It is important to quantify the amount of physical exertion or exercise needed to produce dyspnea.Ĭhest pain and dyspnea occurring acutely should always alert the clinician to a possible cardiac etiology, including acute coronary syndromes and aortic dissection, in addition to possible pneumothorax and acute pulmonary embolism. A change in the ability to tolerate exercise and/or avoidance of exercise can be a surrogate marker of dyspnea, which the patient will often fail to mention or even deny because they are not dyspneic at rest and/or adapt to their symptoms by becoming sedentary. However, dyspnea can occur as a normal physiologic response to more exercise than the patient can tolerate. Diastolic heart failure, on the other hand, typically causes dyspnea on exertion. Patients with systolic heart failure often have dyspnea with exercise and at rest. Orthopnea in a COPD patient should alert the clinician to diagnose systolic heart dysfunction. 3ĬOPD and hepatopulmonary syndrome often cause platypnea. Certain combinations of symptoms with acute dyspnea, such as cough with sputum production, can lead the physician or provider to consider a diagnosis of acute pneumonia, bronchitis, or an exacerbation of COPD.Ĭhronic dyspena, on the other hand, can suggest COPD, chronic pulmonary embolism, anemia, asthma, interstitial lung disease (ILD), drug-induced lung disease (eg, prednisone, amiodarone, methotrexate, antibiotics), cardiac disease, obesity, lack of physical activity, psychological depression, malignancy, and tobacco dependence that may help to narrow your differential and focus your physical examination. Symptoms of chest tightness, not chest pain, are commonly seen in asthma and COPD exacerbations due to dynamic hyperinflation. Does the dypnea occur in specific situations? For example, understanding whether dyspnea is worse in certain positions-ie, orthopnea (dyspnea in the recumbent position, relieved with assuming the upright position), paroxysmal nocturnal dyspnea (dyspnea that awakens the patient from sleep, relieved by the upright position), platypnea (dyspnea in the upright position, relieved with lying down), or trepopnea (dyspnea in only one lateral decubitus position, not both), which is typically found in heart failure-can help diagonse comorbidities.ĭyspnea with COPD occurs primarily after walking when patients develop dynamic hyperinlation or what the authors call “acute air constipation.” COPD patients have no problems breathing air in but become exhausted from not being able to breathe completely out before the intake of the next breath of air, which is compounded by tachypnea and anxiety.Recurrent dyspnea can be a symptom of uncontrolled asthma, acute cardiogenic or noncardiogenic pulmonary edema, acute pulmonary embolism, pulmoanry aspiration, or it can be due to paroxysmal atrial dysrhythmias (ie, atrial fibrillation or intermittent heart block). Note: Do not immediately attribute chronic nor acute dyspnea to physical deconditioning as this will delay the diagnosis of other important and often, treatable, and potentially serious conditions. How does the dyspnea fit into the patient’s daily activities? Dyspnea needs to be interpreted and quantitated in the context of your patient’s rest, exercise, and sleep.Diagnosis and the plan of care will be predicated on the patient’s symptoms and response to treatment. The patient’s clinical history will help narrow the differential diagnosis. Is it a preexisting condition or a new ailment? With acute dyspnea, consider whether it is related to other acute conditions, such as acute coronary syndrome, acute pulmonary embolism, acute pulmonary aspiration, acute asthma, and acute COPD exacerbation.Lastly, ask if the patient has other symptoms in addition to dyspnea. In addition, take note of current medications, as well as smoking and occupational history. Find out how long the shortness of breath has been occurring (ie, days, weeks, or months). Is dyspnea acute or chronic? Ask the patient if the dyspnea began suddenly or increased in severity recently.Patients will seldom volunteer that they are dyspneic unless it is acute and unrelieved by rest. It is often confused with tachypnea, which is an increase in the respiratory rate above 12 to 16 breaths per minute. 1,2ĭyspnea or shortness of breath is the subjective, uncomfortable awareness of one’s breathing. One of the hallmark symptoms of lung disease, dyspnea has very low specificity, and can occur in isolation or accompany chest pain, cough, and/or hemoptysis. Dyspnea in adults-whether acute (minutes to a few days) or chronic (weeks to months or longer)-is a common diagnostic challenge, forcing the physician to be perceptive to clinical clues.
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