Chronic Dyspnea

Differential Overview

❑ Chronic obstructive pulmonary disease

❑ Congestive heart failure

❑ Asthma

❑ Recurrent pulmonary embolism

❑ Interstitial lung disease

❑ Lung cancer

❑ Chronic pleural effusion

❑ Primary pulmonary hypertension

❑ Cystic fibrosis

❑ Kyphoscoliosis

❑ Myasthenia gravis

❑ Tracheal stenosis

❑ Mitral stenosis

Diagnostic Approach

Nonproductive cough may be a “dyspnea equivalent.” Nocturnal coughing to clear the airway of excess secretions can be confused with paroxysmal nocturnal dyspnea.

Trepopnea, dyspnea lying on one side but not the other, occurs with cardiomegaly, unilateral parenchymal lung disease, and mediastinal or endobronchial tumors.

Clinical Findings

Chronic obstructive pulmonary disease  Two patterns predominate: “Blue bloaters” are plethoric, cough incessantly, and have wheezing and rhonchi with a loose cough; “pink puffers” are thin, wrinkled, barrel-chested, and breathe with pursed lips (auto-PEEP). On examination, the chest is hyperresonant, with distant breath sounds and a prolonged expiratory phase. End-inspiratory retraction at the costal margin is consistent with hyperinflation and air trapping.

Congestive heart failure  Dyspnea on exertion progresses to orthopnea and paroxysmal nocturnal dyspnea. Rales, S₃ gallop, jugular venous distention, and edema are diagnostic signs.

Asthma  Intermittent or persisting wheezing is the sine qua non of asthma.

Recurrent pulmonary embolism  Consider this in patients with a stepwise increase in dyspnea, pleuritic chest pain, asymmetric leg swelling, or a predisposing factor such as cancer or oral contraceptive use.

Interstitial lung disease  It is distinguished by cyanosis on exertion, clubbing of the fingers, and fine “Velcro” rales.

Lung cancer  Suspect lung cancer in a smoker with unilateral wheeze or hemoptysis, and weight loss.

Chronic pleural effusion  Breath sounds are decreased with dullness to percussion unilaterally at the lung base.

Primary pulmonary hypertension  The typical setting is a woman in her forties, with chest pain or Raynaud phenomenon.

Cystic fibrosis  This diagnosis is usually made in childhood. The patient has pulmonary symptoms of recurrent respiratory infections and chronic, copious, thick secretions.

Kyphoscoliosis  This is evident on inspection of the thorax, but care should be taken to distinguish it from a barrel chest in emphysema.

Myasthenia gravis  Fatigable dyspnea is associated with diplopia, ptosis, or swallowing difficulty.

Tracheal stenosis Stridor and inspiratory retraction of the supraclavicular space occurs in critical tracheal stenosis. There will be a significant history, such as prior intubation.

Mitral stenosis  Key symptoms/findings are a diastolic rumble, hemoptysis, and malar flushing, especially in a patient with a history of rheumatic fever.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Breathlessness on exertion

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

More About Causes of Breathlessness on exertion

• Back to symptom: Breathlessness on exertion: Introduction (review 6 causes)
• Next Book Extract About Breathlessness on exertion: Apnea (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
• All Book Extracts: All Online Book Extracts for Breathlessness on exertion

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

 » Next page: Apnea (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

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