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Shortness of breath (dyspnea)

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1. Dyspnea + loss of consciousness

A. Central causes

Loss of consciousness suggests a central (central nervous system)  cause. Central causes may present without loss of consciousness. A lot of information can be deduced from observing the pattern of shortness of breath involved.

A. Cheyne-Stokes breathing pattern

Regularly irregular with progressive increase in depth & sometimes frequency in a crescendo-decrescendo manner ends in apnoea (15-60 secs)

Normal in some persons during sleep. It is abnormal when it occurs while the subject is awake (signifies that the respiratory centers are sluggish in their response to variations CO2. Possible causes include aging, obesity, congestive heart failure, neurologic disorders e.g. meningitis, infarction, pontine hemorrhage). It is really more of a folklore than it is a practical clinical sign.

B.  Biot's breathing pattern

A variant of Cheyne-Stokes. There is a  succession of hyperpnoea, hyperventil, apnoea; but not regular, no crescendo-decrescendo.

Causes include meningitis, medullary compression. It eventually leads to death.

C. Apneustic breathing breathing pattern

Deep inspiration - breath holding - rapid exhalation

This usually signifies the presence of brainstem lesions usually at the level of the pons.

D. Central hyperventilation breathing pattern

Very rapid, very deep (faster than Kussmaul which is mainly very deep).

Found in midbrain / upper pointine lesions.

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E. Ataxic (agonal) breathing pattern

Continuous irregular shifts of hyperventilation, hypoventilation & apnoea in no particular succession (unlike Biot's & Cheyne-Stokes).

This is due to damage to the medullary respiratory centers and is a sort of fibrillation of respiratory centers - It usually precedes death.

A. Metabolic causes

E. Kussmaul breathing pattern

Mainly Deep, but also rapid respiration

Kussmaul breathing is clinically significant. It is caused by acidosis which disturbs the level of consciousness.

Memory Aid:
In all the above the patient has coma plus shortness of breath, we then observe the pattern of breathing. First exclude the presence of Kussmaul pattern (Deep, rapid breathing). If not Kussmaul then try to fit the patient into one of the patterns above. The rhythms in all are regular rhythms except in the last one (ataxic). Localization via the respiratory patterns above is not an accurate method. The order in which they are represented here is the order of the localizing center moving from top to bottom.

2. Dyspnea & fever

1. Pneumonia

3. Dyspnea & chest symptoms (cough / chest pain)

Acute Dyspnea

1. Dyspnea + acute chest pain (pulmonary embolism)

2. If accompanied by platypnoea (dyspnea in the erect position e.g. on sitting up) then there is probably a lower lung lesion (effusion)

3. Foreign body

4. Noxious agents

Episodic Dyspnea

1. Asthma

Chronic Dyspnea

1. Dyspnea + lower respiratory tract infections (COPD - asthmatic bronchitis)

2. Cancer and metastasis

4. Dyspnea and cardiac symptoms (dyspnea on exertion / chest pain / orthopnea)

Acute Dyspnea

1. Dyspnea + basal crepitations (pulmonary edema)

Chronic Dyspnea

1. Dyspnea + exertion (if orthopnoea and paroxysmal nocturnal dyspnoea --> heart failure).

5. Other causes of dyspnea

1. Anemia

2. CO poisoning

3. Psychogenic (hysterical and panic attacks)

N.B. Dyspnea literally means difficulty in breathing. This does not necessarily mean rapid breathing. Sometimes it signifies slow breathing as well.

Hypoventilation

Here the depth of respiration is decreased (shallow) while the rate is normal or slow (but not rapid).

1. Pickwickian syndrome

2. Respiratory failure

Bradypnoea

In bradypnea the rate is slow.

1. Hypothyroidism

2. CNS disease

3. Narcotics & analgesics

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