCLUSION!!!
An increased ventilatory rate that
DOES NOT have a pathologic origin
Results from anxiety
Remains a real problem for the patient
Hyperventilation Syndrome: Pathophysiology
Tachypnea or Hyperpnea
secondary to anxiety
Decreased PaCO2
Respiratory alkalosis
Symptoms
Light-headedness, giddiness, anxiety
Numbness, paresthesias of:
Hands
Feet
Circumoral area
Cold hands, feet
Carpopedal spasms
Dyspnea
Chest pain
Hyperventilation Syndrome : Signs & Symptoms
Signs
Rapid breathing
Cool & possibly pale skin
Carpopedal spasm
Dysrhythmias
Sinus Tachycardia
SVT
Sinus arrhythmia
Loss of consciousness and seizures (late &
rare)
Hyperventilation Syndrome : Management
Central Respiratory
Depression
Respiratory Depression : Causes
Head trauma
CVA
Depressant drug toxicity
Narcotics
Barbiturates
Benzodiazepines
ETOH
Respiratory Depression : Recognition
Use Your
Stethoscope
Look, Listen, Feel
Airway
Open, clear, maintain
Consider endotracheal intubation
Breathing
Oxygenate, ventilate
Restore normal rate, tidal volume
Circulation
Obtain vascular access
Monitor EKG (Silent MI may present as CVA)
Manage Cause
Check Blood Sugar
Consider Narcan 2mg IV push if S/S suggest
narcotic overdose
Intubate if can not find or treat cause
Guillian-Barre´ Syndrome
Autoimmune disease
Leads to inflammation and degeneration of
sensory and motor nerve roots (de-
myelination)
Progressive ascending paralysis
Progressive tingling and weakness
Moves from extremities then proximally
May lead to respiratory paralysis (25%)
Guillian-Barre´ Syndrome Management
Autoimmune disease
Causes loss of ACh receptors at
neuromuscular junction
Attacks the ACh transport mechanism at the
NMJ
Episodes of extreme skeletal muscle
weakness
Can cause loss of control of airway,
respiratory paralysis
Myasthenia Gravis Presentation
Treat symptomatically
Watch for aspiration
May require assisted ventilations
Assess for Pulmonary infection
Transport based upon severity of
presentation
Plasmapharesis
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