DYSPNEA

Ask the following questions:

1. Is the dyspnea acute? If the dyspnea is acute onset, one should ask if there is a drug history, particularly a history of mainlining narcotics. If so, adult respiratory distress syndrome should be considered. Furthermore, is there an embolic source for a possible pulmonary embolism? If the onset is gradual, one should move on to consider chronic diseases such as congestive heart failure and pulmonary emphysema and fibrosis.
2. Is there fever or purulent sputum? Obviously, fever and purulent sputum should make one think of pneumonia.
3. What kind of rales are there? If there are crepitant rales, one should consider congestive heart failure or pneumonia. If there are sibilant and sonorous rales or wheezing, one should consider bronchial asthma or pulmonary emphysema.
4. Is there hepatomegaly? Hepatomegaly would be a sign of congestive heart failure. However, in the acute stages it may not manifest immediately. Hepatomegaly may also be an indication of other systemic diseases that are associated with either lung disease or heart disease. The collagen diseases in particular come to mind.

DIAGNOSTIC WORKUP

The basic workup of acute onset dyspnea should include a CBC to exclude anemia; a chest x-ray and arterial blood gases to exclude pneumothorax, pneumonia, and other pulmonic diseases; and an EKG and serial cardiac enzymes to exclude myocardial infarction and some of the causes of congestive heart failure. A sputum smear and culture should always be done when there is adequate sputum. Eosinophils should be sought. It is important to make sure that you have an adequate specimen and, therefore, leukocytes should be reported on the smear.

If there is chest pain accompanied by hemoptysis, arterial blood gases and a ventilation-perfusion scan should be done to rule out pulmonary embolism. Even without chest pain and hemoptysis, a pulmonary embolism may need to be excluded. If the ventilation-perfusion scan is inconclusive, a pulmonary angiography may still need to be done in difficult cases. If routine smears and cultures are negative, cultures for AFB and fungi may need to be done, especially when there is continuing purulent sputum. The clinician should also consider doing skin testing for these diseases.

If congestive heart failure is suspected, an arm-to-tongue circulation time and pulmonary function testing should also be done. Echocardiography may also be diagnostic. A therapeutic trial of a diuretic may be valuable. When there is significant wheezing, a trial of sublingual isoproterenol hydrochloride (Isuprel®) or epinephrine 0.3 cc subcutaneously may clear up the confusion.

In chronic dyspnea the chest x-ray and EKG should be complemented by pulmonary function testing, exercise testing, and arterial blood gases. Pulmonary function testing will be very useful in diagnosing asthma and distinguishing pulmonary emphysema from pulmonary fibrosis. A diagnosis of pulmonary fibrosis is substantiated by a reduction in a single-breath carbon monoxide-diffusing capacity. The advice of a pulmonologist should be sought when extensive pulmonary function testing, such as compliance and diffusing capacity, need to be determined. Bronchoscopy may need to be done to exclude a foreign body, neoplasm, or bronchiectasis. Cardiac catheterization and pulmonary angiography may be needed to identify chronic recurrent pulmonary embolism, intracardiac shunts, and pulmonary hypertension. Dyspnea without objective findings on physical examination should prompt a referral to a psychiatrist.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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