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Diagnostic Approach of Dyspnea in Children

Nastiti Kaswandani

Dyspnea approach
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 approach
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 the lecture focus on acute dyspnea

Chest and Respiratory System

Dyspnea classification
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

Dyspnea classification
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


rhinitis with nasal obstruction, nasal polyp cranio-facial malformation OSAS tonsil-adenoid hypertrophy laringo-tracheo-malacia larynx papilloma diphtheria croup, epiglottitis thymus hypertrophy

Obstruction of proximal / larger airways

clinical: inspiratory stridor

age : infant below five

Thymus hyperplasia

Vascular Rings
Secondary Tracheomalacia (Extrinsic) Compression disorder Collection of congenital vascular anomalies that encircle and compress the esophagus and trachea

Diagnostics seen on MRI and echocardiograph

Dyspnea classification
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

Intra-thorax FLOW disorders


Obstruction of distal / smaller airways

asthma
bronchiolitis

vascular ring
solid foreign body aspiration lymph node enlargement pressure clinical: expiratory effort

age: infants, below five age bronchiolitis

Bronchiolitis

Dyspnea classification
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

Intra-thorax VOLUME disorders


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

clinical: inspiratory effort

Dyspnea classification
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

Intra-thorax VOLUME disorders


Extra-pulmonary disorders pneumothorax, pneumomediastinum cardiomegaly, heart failure (perfusion) pleural effusion (incl empyema, hematothorax) hernia diaphragmatica diaphragmatica eventration intra-thorax mass (non pulmonary) chest trauma (rib fracture, lung contusion) thorax deformity (pectus excavatum, scoliosis)

klinis : inspiratory effort

Dyspnea classification
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 VOLUME disorders


Lung compliance disorders neuromuscular disorders (CP, GBS, MG) gastritis, peptic ulcer extreme obesity peritonitis, appendicitis, acute abdomen aerophagia, meteorismus ascites hepato-splenomegali abdominal solid tumor

clinical: inspiratory constraint

Dyspnea classification
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 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

Clinical approach
symptomatology pathophysiology
pathology treatment

dyspnea evaluation
etiology treatment ~ etiology

Dyspnea

clinical approach - 1

first step : ANAMNESIS identity: age, sex, etc dyspnea:


acute, chronic, recurrent degree of dyspnea how long has been dyspneic timing of dyspnea: at rest, at activity, day or night triggers, factors make worse / better response to therapy

underlying cardiopulmonary / neuromuscular disease associated symptoms: chest pain, cough, wheezing other signs & symptoms

80% of cases can be diagnosed

Dyspnea

clinical approach - 2

next step : PHYSICAL EXAMINATION sternal, intercostal, subcostal, epigastrium), chest indrawing (retraksi arkus kosta) expiratory : prolonged expirium, wheezing, abdominal muscle contraction respiratory examination: respiratory rate; stridor, symmetry of breath sound & on percussion; rales; sign of heart failure other holistic examination

inspiratory : nasal flaring, retraction (supra

Dyspnea

clinical approach - 3

further step : SUPPORTING EXAMINATION

Routine blood examination Pulse oximetry Imaging diagnostic: CXR, ultrasound, Blood gas analysis Pulmonary function test Electrocardiography, echocardiography Rhinoscopy, laryngoscopy, bronchoscopy

Dyspnea

clinical approach - 4

last step : TREATMENT based on etiology first aid: give O2, before we can identify the etiology; since most cases need it other cases, does not need O2 (see next)

Dyspnea classification
maybe oxygen is not needed
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

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