Problem Based Learning

Modul

Dyspnea
A5

Scenario
1 year and 1 month old a boy, came to
hospital with dyspnea since 3 days ago,
before he came to hospital. The others are
productive cough and fever. He was born
with weight 3 kgs, spontaneous birth, and
sufficient month. There is no dyspnea
history.

Key words
Boy, 1 year and 1 month old
Dyspnea since 3 days
Productive cough
fever
No dyspnea history
Weight 3 kgs
Spontaneous birth
sufficient month

The Questions
1. How the patomechanism of the symptomps?
2. What conditions can occure dyspnea?
3. What is the correlation beetwen dyspnea,
procductive cough, and fever?
4. Why the dyspnea can occurred suddenly
without the history?
5. Is there any the dyspnea can occurred
suddenly without the history?
6. What is the differential diagnose(aetiolgy,
clinical sign, clinical examination, treatment,
complication, prevention)

the patomechanism

Mucous production, mucosal oedema,

bronchoconstriction

Reduced airway
diameter (airway
obstruction)

Dyspnea
dyspne
a

limited air flow

into lungs

Respiratory
muscle fatigue

Reduced
ventilation

respiratory work
against limited
airway

PO2 &
blood

PCo2 in

Stimulation of respiratory
center

Productive cough
Inflammation of the airway
Excessive mucous production, ephithelial damage
Afferent (vagus nerve)
Medullar cough center
Efferent (glossopharyngeal)
Stimulation of laryngeal, intercostalis muscle, diaphragm

Cont..
Deep inspiration and closure of glottis
Contraction of abdominal muscle
Phuses diafragm
Increased intrhathoracic pressure
Glottis open suddenly
Expulsion of mucous and other desquamated cell
PRODUCTIVE COUGH

fever
bacteria invation pyrogen induction release citokin

release PG E-2 stimulate hipotalamus anterior

stimulate termoregulator centre Prod. heat

fever

Some conditions can occure

dyspnea
1. Psychis factor
2. Increase respiratory working factor
- increasi ventilation
- physical changing
3. Abnormality respiratory muscle
- muscle disease
- decrease of muscle mechanism
function

the dyspnea can occurred suddenly

without the history
Because the causal factor or the agents can
enter the body defences when the weak
immunologies condition and there is no
dyspnea history

the dyspnea can occurred suddenly

without the history
Some of disease like ARDN, in the
premmature birth the development of the
lungs have not perfect (the lungs function
can not work perfectly).

the differential diagnose

Bronchiolitis
Bronchopneumonia

ACUTE
BRONCHIOLITI
S

DEFENITION
Obstructive disease result to
the acute inflammation to the
small respiratory path
(bronchiolus), occurred to the
children from 2 years old with
proud incident around 6
months.

ETIOLOGY
Respiratory syncytial virus (RSV) at
50-80% cases
Parainfluenza
Mikoplasma
Adenovirus
Most rarely bacterium primary
infection
(virus is infected through saliva
fragment).

RISK FACTOR THE

HAPPENING OF
BRONCHIOLITIS

Age les than 6 months

Have never got ASI
Premature
Breathing in cigarette smoke

PATOGENESIS
Invention virus bronchiolus obstruction
(mucus accumulation, debris and edema)
respiration air stream resistance
which is inversely proportional it is
good for at inspiration phase and
expiration there are valve mechanism
(the snaring of air generating chest
overinflation) transfer of annoyed air
ventilation decrease and hipocsemia
improvement of the breath frequency
as compensation in the situation very
heavy earn happened hyperkapny
total obstruction and absorbent of the
air atelectasis

Bronchus swelling

In bronchiolitis,
obstruction of
airway cause
bronchioli wall
are swelling

CLINIC SYMPTOMS

Cough head cold

Subfebris
Dispneu
Jumpy
Anorexia
Vomiting
Tachycardi
Tachypnoe
Sianosis around the mouth and nose
Muscle retraction

INVESTIGATION
A.

INSPECTION OF FISIS
- Percussion hipersonor, deaf for hear
(-)
- Auscultation B.P (Bronchial)
B.T (Ronki,Wheezing,
Crepitating)

Cont..
B. INSPECTION OF SUPPORTER
- Chest photo of AP and lateral
- CGA (Chest Gas Analysis)
- Inspection detect quickly RSV
antigen which do
not earn to be done by beside

PERFORMANCE
Giving of the oxygen 1-2 liters/minutes.
IVFD :
- neonatus (dekstrose 10% : NaCl 0,9%= 4 :
1,+KCl
1-2mEq/kgBB/day)
- baby less than 1 month (dekstrose 10% :
NaCl
0,9 %= 3 :1,+KCl 10mEq/500 ml dilution )
Dilution amount according to body weight,
increase
of temperature, and hydration status.
Correct trouble of the electrolyte and alkali

Antibiotic in fact do not be needed,

but because difficult to differentiate
whit pneumonia of intertisialis,
antibiotic remain to be given.
Steroid
Initial 0.5 mg/kg dexamentasons,
0.5mg/kg/BB/days is continuited and
is divide 3-4 doses.
Inhalation whit the normal copy an
agonic beta to improve of the
mucosilier transport.

COMPLICATION
Secondary infection
pneumotorax
Pneumomediastinum
Cor pulmonale

PROGNOSIS
Including self limiting
disease 14 days
Child can usually overcome of
attack
after 48 to 72 hours.
At premature baby very
heavy.
Mortality less than 1%

PREVENTION
Dont bring of old age baby less than
3 months to common place, especially if
many children.
Patient of breath channel infection have
to clean hand or use masker it nearby
baby.

Bronchopneumonia

Defenition
Bronchopneumonia

refers to a type of
pneumonia that is localized, often to the
bronchioles and surrounding alveoli

Etiology
Variety of aspirated organisms.
Organism dependent on whether community
acquired in previously healthy patient (more
likely Streptococcus) or
Community acquired in patient with depressed
pulmonary defenses such as a patient with
chronic bronchitis (more likely Klebsiella or
Pseudomonas spps) or
Hospital acquired

Pathogenesis

Aspiration of organisms results in

inflammation and necrosis of underlying
parenchyma
Tends to scar if alveolar septae are
destroyed,

Bronchopneumonia

Lobar Pneumonia

Location

1. often bilateral
2. basal (i.e. lower lobes)

large area, even whole lobe

involvement

Route of infection

spreads from bronchioles to nearby alveoli

both alveoli and bronchioles

Spread of infection

consolidation is patchy

Whole lobe becomes

consolidated

Susceptible group

infants, elderly

Adults especially alcoholics and

vagrants.

Causing Organism

Dependent on circumstances predisposing

to infection(i.e. nosocomial or community
acquired

Often caused by Pneumococcus

or Klebsiella.

Recovery

If treated, recovery usually involves focal

organisation of lung by fibrosis.

If treated promptly, many

recover with lungs returning to
normal structure and
functioning by resolution. In
other cases the exudate in
alveoli is organised, leading to
lung scarring and permanent
lung dysfunction.

Notes

Patients who are immobile develop retention

of secretions; thus, most commonly involves
the lower lobes

Patient are severely ill and

usually associated bacteriemia.

Epidemiology
Common in hospitalized patients and
contributes to the cause of death in
moribund patients
Most common community acquired
pneumonia as well

General Gross Description

Patchy distribution particularly around
small airways
Nodular, elevated, firm, airless regions
Range from red to gray depending on
age of the lesion
Can become confluent to mimic lobar
pneumonia

Bronchopneumonia
Click on Image to Enlarge it

Bronchopneumonia
The photo is of a slice of
pulmonary parenchyma.
The lung is congested.
A barely visible nodularity
which is easier palpated
indicates bronchopneumonia.
Arrows point to examples of
nodules. (Description
By:Melinda Sanders, M.D. )
(Image Contrib. by: Saint
Francis Hospital )

General Microscopic Description

Bronchocentric lesions
Neutrophils fill airway and surrounding
alveoli
Parenchymal destruction depends on
organism
Uninvolved parenchyma may contain
acellular pink edema

Clinical Correlation
Clinical course dependent on underlying
disease processes
Patients present with fever, cough and
purulent sputum

Caption:
Chest radiographs of
patients with (A)
parainfluenza virus type 3
bronchopneumonia and (B)
pneumonia

examination
Physical
Inpiration: local injury, retraction, respiratory
frecuency > 50x/min.
Palpation : Percusion : sonor
Auscultation : crackles

treatment
A.B. polifragmasi : streptomicin, ampic +
chloramphenicol
< 2 monts = ampicilin + gentamicyn
Sonde
2. Intake guarantee -----infus
3. O2
4. Sedative ( if nervous(worried) , seizure)
5. Asidosis----- natrium bicarbonate
6. kortikosteroid
1.

complication
Sepsis--- oma, sinusitis, meningitis
Empiema torachis
Lung abces
Brhonciectasis
Cor pulmonale