Shortness of breath (dyspnea)
1. Acute dyspnea
Acute dyspnea is shortness of breath that lasts between hours to days and is always an alarm symptom that requires prompt attention. A chest x-ray is requested to rule out respiratory, cardiac and mediastinal disease.
If the patient is unable to complete a full sentence without pausing then move quickly to stabilize the patient hemodynamically and delay the medical interview for later.
The following algorithm helps narrow down the causes for acute dyspnea.
1. Exertional dyspnea. Dyspnea on mild exertion is indicative of left sided heart failure is usually accompanied by other manifestations (orthopnea, paroxysmal nocturnal dyspnea).
- Heart murmurs: valvular heart disease.
- Pink frothy sputum: cardiogenic pulmonary edema.
- Substernal chest pressure: acute myocardial ischemia or infarction.
- Trepopnea: on lateral decubitus - while lying on one side but not on the other. Disease of one lung, one major bronchus, or chronic congestive heart failure.
- Platypnea upright position and is relieved with recumbency. COPD. Platypnea in association with orthodeoxia (arterial deoxygenation in the upright position) has been reported in several forms of cyanotic congenital heart disease.
2. Positional dyspnea: pericardial disease.
- Jugular venous distention: pericardial effusion.
- Beck's triad (hypotension, jugular venous distention, muffled heart sounds): cardiac tamponade.
Dyspnea + wheezing, cough
- Aspiration (history of foreign body inhalation or inhalation of noxious agents)
- Anaphylaxis or angioedema (lip swelling, hives in addition to wheezing)
- COPD exacerbation
- Other pulmonary disease (chest x-ray)
- Fever, progressive sore throat, dysphagia and hoarseness: epiglottitis, pharyngitis.
- Fever& sputum: acute pneumonia, bronchitis.
- Fever and signs of serious infection or shock: acute respiratory distress syndrome.
- Pulmonary embolism, pneumothorax, pneumococcal pneumonia
- Also: Tietze’s syndrome (chest wall joint swelling), rib fracture.
- Known or suspicious history of diabetes or renal failure: DKA or metabolic acidosis.
- Suicidality or chronic pain: aspirin overdose, panic disorder, primary hyperventilation.
Chronic dyspnea + cough (pulmonary: chest x-ray and if needed pulmonary function tests, bronchoscopy)
- Cough + wheezing: asthma (episodic dyspnea).
- Cough without wheezing: Other pulmonary --> chest x-ray (interstitial lung disease, malignancy, chronic pneumonia, pleural effusion).
- Cardiac disease.
- Metabolic: anemia, acidosis, thyrotoxicosis.
Chronic dyspnea without cough:
- Pulmonary hypertension, cardiomyopathy, deconditioning, anemia, neuromuscular disease.
Several ventilation patterns have been described in the comatosed/unconscious patient. These are not clinically useful as they are either rare/not specific.
Cheyne-Stokes breathing can occur in elderly. Alternating episodes of hyperventilation and apnea. Seen in pending herniations, extensive cortical lesions, or brainstem damage
Apneustic breathing is very rare. sudden pauses of inspiration and is due to a lesion of the pons.
- Ataxic breathing is irregular and is due to a lesion (damage) of the medulla.
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