Dyspnea

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Resident
Survival
Guide

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Dyspnea Microchapters

Patient Information

Overview

Pathophysiology

Causes

Differentiating Dyspnea from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Dyspnea is defined as "uncomfortable sensation of breathing". Dyspnea involves multiple qualitatively precise sensations, which derived from various pathophysiologic processes. Shortness of breath is consisted of eight different sensations, include rapid breathing, incomplete exhalation, shallow breathing, increased work or effort, feeling of suffocation, air hunger, chest tightness, and heavy breathing. Common pathophysiology of shortness of breath is a combination of sense of respiratory effort, chemoreceptors, mechanoreceptors, and afferent mismatch. Common Causes of dyspnea include anemia, foreign body aspiration, heart failure, pneumonia, pregnancy, and pulmonary edema.

Pathophysiology

The common pathophysiology of shortness of breath (dyspnea)[1]



 
 
 
 
 
 
 
 
 
 
 
 
 
Dyspnea pathophysiology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sense of respiratory effort
 
 
 
Chemoreceptors
 
 
 
 
 
 
 
Mechanoreceptors
 
 
 
 
 
Afferent mismatch
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypercapnia
 
Hypoxia
 
Upper airway receptors
 
Lung receptors
 
Chest wall receptors
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Simultaneous activation of the sensory cortex
• Sense of effort is the predominant factor contributing to breathlessness when the respiratory-muscles are fatigued, weakened, or increasingly loaded
 
Hypercapnia causes dyspnea independent of any reflex increase in respiratory-muscle activity
• There are many clinical settings, such as asthma in which dyspnea develops under eucapnic or hypocapnic
 
Hypoxia appears to have a direct effect on shortness of breath, independent of any change in ventilation conditions
Hypoxia plays a limited role in the dyspnea in patients with cardiopulmonary disease
 
Upper airway and facial receptors modify the sensation of dyspnea
Receptors in the trigeminal nerve distribution influence the intensity of dyspnea
 
Pulmonary stretch receptors (respond to lung inflation)
• Irritant receptors in the epithelium (respond to a mechanical and chemical stimuli)
C fibers, unmyelinated nerve endings, located in the alveolar wall and blood vessels (respond to interstitial congestion)
 
Receptors in the joints, tendons, and muscles of the chest wall (might influence the sensation of dyspnea)
• Application of a physiotherapeutic vibration over the parasternal intercostal muscles reduced dyspnea
 
• Dyspnea arises from irrelevance between the force or tension generated by the respiratory muscles and the resulting change in muscle length and lung volume
 
 

Causes

Life Threatening Causes

Common Causes

Causes Based on Pathophysiology

Obstructive Lung Diseases

Diseases of Lung Parenchyma and Pleura

Contagious
Non-Contagious

Pulmonary Vascular Diseases

Obstruction of the Airway

Immobilization of the Diaphragm

Restriction of the Chest Volume

For the complete list of causes for shortness of breath or dyspnea click here

Differentiating Shortness of Breath or Dyspnea from other Diseases

Diseases that cause shortness of breath have to be differentiated upon the following table[2]

To review the differential diagnosis of dyspnea and fever, click here.

To review the differential diagnosis of dyspnea and chest pain, click here.

To review the differential diagnosis of dyspnea and cough, click here.

To review the differential diagnosis of dyspnea and jugular vein distention, click here.

To review the differential diagnosis of dyspnea and cyanosis or clubbing, click here.

To review the differential diagnosis of dyspnea and loss of consciousness or agitation, click here.

To review the differential diagnosis of dyspnea with normal auscultation, click here.

To review the differential diagnosis of dyspnea with stridor, click here.

To review the differential diagnosis of dyspnea with wheezing, click here.

To review the differential diagnosis of dyspnea with crackle, click here.

To review the differential diagnosis of dyspnea with rhonchi, click here.

To review the differential diagnosis of dyspnea, fever, and cough, click here.

To review the differential diagnosis of dyspnea, fever, and chest pain, click here.

To review the differential diagnosis of dyspnea, cough, and cyanosis or clubbing click here.

To review the differential diagnosis of dyspnea, fever, chest pain, cough, and cyanosis or clubbing click here.

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); DOE (dyspnea on exercise); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Loss of consciousness Agitation Weight loss Fever Chest pain Cough Orthopnea DOE Cyanosis Clubbing JVD Peripheral edema Auscultation CBC ABG Imaging Spirometry Gold standard
Acute Dyspnea Respiratory system Head and Neck,

Upper airway

Angioedema[3] - - - - - +/- + - - +/- - + Normal Normal O2, ↑CO2 Normal N/A Physical exam Generalized edema
Anaphylaxis[4] +/- + - +/- - - - - +/- - - - Scattered wheezing Normal Normal Normal N/A Vital sign Type 1 hypersensitivity
Aspiration[5] - + - - +/- + - - + - - - Diminished breath sounds Normal Normal Atelectasis Vt, ↑RV Bronchoscopy Choking
Croup[6] - + - +/- - + - - + - - - Stridor WBC Normal Steeple sign Normal Physical exam Barking cough
Epiglottitis[7] - + - + - + - - - - - - Stridor WBC Normal Thumb sign Normal Laryngoscopy Drooling
Rhinosinusitis[8] - - - + - +/- - - - - - - Normal WBC Normal Air fluid level Normal Physical exam Headache
Vocal cord dysfunction[9] - - - - - +/- - - - - - - Stridor Normal Normal Normal FVC Laryngoscopy Choking sensation
Chest and Pleura,

Lower airway

Asthma attack[10] - + - - +/- + - - + - - - Wheeze Eosinophil Respiratory alkalosis Normal FEV1, PEF Physical exam and

Spirometry

Chest pain
Atelectasis - - - +/- +/- +/- - - +/- - - - Diminished breath sounds, Wheeze Normal O2, Normal/↓CO2 Collapsed lung lobe, fissuresdisplacement FVC Chest CT scan Surgical procedure, Aspiration,

Mechanical ventilation

Bronchitis[11] - - - + + + - - - - - - Rhonchi  WBC Normal Normal Normal Physical exam Rhonchi relieved by cough
Bronchospasm[12] +/- + - - + +/- - - + - - - Wheeze Normal O2, ↑CO2 Normal Vt, ↑RV Physical exam Allergic reaction
Bronchiolitis[13] - - - + +/- + - - - - - - Wheeze and Crackles WBC Normal Bronchovascular markings Vt Clinical assessment Respiratory syncytial virus (RSV)
COPD exacerbation[14] - + - + + + + - + +/- +/- +/- Wheeze, Rhonchi, and Crackles WBC, ↑RBC Respiratory alkalosis Hyperexpansion FEV1/FVC Clinical assessment Acute exacerbations of chronic bronchitis (AECB)
Lung carcinoma[15] - - + - - + - - + + - - Wheeze and Crackles Normal Normal Mass lesion, hilar lymphadenopathy Vt, ↑RV Bronchoscopy  Paraneoplastic syndromes, such as SIADH and lambert-Eaton
Pneumonia[16] - - - + + + - - - - - - Wheeze, Rhonchi, and Crackles WBC, neutrophilia Normal Lobar consolidation Normal Chest X-ray and CT Scan productive cough
Pneumothorax[17] - - - - + - - - - - +/- - Diminished breath sounds Normal O2, ↑CO2 Radiolucency without lung marking Vt CXR and Chest CT scan Tracheal deviation
Pulmonary embolism[18] - - - - + - - +/- - - - - Normal Normal Respiratory alkalosis Normal Normal Pulmonary CT angiography Pleuritic chest pain
Rib fractures (flail chest)[19] - + - - + - - - - - - - Normal Normal Respiratory acidosis Fracture marks Normal Chest X-ray Pneumothorax
Cardiovascular system Acute myocardial ischemia[20] +/- + - +/- + - + + - - - - Normal Normal Normal Normal Normal Cardiac troponin I Nausea and vomiting, Positive pertinent risk factors, such as hypertension, diabetes, and smoking
Acute heart failure[21] +/- + - - +/- + +/- + + - + + S3 Normal Respiratory alkalosis Cardiothoracic ratio Vt B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) Excessive sweating, high blood pressure
Pericardial tamponade[22] +/- - - - + - +/- +/- - - + - Muffled heart sounds Normal Normal Water bottle appearance enlarged heart Normal Echocardiography Fluid accumulation in pericardium
Tachyarrhythmia[20] +/- + - - +/- - - - - - - - High pulse rate Normal Normal Normal Normal ECG Palpitation
Pulmonary edema[23] +/- + - + + + + + + + + + Basal crackle Normal Respiratory alkalosis Bat wing pattern, air bronchograms Vt, ↑RV Cardiac Catheterization Tachypnea
Central nervous system Stroke + - - +/- - - - - - - - - Normal Normal Normal Intracranial infarct or hemorrhage Normal Brain MRI Paralysis or paresthesia
Encephalitis[24] + + - + - - - - - - - - Normal WBC, neutrophilia Normal Normal Normal CSF PCR Confusion
Traumatic brain injury[25] + +/- - - - - - - - - - - Normal Normal Respiratory acidosis Intracerebral hemorrhage Normal Brain CT scan Lucid interval
Toxic/Metabolic Organophosphate poisoning[26] + - - + - - - - - - - - Wheeze Normal O2, ↑CO2 Normal Normal Blood test Salivation, Lacrimation, Emesis, Miosis
Salicylate poisoning[27] + - - - - - - - + - - - Normal Normal Metabolic acidosis, Respiratory alkalosis Normal Normal Blood test Vomiting, Tinnitus, Confusion, Hyperthermia
Carbon monoxide poisoning[28] + - - - + + - - + - - - Wheeze Carboxyhemoglobin O2, ↑CO2 Normal N/A Carboxyhemoglobin (HbCO) level Headache, Dizziness, Weakness, Vomiting, Confusion
Diabetic ketoacidosis[29] + +/- - - - - - - - - - - Scattered wheeze, Kussmaul's respiration WBC Metabolic acidosis Normal Normal Blood test (acidosis, hyperglycemia, ketonemia) Vomiting, Abdominal pain, Weakness, Confusion
Systemic Panic attack[30] +/- + - - - - - - - - - - Normal Normal Normal Normal Normal Clinical assessment Severe anxiety
Pregnancy[31] - - - - +/- - - - - - - + Normal WBC, RBC O2, ↑CO2 Normal Vt, ↑RV βhCG Missed period, Hyperemesis
Sepsis[32] +/- - - + - - - - - - - - Normal WBC, neutrophilia O2, ↑CO2 Normal Normal SIRS criteria Chills, Confusion
Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Loss of consciousness Agitation Weight loss Fever Chest pain Cough Orthopnea DOE Cyanosis Clubbing JVD Peripheral edema Auscultation CBC ABG Imaging Spirometry Gold standard
Chronic Dyspnea Respiratory system Head and Neck,

Upper airway

Goiter[33] - - - - - - - - - - - + Normal Normal Normal Normal Normal Blood test (TSH, T4) Weight gain
Laryngeal adenocarcinoma[34] - - + - - +/- - - - - - - Stridor Normal O2, ↑CO2 Retropharyngeal tissue thickness Normal Laryngoscopy Choking sensation
Vocal cord paralysis[9] - - - - - +/- - - - - - - Stridor Normal Normal Pharyngeal constrictor muscles thinning, uvular deviation Normal Laryngoscopy Choking sensation
Tracheal stenosis[35] - - - - +/- +/- - - + + - - Stridor, Stertorous Normal O2, ↑CO2 Soft tissue thickening internal to normal-appearing tracheal cartilage Normal Bronchoscopy Respiratory distress
Chest and Pleura,

Lower airway

Bronchial asthma[10] - + +/- - +/- + - - + + - - Wheeze Eosinophil Respiratory alkalosis, Metabolic acidosis Pulmonary hyperinflation,

Bronchial wall thickening

FEV1/FVC Spirometry before and after bronchodilator Paroxysmal respiratory distress
Bronchiectasis[11] - - - + + + - - + + - - Rhonchi, Wheezing, Crackles WBC, neutrophilia O2, ↑CO2 Tram-track opacities FEV1/FVC High resolution computed tomography (HRCT) Chronic productive cough
COPD[14] - - +/- - - + + + + + + +/- Expiratory wheeze RBC Respiratory alkalosis, Metabolic acidosis ↑ Bronchovascular markings, Cardiomegaly FEV1/FVC Physical exam and

Spirometry

Heavy smoking history
Emphysema[36] - - - - - +/- - - + + - - Expiratory wheeze, Hyperinflation Normal Respiratory alkalosis, Metabolic acidosis Flattening of diaphragm, vertical heart FEV1/FVC Physical exam and

Spirometry

Barrel chest
Pulmonary hypertension[37] - - - - +/- +/- - - +/- +/- + + Accentuated S2 Normal Hypoxia and acidosis Enlarged pulmonary arteries Physiologic RV Cardiac catheterization Syncope,

Ascites, Pleural effusion

Interstitial lung disease[38] - - - - + + - - + + - - Rhonchi, Wheezing, Crackles Normal O2, ↑CO2 Peripheral pulmonary infiltrative opacification FEV1/FVC High resolution computed tomography (HRCT) Pneumoconiosis
Sarcoidosis[39] - - +/- - +/- + - - + - - - Crackles Normal O2, ↑CO2 Hilar adenopathy FEV1/FVC High resolution computed tomography (HRCT) Hypercalcemia, high ACE
Alveolitis[40] - - - + + + - - - - - - Basal crackle WBC, neutrophilia Normal  Basal reticulonodular opacification   FEV1/FVC High resolution computed tomography (HRCT) Dry cough
Bronchiolitis obliterans[13] - - - + + + - - + + - - Expiratory wheeze WBC O2, ↑CO2 Hyperinflation, Reticulonodular opacities FEV1/FVC Lung biopsy Complication of allogeneic hematopoietic stem cell transplantation
Cystic fibrosis[41] - - + + - +/- - - + + - - Rhonchi, Wheezing, Crackles Normal Metabolic alkalosis Thick-walled bronchiectasis FEF75%/FVC Sweat test Absent vas deferens
Pleural effusion[42] - +/- + - + - +/- - - - +/- +/- Egophony ("E-to-A" change) Normal Normal Blunting of the costophrenic and cardiophrenic angle Vt, ↑RV Light's criteria Tactile fremitus, Asymmetrical chest expansion
Pulmonary right-to-left shunt[43] - - - - +/- + - - + + - - Diminished breath sounds Normal O2, ↑CO2, Respiratory acidosis Normal Vt, ↑RV

(physiological)

Pulmonary CT angiography Chronic hypoxemia
Diaphragmatic paralysis[44] - - - +/- +/- +/- - - - - - - Normal Normal Normal Unilateral or bilateral diaphragmatic flattening Vt, ↑RV

(anatomical)

CXR confirmed by fluoroscopic sniff test Respiratory insufficiency
Tuberculosis[45] - - + + + + - - +/- - - - Rhonchi, Wheezing, Crackles WBC O2, ↑CO2 Patchy consolidation or poorly defined linear and nodular opacities Restrictive, obstructive, or mixed IFN-γ release assay (IGRA)

Acid-fast staining

Night sweat
Cardiovascular system Constrictive pericarditis[22] - - - - + - + + - - + - Muffled heart sounds Normal Normal Calcifications  Normal Chest CT scan Syncope
Restrictive cardiomyopathy[46] - - - - + - + + - - - +/- Normal Normal Normal Dilatation of the inferior vena cava and right atrium Normal Right ventricular biopsy Weight gain,

Nausea

Valvular heart disease[20] - - - - + - +/- + - - - - Cardiac murmur Normal Normal Dilatation of heart chambers Normal Echocardiography Syncope, Palpitation
Bradyarrhythmia[47] - - - - - - - - - - - - Normal Normal Normal Normal Normal ECG Syncope, Palpitation
Pericardial effusion[48] - - - +/- + + +/- +/- - - + - Muffled heart sounds Normal Normal Fluid density around the heart Normal M-mode and 2-dimensional Doppler echocardiography Hoarseness, Palpitation
Coronary heart disease[20] - +/- - - + - + + - - - - Normal Normal O2 Normal Normal Cardiac troponin I Nausea, Lightheadedness, Sweating
Intracardiac shunt[49] - - - - +/- - +/- + + + - - Cardiac continuous murmur Normal O2 Dilatation of heart chambers Normal Echocardiography Syncope, Palpitation
Neuromuscular disease Amyotrophic lateral sclerosis[50] +/- - +/- - - - - - - - - - Normal WBC Normal Normal Vt, ↑RV Revised El Escorial criteria (clinical) Muscle weakness, Dysphagia
Polymyositis/dermatomyositis[51] - - +/- - + - - - - - - +/- Normal WBC Normal Normal Vt, ↑RV Muscle biopsy Muscle weakness, Heliotrope
Mitochondrial diseases[52] - - +/- - - - - - - - - - Wheeze WBC, Plt Normal Normal Vt, ↑RV Muscle biopsy Muscle pain
Glycolytic enzyme defects (e.g., McArdle)[53] +/- - - - - - - - - - - +/- Normal Normal Normal Normal Vt, ↑RV Muscle biopsy (ragged red fibers) Myoglobinuria,

Muscle weakness

Toxic/Metabolic Metabolic acidosis[54] - - + - - - - - - - - - Normal Normal Metabolic acidosis, Respiratory alkalosis Normal Normal ABG Confusion, Vomiting
Renal failure[55] - - + - - - + + - - - + Normal RBC Metabolic acidosis Normal Normal Cr Nausea, Vomiting, Oliguria
Systemic Anemia[56] - - + - - - - +/- - - - - Normal RBC O2 Normal Normal HGB, MCV Weakness, Fatigue
Anxiety[57] + + + - +/- +/- - - - - - - Normal Normal Normal Normal Normal Psychological interview Sweating, Palpitation
Ascites[58] - - - - - - - - - - - - Normal Normal Normal Peritoneal fluid accumulation Vt, ↑RV Abdominal ultrasound Abdominal distention
Depression[59] - + + - - - - - - - - - Normal Normal Normal Normal Normal Psychological interview Depressed mood, Fatigue
Kyphoscoliosis[60] - - - - - - - - - - - - Wheeze Normal Normal Deviated vertebral column Vt, ↑RV

(anatomical)

Standing lateral spine radiograph Low back pain
Obesity[61] - - - - - - - - - - - - Normal Normal O2 Normal Vt, ↑RV

(anatomical)

BMI Low stamina,

Sweating

Autoimmune Churg-Strauss syndrome[62] - - - - - + - - - - - - Scattered wheezing Normal Normal Areas of parenchymal opacification Vt, ↑RV Biopsy  Fatigue,Numbness
Microscopic polyangiitis[63] - - +/- + + - - - - - - +/- Scattered wheezing WBC O2, ↑CO2 Normal Vt, ↑RV Histological confirmation Skin lesions, Nerve damage
Wegener's granulomatosis[64] - - +/- - - + - - - - - - Wheezing, Crackles RBC O2, ↑CO2 Cavitate nodules, ground-glass opacity FEV1/FVC Biopsy demonstrating a granulomatous vasculitis Chronic rhinosinusitis
Goodpasture's disease[65] - - - - - + - - - - - -  Bilateral coarse crepitations RBC, HGB, HCT Normal  Like pulmonary edema Normal Kidney biopsy Hematuria,

Hemoptysis

Related Chapters

  • Air hunger - The sensation of an urgent need to breathe, sensation that you cannot take in a full breath
  • Tachypnea - Breathing rapidly
  • Bradypnea - Breathing slowly
  • Eupnea - Normal unlabored breathing
  • Orthopnea - Dyspnea that occurs with lying flat
  • Trepopnea - An abnormal awareness of one's own breathing that is seen in one lateral position but not in the other
  • Paroxysmal nocturnal dyspnea - Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

References

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