Dyspnea

o Underlie sensations of respiratory effort

and may contribute to “air hunger,”
especially with increased ventilatory
load (e.g., COPD).
• Anxiety and fear can amplify dyspnea by
disrupting breathing patterns or increasing
respiratory rate.

Assessing Dyspnea
• Assessment is complex due to its subjective
Definition nature and varying domains (e.g., sensory
• Defined by the American Thoracic Society as a experience, distress, symptom impact).
subjective experience of breathing discomfort • No universally agreed-upon tools for dyspnea
with varying sensations and intensities. measurement; assessment should focus on
• Originates from multiple physiological, patient management and relevant contexts.
psychological, social, and environmental factors. • Emerging Assessment Tools:
• Must be self-reported by the patient, unlike o The Modified Medical Research Council
observable signs like tachypnea or use of Dyspnea Scale is recommended in the
accessory muscles. GOLD criteria for assessing symptom
burden in COPD.
Epidemiology
• Common in clinical settings:
o Affects up to 50% of inpatients and 25%
of ambulatory patients.
o Community prevalence: 9–13%,
increasing to 37% in adults aged 70+.
o Frequent cause for ER visits, with 3–4
million cases annually.
• Predicts outcomes in chronic diseases:
o Particularly significant in COPD, often a
better predictor of outcomes than FEV1.
o Incorporated into COPD severity Differential Diagnosis of Chronic Dyspnea
assessment (GOLD guidelines). Definition & Focus
• Also predictive in other chronic heart and lung
• Chronic dyspnea: symptoms persisting for more
diseases.
than 1 month.
• Majority of cases (85%) are due to pulmonary or
Mechanisms Underlying Dyspnea cardiac conditions.
• Arises from multiple pathways; includes afferent
• Up to one-third of patients may have
and efferent signals that interact within the CNS.
multifactorial causes for dyspnea.
• Afferent Signals (from respiratory system to
CNS):
Common Causes & Mechanisms
o Chemoreceptors (carotid body, aortic
1. Respiratory System Causes:
arch, and medulla): Detect hypoxemia,
o Airway diseases: asthma, COPD.
hypercapnia, or acidemia, triggering “air
o Parenchymal diseases: interstitial lung
hunger.”
diseases; alveolar filling processes like
o Mechanoreceptors (lungs, upper
hypersensitivity pneumonitis or
airways, chest wall):
bronchiolitis obliterans organizing
▪ Stretch receptors, irritant
pneumonia (BOOP).
receptors, and J receptors
o Chest wall diseases: bony abnormalities
\respond to airway resistance or
(e.g., kyphoscoliosis) or neuromuscular
decreased compliance (e.g.,
conditions (e.g., amyotrophic lateral
asthma, COPD, pulmonary
sclerosis).
fibrosis).
o Pulmonary vascular diseases:
o Pulmonary Vascular Receptors:
pulmonary hypertension, chronic
Respond to changes in pulmonary artery
thromboembolic disease.
pressure.
2. Cardiovascular System Causes:
o Metaboreceptors in Skeletal Muscle:
o Left heart dysfunction: coronary artery
Sense biochemical changes during
disease, cardiomyopathy.
respiratory effort.
o Pericardial diseases: constrictive
• Efferent Signals (from CNS to respiratory
pericarditis, cardiac tamponade.
muscles):
3. Other Non-Pulmonary or Non-Cardiovascular
o Sent from the motor cortex and
Causes:
brainstem to respiratory muscles and
o Anemia: reduces oxygen-carrying
sensory cortex (corollary discharge).
capacity.
 o Deconditioning: reduced physical fitness
impacting respiratory efficiency.
o Psychological factors: anxiety can
exacerbate or mimic dyspnea.

Diagnostic Approach
• Initial Steps: Begin with a thorough history and
physical examination.
• Follow-Up: Use targeted laboratory tests as
indicated by initial findings.
• Further Diagnostics: May require advanced
imaging, pulmonary function tests, or
subspecialty referral if initial work-up is
inconclusive.
• Persistent Dyspnea: Some patients may
continue to experience dyspnea despite
treatment or without an identifiable cause.

Approach to Patient with Dyspnea o Acute, intermittent episodes: Consider

Overall Evaluation Strategy myocardial ischemia, bronchospasm, or
• Known prior condition (pulmonary, cardiac, pulmonary embolism.
neuromuscular): Assess if dyspnea is due to o Chronic dyspnea: Typically COPD,
disease progression or a new issue. interstitial lung disease, or chronic
• No known prior cause: Focus on identifying an thromboembolic disease.
etiology as treatment varies widely with • Position-related symptoms: Platypnea (dyspnea
underlying causes. in upright position) suggests left atrial myxoma
• Initial Steps: Start with history, physical or hepatopulmonary syndrome.
examination, and initial diagnostic tests; refer to • Risk factors: Assess for occupational lung disease
specialists if needed. or CAD.

Key Elements of History Physical Examination

• Patient description: Self-reported sensations • Vital signs:
help narrow down causes (e.g., chest tightness o Fever may indicate
may suggest bronchoconstriction, inability to infection/inflammation.
take a deep breath may indicate COPD). o Hypertension may suggest heart failure.
• Symptom patterns: o Tachycardia could indicate fever, cardiac
o Orthopnea: May suggest CHF, dysfunction, or deconditioning.
diaphragm issues, or reflux-triggered o Resting hypoxemia suggests potential
asthma. ventilation-perfusion mismatch or
o Nocturnal dyspnea: Often CHF or impaired diffusion.
asthma.
 • Breathing indicators: Differentiating Cardiovascular from Respiratory
o Inability to speak in full sentences Dyspnea
suggests ventilatory impairment. • Cardiac indicators during CPET include high
o Signs like supraclavicular retractions and heart rate, early anaerobic threshold, abnormal
accessory muscle use indicate increased BP response, decreased O₂ pulse, or ECG
airway resistance or lung stiffness. ischemic changes.
• Cardiac examination: Check for signs of elevated • Respiratory indicators include reaching maximal
right heart pressures, left ventricular ventilation, dead space increase, hypoxemia, or
dysfunction, and valvular disease. bronchospasm during peak exercise.
• Additional signs:
o Anemia (pale conjunctivae), cyanosis, or Treatment of Dyspnea
cirrhosis signs. Primary Goals and Approaches
o Paradoxical abdominal motion 1. Correct Underlying Conditions:
(diaphragm weakness) or rounding of o Address reversible causes with
abdomen on exhalation (pulmonary appropriate treatments tailored to the
edema). specific condition(s) contributing to
o Clubbing may indicate interstitial fibrosis dyspnea.
or bronchiectasis. 2. Symptom Relief:
o If dyspnea persists after optimal
treatment of the underlying causes, the
focus shifts to reducing symptom
intensity and improving quality of life.
o Persistent dyspnea, or Chronic
Breathlessness Syndrome (defined in
2017), is characterized by ongoing
breathlessness despite optimal
treatment, leading to disability.

Interventions
1. Supplemental Oxygen:
o Indicated if resting O₂ saturation is ≤88%
or drops to this level during activity or
sleep.
o In patients with COPD and hypoxemia,
supplemental oxygen has been shown to
improve mortality.
Diagnostic Testing 2. Pulmonary Rehabilitation:
1. Imaging: o Programs that include exercise (e.g.,
o Chest X-ray: Assess lung volumes, community-based programs like yoga
parenchyma, pulmonary vasculature, and Tai Chi) have shown benefits in
cardiac silhouette, and pleural effusions. improving dyspnea, exercise capacity,
o CT scan: Used if further evaluation of and reducing hospitalization rates.
lung parenchyma or pulmonary
embolism is needed. 3. Opioids:
2. Laboratory Studies: o Shown to alleviate symptoms of dyspnea
o Hematocrit: Rule out anemia. by reducing “air hunger” and possibly
o Metabolic Panel: Check for metabolic suppressing respiratory drive.
acidosis or CO₂ retention. o Requires individualized assessment due
o ECG: Evaluate for ventricular to risks of respiratory depression.
hypertrophy, past MI. 4. Anxiolytics:
o Spirometry: Identify obstructive or o Studies show inconsistent benefits for
restrictive defects; may prompt further dyspnea relief.
pulmonary function tests. 5. Experimental Treatments:
o Echocardiography: Indicated for o Inhaled Furosemide: Under study as it
suspected heart dysfunction or may alter afferent sensory information
pulmonary hypertension. related to dyspnea.
o Brain Natriuretic Peptide (BNP): Used in
suspected CHF cases.
3. Specialized Testing:
o Bronchoprovocation: For suspected
asthma with normal spirometry.
o Cardiopulmonary Exercise Testing
(CPET): Distinguishes between cardiac
and respiratory limitations if both are
suspected or unresolved by treatment.