Diagnostic Approach of Dyspnea in

Children

Nastiti Kaswandani

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

Dyspnea approach

Chest and Respiratory System

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic, disorders

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic, disorders

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

• clinical: inspiratory stridor• age : infant – below five

Extra-thorax FLOW disorders Obstruction of proximal / larger airways

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

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic, disorders

asthma bronchiolitis vascular ring solid foreign body aspiration lymph node enlargement pressure

• clinical: expiratory effort• age: infants, below five age – bronchiolitis

Intra-thorax FLOW disorders Obstruction of distal / smaller airways

Bronchiolitis

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic disorders

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

clinical: inspiratory effort

Intra-thorax VOLUME disorders

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic 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

Intra-thorax VOLUME disorders Extra-pulmonary disorders

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic, 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

Extra-thorax VOLUME disorders Lung compliance disorders

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification pathophysiology, anatomic 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

Extra-thorax VOLUME disorders Respiratory center disorders

Clinical approach

symptomatology

pathophysiology

pathology

treatment

dyspnea

evaluation

etiology

treatment ~ etiology

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 - 1

next step : PHYSICAL EXAMINATION inspiratory : nasal flaring, retraction

(supra 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

Dyspnea clinical approach - 2

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 - 3

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 clinical approach - 4

Obstruction of proximal / larger airway

Obstruction of distal / smaller airway

Respiratory center disorders

Extra-pulmonary disorders

Lung compliance disorders

Lung parenchyma disorders

FLOW disorders

VOLUME disorders

EXTRA thorax

INTRA thorax

EXTRA thorax

INTRA thorax

Dyspnea classification maybe oxygen is not needed

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