Dyspnea

Shortness of breath or breathlessness

Sensation of uncomfortable breathing

 – A 67-year-old man comes to your clinic for his annual
appointment concerned about increasing shortness of breath.

One year ago he was able to walk up the stairs to his apartment
without difficulty, but now he has difficulty walking one block.

He has a 70 pack-year smoking history, and several previous

attempts to stop smoking have been unsuccessful.

• Does the patient require urgent intervention?

• What additional questions would you ask to learn more about his
shortness of breath?
• Do you need any diagnostic tests for this case?
• Differential diagnosis?
 Causes of dyspnea
• Cardiac
• Respiratory
• Hematological
• Abdominal
• Metabolic
• Psychogenic
• Neurological
• Physiological
• Toxic ingestions
• Uncommon causes
Berliner D et al. Dtsch Arztebl Int 2016; 113: 834–45
 first classify the duration of dyspnea as acute or chronic

Open ended questions Tips for effective Intervieving

Tell me about your problem with Allow the patient to tell the story in
breathing his/her own words.
Ask focused questions later
How long this shortness of breath been The differential diagnosis varies depend in
going on? on the time course
• First, classify the duration of dyspnea as acute
or chronic.

– Acute: hours to days due to immune problems ya da astma COPD, kalp yetmezliği
– Chronic dyspnea: at least 4 weeks
 Acute dyspnea
life-threatening!!
• Pulmonary embolism
• Pump failure
– myocardial infarction
– acute heart valve insufficiency
– cardiac tamponade
• Pneumothorax
• Pulmonary broncial constriction
– anaphylaxis
• Possible foreign body aspiration
• Pneumonia
 COVID-19
• Patients with (COVID-19) often
have clinical characteristics, such
as chest tightness and dyspnea.
• The primary target organ of SARS-
CoV-2 in the human body is the
lung.
• Sudden or exacerbated dyspnea in
the clinic often indicates an
increase in lung lesions and Ground-glass opacity
Buzlu cam opaklığı
further aggravation of the disease.
 History Taking
occurs ar rest or with exertion
ortopnea
• Listen to the patient’s PND

description of dyspnea
timing, setting, exacerbating and alleviating
factors
associated signs and symptoms.
the effect of dyspnea on activities of daily living
• Ask about risk factors for conditions causing
dyspnea from the past medical, social, and
family histories.
 History
• A thorough social history should include home and
occupational environments.
• Personal tobacco use, exposure to tobacco smoke, and
other irritant substances–both at home and at work–
should be questioned.
• Irritants include chemical fumes, molds, allergens, and
other substances that may cause or aggravate the
patient’s dyspnea.
• A full review of the patient’s current medications,
including supplements and herbal preparations, should
be conducted.
 Physical exam
• A comprehensive physical exam should be performed
• Vital signs with height, weight and pulse oximetry at rest
should be measured.
Normal pulse oximetry will not rule out a pulmonary
cause
• The general appearance of the patient and any presence
of distress should be noted.
• Evaluate mental status
• Skin color should be evaluated for pallor or cyanosis, and
nails should be assessed for clubbing
• Skin should also be assessed for eczema
 Physical exam
• A through exam of the eyes, ears, nose, throat, and
sinuses to evaluate for allergies, postnasal drip, and
chronic sinusitis should be performed
• The neck should be evaluated for the presence of
thyromegaly, and jugular vein distension should be
estimated
• The thorax should be evaluated for the presence of
spinal, rib cage, or sternal deformities that could cause
restriction of the chest cavity, and therefore, chronic
shortness of breath.
 Physical exam
• The ease of respirations, use of accessory muscles,
symmetry of chest excursion
• The respiratory rate and depth
should be noted while at rest
• The lungs should be percussed for areas of dullness
(consolidation or atelectasis) or diffuse hyperresonance
(air-trapping).
• Diminished breath sounds or the presence of crackles or
wheezes should be noted.
 Physical exam
• Cardiac rate, rhythm, location of the point of maximal
impulse (apical impulse), and presence of extra heart
sounds and murmurs should be documented.

• The abdomen should be examined for hepatomegaly,

hepatojugular reflex, and presence of ascites.

• Peripheral extremities should be evaluated for presence of

edema and for coolness.
 very impo

The history and physical examination identify the

etiology of dyspnea in nearly 70% of cases.

The remainder will require more specific testing, such as chest

radiographs or pulmonary function tests
 Red flags
for serious forms of dyspnea
• Hypotension
• Respiratory rate >40 breaths/minute
• Altered mental status (confusion)
• Hypoxia (<95% SpO2)
• Cyanosis (new onset)
• Stridor
• Breathing effort without air movement
• Tracheal deviation with unilateral breath sounds
• Unstable arrhythmia
Modified Medical Research Council (MMRC)
Dyspnea Scale

normalden anormale
Berliner et al. Dtsch Arztebl Int 2016; 113: 834–45
• Patients who complain of air hunger may have heart failure
(HF)

• Chest tightness is highly suggestive of bronchoconstriction

• Complaint of having a “hard time” breathing may be

related to
– chronic obstructive pulmonary disease (COPD)
– interstitial lung disease (ILD)
– physical deconditioning
 Chronic exertional dyspnea and PND!

• Chronic exertional dyspnea and paroxysmal nocturnal

dyspnea (PND) are both associated with heart failure

• Asthma is also associated with exertional and nocturnal

dyspnea, but unlike PND does not usually improve with
sitting or standing.
 Intermittent dyspnea
• Cold air or animal dander exposure suggests asthma

• Work-related dyspnea may suggest occupational asthma

• Dyspnea following upper respiratory infections may be

due to asthma or chronic obstructive pulmonary disease
(COPD)
 LAB
• An acute myocardial infarction or cardiac arrhythmia can
be detected with an ECG.

• A plain chest x-ray can reveal pulmonary congestion,

pneumothorax, or pneumonia.
 LAB
• Specific blood tests:
• The natriuretic peptides, brain natriuretic peptide (BNP)
• N-terminal prohormone brain natriuretic peptide (NT-
proBNP) for congestive heart failure

(the negative predictive value of the natriuretic peptides for

the exclusion of congestive heart failure is 94% to 98%)

• Troponins for MI
(the positive predictive value of repeated troponin
measurement for acute myocardial ischemia is 75% to 80%)
 LAB
• D-dimers
– they are found in higher concentrations after
thrombotic events
– for the diagnosis and treatment of pulmonary
embolism that the use of age-adjusted threshold
values (age × 10 µg/L for patients over age 50)
markedly improves the specificity of the D-dimer
test, while keeping its sensitivity above 97% .
 The five most common causes of
chronic dyspnea
●Asthma
●Chronic obstructive pulmonary disease (COPD)
●Interstitial lung disease
●Myocardial dysfunction
●Obesity/deconditioning
 Chronic Dyspnea
Diagnosis
• Most common causes:
– Cardiovascular
– Respiratory disorders

• Less common causes:

• Psychiatric
• Gastrointestinal
• Neuromuscular disorders
 Evaluation
• The evaluation of chronic dyspnea begins with
a thorough history and physical examination
 – A 67-year-old man comes to your clinic for his annual
appointment concerned about increasing shortness of breath.

One year ago he was able to walk up the stairs to his apartment
without difficulty, but now he has difficulty walking one block.

He has a 70 pack-year smoking history, and several previous

attempts to stop smoking have been unsuccessful.

• Does the patient require urgent intervention?

• What additional questions would you ask to learn more about his
shortness of breath?
• Do you need any diagnostic tests for this case?
• Differential diagnosis?
 Case
Additional History
CASE (History Taking)
• This patient has had slowly progressive dyspnea with exercise but
no symptoms at rest.
• The chronicity of the patient's symptoms and his ability to engage in
conversation reassure you that he does not require urgent
intervention.
• He expresses frustration that he is unable to get a full breath when
simply walking around his home.
• The dyspnea often worsens when he has a "cold," but he denies an
acute increase in symptoms.
• There are no other triggers.
• When you ask about related symptoms, he describes a persistent
cough productive of thick green sputum. The cough has been an
irritating presence for the past several months.
• He denies fevers, chest pain, chest tightness, or orthopnea.
 Question: What Is the Most Likely
Diagnosis?

• Asthma
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Pneumonia
 Dyspnea and COPD
• COPD:
– Cough and dyspne
– Productive cough
– Smokers
– Second-hand smokers
– Exposure of pollution, and other respiratory
irritants
 COPD
• Productive cough for greater than 3 months
• Impressive smoking history;
both have high likelihood ratios for chronic obstructive
pulmonary disease (COPD).
• However, congestive heart failure and COPD frequently
occur together; thus a diagnosis of one does not
exclude the other.
• Further evaluation for cardiac causes should be
pursued because the patient has several coronary
artery disease risk factors
(smoking, male sex, and age over 60) and CHF may be
contributing to the patient's dyspnea.
 COPD? Asthma?
The classic symptoms of asthma are
dyspnea, wheezing, and cough, which
overlap with those of COPD, making diagnostic
distinction difficult.
In this case, the patient's older age of onset
makes asthma less likely.
Pneumonia is unlikely based on the chronicity of
symptoms and lack of systemic symptoms or
signs of infection.
 Dyspnea and Asthma
• Patients with asthma may complain of chest tightness
and shortness of breath with or without wheezing or
with cough only
• Wheezing and/or cough are not specific to respiratory
conditions and may also be present in the patient with
HF or other conditions.
• Patients with asthma may be able to identify a trigger,
such as weather changes or a particular respiratory
irritant that precipitates the symptoms.
• Patients with asthma often have worsening of
symptoms at night and symptoms that interfere with
sleep.
 Less Common Respiratory Causes Of
Chronic Dyspnea
• Postnasal drainage
• Chronic pneumonia
• Chronic pulmonary embolism

Chronic postnasal drainage rarely presents

with the chief complaint of chronic dyspnea and
is generally determined early in the physical
exam
Cardiac Disease and Dyspnea
• Heart Failure
• Myocardial ischemia
• Cardiac dysrhythmia, typically atrial fibrillation

• Patients with HF exacerbation may present with

complaints of suffocating or worsening dyspnea
with activity
• They may also present with cough or wheezing.
• Patients with left-sided HF (systolic or diastolic
dysfunction) may have fatigue, cough, and dyspnea
that interferes with sleep due to orthopnea or
episodes of paroxysmal nocturnal dyspnea.
• Patients with right-sided HF may present with
complaints of increased weight gain, frequent
urination, and dyspnea that is due to abdominal
distension from liver enlargement and possible
ascites.
 Cardiac Disease and Dyspnea
• Physical Examination:
Elevated jugular venous pressure
Peripheral edema
Tenderness in the right upper abdomen
associated with hepatomegaly may be found.
A positive hepatojugular reflex
(distension of jugular veins with pressure
over the liver) may be elicited
 Diagnostic studies
• Basic lab studies
– Patients should have (at minimum) a complete
blood cell count to evaluate for anemia
– thyroid-stimulating hormone (TSH)
– A comprehensive metabolic panel (renal and
hepatic function) Glucose, blood urea nitrogen,
creatinine, electrolytes
 Additional initial testing
• Additional initial testing should be based on the provider’s
suspected diagnosis, although a plain chest film is
recommended for most patients even with a normal
cardiopulmonary exam.

• A plain chest film may reveal the presence of hyperinflation,

consolidation (tumor or pneumonia), cardiomegaly, or
pulmonary congestion.
 Spirometry
• Spirometry is indicated if a pulmonary cause is
suspected.
• Persistent airflow limitation, defined as the ratio of
FEV1/FVC less than 0.70, is suggestive of COPD.
• Both asthma and COPD demonstrate obstructive
patterns on spirometry.
• ILD and other disorders should be considered if the
total lung capacity is decreased, which is suggestive of
a restrictive disorder.
• Patients with restrictive disorders are typically referred
to a pulmonologist for management.
ECG
• An ECG should be performed if the cause is thought to
be of cardiac origin,

BNP
• Brain-type natriuretic peptide (BNP) should be drawn.
Elevations of BNP greater than 100 pg/mL are suggestive of
HF.

These initial diagnostic tests are evidence-based, readily

accessible, with relatively low-cost and low-risk to the
patient.
Follow-up Testing In Chronic Dyspnea
• Pulmonary function tests
• Chest computed tomography
– Abnormalities on the chest radiograph that need
further characterization
– When HRCT is helpful despite a normal chest
radiograph
– Evaluation for suspected thromboembolic disease
• Echocardiography
• heart failure (HF) or pulmonary hypertension
Unstable patients typically present
with one or more symptom patterns
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• Hypotension, altered mental status, hypoxia, or
unstable arrhythmia.
• Stridor and breathing effort without air
movement (suspect upper airway obstruction).
• Unilateral tracheal deviation, hypotension, and
unilateral breath sounds (suspect tension
pneumothorax)
• Respiratory rate above 40 breaths per minute,
retractions, cyanosis, low oxygen saturation.
Pulmonary broncial constriction
• Asthma
• COPD
• Emphymphysema
• Chronic bronchitis
• Lung infections
• Smoking
• Air pollution or smoke
• Environmental allergens (pet
dander, pollen, mold, and dust)
Pneumonia
• Some chemicals
• Fumes from chemicals used in
cleaning products and
manufacturing
• Cold weather
• General anesthesia, mostly causing
airway irritation
• Exercise
• Blood-thinning medications, such as
blood pressure medications and
NSAIDs