Dyspnea

Dyspnea is defined as an abnormally uncomfortable awareness of breathing. It is one of the cardinal symptoms of cardiac and pulmonary disease, but may also result from abnormalities of the chest wall, neurologic disorders, and anxiety. A complete history and physical exam focused on the chest, abdomen, and cardiovascular and pulmonary systems are generally sufficient to narrow the differential, which can be further refined with an appropriate diagnostic and laboratory evaluation.

Differential Diagnosis

• Asthma
  –Classic triad of chronic cough, dyspnea, and wheezing

• Coronary artery disease
  –May present without chest pain (“anginal equivalent”)
• Pneumonia
• Pleural effusion
  –Common causes: CHF, pneumonia, cancer, pulmonary embolus, connective tissue disease (e.g., SLE, rheumatoid arthritis), pancreatitis, and renal or liver disease
• Pulmonary embolism
  –Risk factors (Virchow's triad) present in 90% of cases: Venous stasis (e.g., immobility, pedal edema), endothelial damage (e.g., recent trauma or surgery, burns, indwelling catheters, IV drug use), hypercoagulability (e.g., malignancy, obesity, pregnancy, HRT/OCP)
• Pneumothorax
• Interstitial lung disease
  –A group of disorders characterized by inflammation and fibrosis of alveolar walls and the interstitium
• Pulmonary hypertension
  –Primary pulmonary HTN: No identifiable cause
  –Secondary pulmonary HTN: Due to underlying disease (e.g., mitral stenosis, PE, COPD)
• Less common etiologies (“zebras”) include pericardial disease, chest wall abnormality, tracheal obstruction, neuromuscular diseases, and psychogenic

Workup and Diagnosis

• Thorough history and physical exam
  –Note onset (sudden or chronic, progressive)
  –Timing (persistent or intermittent)
  –Associated symptoms (e.g., chest discomfort, syncope)
• Initial laboratory studies should include CBC, BUN/creatinine, calcium, electrolytes, thyroid function tests, pulse oximetry (resting, ambulatory, and nocturnal), and chest X-ray
• ABG will identify barriers to oxygen diffusion (increased A-a gradient), hypoxemia, and chronic hypercapnia
• ECG may reveal evidence of MI, right ventricular strain (e.g., due to PE, pulmonary hypertension), dysrhythmias, and/or bundle branch block
• Pulmonary function tests are indicated to identify restrictive or obstructive disease and barriers to diffusion
• BNP may be useful, if the etiology is uncertain, to distinguish CHF from other causes of dyspnea
• Echocardiogram to establish a diagnosis of structural heart disease, LV dysfunction, or elevated PA pressure
• Chest CT scan, V/Q scan, and/or lower extremity dopplers if PE is suspected
• Sputum culture and blood cultures may be necessary in cases of pneumonia

Treatment

• Attention to airway, breathing, and circulation
• Administer supplemental O₂ as needed
• Asthma: Avoid triggers; bronchodilation with inhaled β ₂ agonists (e.g., albuterol) and anticholinergics (e.g., ipratropium); inhaled, oral, and/or IV steroids
  • COPD: Inhaled bronchodilators (e.g., albuterol, ipratropium); systemic corticosteroids; antibiotics (e.g., azithromycin, doxycycline) in severe exacerbations; mechanical ventilation (CPAP or BiPAP)
  • Cardiogenic pulmonary edema: Vasodilators (e.g., IV nitroglycerin, ACE inhibitors), loop diuretics (e.g., IV furosemide), morphine, digoxin, and/or inotropes
  • Noncardiogenic edema generally requires only supportive care; treat underlying etiology (e.g., surgical correction of valvular lesions)
  • Pleural effusion: Address underlying cause; diagnostic or therapeutic thoracentesis may be indicated; pleurodesis for recurrent effusions
  • Pneumothorax: 100% O₂ accelerates resorption

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Breathing difficulties

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Breathing difficulties

• Back to symptom: Breathing difficulties: Introduction (review 2668 causes)
• Next Book Extract About Breathing difficulties: Paroxysmal Nocturnal Dyspnea (In a Page: Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Breathing difficulties

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Paroxysmal Nocturnal Dyspnea (In a Page: Signs and Symptoms)

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