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Facing Forward: Science and Arts in

Respiratory Medicine
FABRIKAM RESIDENCES

Early Assessment of Respiratory Distress

Menaldi Rasmin
ARDS : Acute Respiratory Distress Syndrome

Is a life-threatening form respiratory failure, characterized by acute, diffuse, inflammatory lung injury that results in
increased alveolar capillary permeability and the development of nonhydrostatic pulmonary edema

Fernando SM, Ferreyro BL, Urner M, Munshi L, Fan E. Diagnosis and management of acute respiratory distress syndrome. CMAJ 2021; 193(21): E761-E768
Normal breathing

Dyspnea

Hypoxemia

Respiratory Distress

Respiratory Failure

Respiratory Arrest
Respiratory Disturbance
KENDALA NAPAS
( RESPIRATORY IMPAIRMENT )
INSUFISIENSI NAPAS
( RESPIRATORY INSUFFICIENCY )
GAWAT NAPAS
( RESPIRATORY DISTRESS )
GAGAL NAPAS
( RESPIRATORY FAILURE )
Disfungsi napas yang bermakna secara klinis untuk menyebabkan ketidaknyamanan
(Respiratory disfunction clinically significant to produce
discomfertness)
Gangguan napas hebat, mengganggu kegiatan harian, dapat diukur dari mekanik
pernapasan dan atau pertukaran gas
(Respiratory disturbance, strong enough to hamper daily
certain activities, that can be measured from the mechanic
of breathing and or from gas exchange)
Peningkatan & perburukan usaha napas yang terlihat dari penampakan klinis
(Increase & worsening respiratory effort that can be seen
from clinical appearance)
Gangguan satu atau lebih fungsi pernapasan & mengancam kehidupan
(Disturbance of 1 (one) aspect or more respiratory function
& life threatening)
Menaldi Rasmin, 2015
Normal Breathing

Dyspnea : healthy people , Respiratory Rate 12 - 20/minute

health problem , Respiratory Rate >15/minute

Normal breathing àDyspnea

1. Neural sensory stimulation (i.g: pneumothorax, interstitial inflammation, Pulmonary emboly)
2. Increase mechanic weight on respiratory muscles (i.g: airflow obstruction, lung fibrosis)
3. Pulmonary diseases/disorders causing hypoxemia, hypercapnia or acidemia that stimulate
chemoreceptor

1. Pulmonary congestion that lowers lung compliance causing small airways obstruction
2. Decreased cardiac output limiting oxygen supply to skeletal muscles

1. Central – neural (i.g: ibrain stem trauma/infarction

2. Periphery – neuromuscular (i.g: myasthenia gravis, dipraghm muscle paresis etc)
 Dyspnea

“ a subjective experience of breathing discomfort

that consists of qualitatively distinct sensations that vary in intensity”
[ATS Concensus Statement, 1999]

• Daily problem : in nearly 50% EU patient of Tertiary Hospital and, in 25% outpatient clinic

9-13% : mild to moderate dyspnea

• Prevalence : 15-18% : in adult age > 40 y.o
25-37% : in adult age > 70 y.o

Parshall MB, Schwartzstein RM, Adam L, Banzett RB et al. An Official American Thoracic Society Statement: Update on Mechanism, Assessment, and Management of Dyspnea. Am J Respir Crit Care Med 2012;185:435-452
Terminal Dyspnea
• Claessens & coinvestigators :
Severe dyspnea found in 32% lung cancer patient (N:939) and 56% in COPD patients (N:1008)

• Fainsinger et al :
a study of 100 patients in the last 7 of their life, in a hospital palliative unit care, 46% suffering dyspnea

• Reuben and Mor :

dyspnea found in 70% terminal cancer patients in the last 6 weeks of their life

• Dyspnea in CHF :
61% patient in the last year and 51% at the last week of their life

Dyspnea àHypoxemia ….???

Campbell LC. Terminal dyspnea and respiratory distress. Crit Care Clin 2004;20:403-417
Hypoxemia
Decrease PaO2
• In adults, adolescent and baby (<28 hari) :
PaO2 < 69 mmHg or SaO2 < 90%

• In neonates : PaO2 < 50 mmHg or SaO2 < 88%

Etiology Condition
a. O2 input High altitude
b. V/Q mismatch Obstructive Lung Diseases, Pulmonary edema
c. Alveolar hypoventilation COPD
d. Right to Left shunt ARDS, Pneumonia, Pulmonary emboly, ASD
e. Diffusion problems Pulmonary fibrosis

Hypoxemia Mild : PaO2 80-60 mmHg

Moderate : PaO2 60-40 mmHg Hypoxemia à Respiratory Distress
Severe : PaO2 <40 mmHg
 Respiratory distress (severe dyspnea)

• Appearance : anxiety, restlessness, agitation, diaphoresis

• Work of Breathing : still able to communicate, active movement of chest wall,
tachypnoea, work of accessory respiratory muscles,
sternal & supraclavicular retraction

• Auscultation : stridor, tracheal deviation

• Respiratory Rate : 25-29 NPM à Mortality 21%
> 27 NPM à strong predictor of cardiac arrest

1.Johannigman JA. Prehospitas Respiratory Care. In: Danztker,MacIntyre,Bakow.Eds.Comprehensive

Respiratory Care. W.B.SAUNDERS COMPANY 1995:1090-1114
2.American Thoracic Society Documents 2013
3.Campbell ML. Terminal Dyspnea and Respiratory Distress. Crit Care Clin 2004;20:403-417
Hypoxemia à Respiratory Distress
4.Smith I, MacKay J, Fahrid N. Respiratory Rate Measurement: a Comparison of Methodes. British Journal of Healthcare Assistants 2011;05(01):18-23
Clinical Classification of Respiratory Distress

Mild
• Level of consciousness : CM, adequate contact
• Breathing: 15-20/m, Accessory Respiratory Muscles (-), SpO2 >95%
• Hemodynamic : stable

Moderate
• Level of consciousness : CM, adequate contact
• Breathing: 20-25/m, Accessory Respiratory Muscle (+/-), SpO2 95%-93%
• Hemodynamic stable with/without supporting drugs

Severe
• Level of consciousness: ApathyàSomnolent, Contact (+/-)
• Breathing: 25-30/m, Accessory Respiratory Muscles (+), SpO2 93%-88%
• Hemodynamic unstable

[Menaldi Rasmin,2018]
 Breath per Clinical Apperance Clinical Classification of Physiological
Minute Respiratory Distress Disturbances
HEALTHY 12-20 Normal Breathing

NOT HEALTHY 15-20 Mild Dyspnea Mild Respiratory Distress Ventilation disturbance
20-25 Moderate Dyspnea Moderate Respiratory Distress Ventilation disturbance
and/or V/Q mismatch
25-30 Severe Dyspnea Severe Respiratory Distress V/Q mismatch
>30 Crisis Dyspnea Respiratory Failure Shunt
Oxygen Therapy

• SUPLEMENTAL OXYGEN THERAPY : à 30 days

• SHORT TERM OXYGEN THERAPY (STOT). : 30 – 90 days
• LONG TERM OXYGEN THERAPY (LTOT). : > 90 days
Flow
DAVID PEARSON, 1989 :
• Low Flow : 1-15 LPM
• Medium Flow : 15-60 LPM
• High Flow : > 60 LPM

Low Flow : Nasal Cannula (1-8 LPM) , Mask (8-15 LPM)

Moderate Flow : Mask (simple, special : Nonrebreathing, Rebreathing à Noninvasive ventilation (NIV)
High Flow : noninvasive (HFNC : High Flow Nasal Cannula) à invasive (ventilator)
 Nasal Cannule

Respiratory Distress à Respiratory Failure

All types of Masks

Prone position with High Flow Nasal Cannule

High Flow Nasal Cannule (HFNC)

NonInvasive Ventilation (NIV) Mechanical ventilator

 Conclusion

Early assessment of Respiratory distress:

• Begin with assessment of health condition of the person
• Respiratory disturbance consists of: Respiratory: Impairment, Insufficen, Distress & Failure
Dyspnea àHypoxemia à Respiratory Distress à Respiratory Failure à Respiratory Arrest
• Hypoxemia is a sign of the possibility of fail into Respiratory Distress
• Respiratory Rate with SpO2 will help to decide the Clinical Classification of Respiratory Distress
 Thank You.
FR
FABRIKAM RESIDENCES