C H A P T E R

Practical Approach to Breathlessness

18 Alladi Mohan, D Arun kumar

ABSTRACT well as the integrative processing of this information that

Breathlessness is one of the most common presenting is postulated to be occurring in the brain. This incongruity
symptoms encountered by clinicians. The causes of may be the consequence of increased metabolic demand,
breathlessness can range from cardiac, pulmonary, increased dead-space volume, decreased compliance or
anaemia, hysterical/psychogenic, infectious, traumatic, from other disorders.11,12 In addition to the traditionally
neuromuscular, haematological conditions among others. defined sensory afferents like chest wall receptors,
Dyspnoea has to be measured to assess it adequately. pulmonary vagal receptors, chemoreceptors, among
Instruments pertaining to dyspnoea measurement are others, information on the state of respiration available
classified as pertaining to domains of sensory–perceptual from respiratory motor areas of the brain which send
experience, affective distress, or symptom/disease impact an ascending copy of their descending motor activity
or burden. Patients presenting with acute dyspnoea should to perceptual areas (corollary discharge). The corollary
be immediately evaluated and triaging should be done for discharge from these different sources is thought to give
signs of clinical instability. While evaluating a patient with rise to different sensations.
dyspnoea, the following should be meticulously recorded:
onset, duration, pattern, progression, severity, diurnal
DEFINITION
Several definitions for describing dyspnea have been
variation, relation to exercise, exertion, aggravating and
postulated including “uncomfortable sensation of
relieving factors. A detailed history, thorough clinical
breathing”,13 “difficult, laboured, uncomfortable
examination, judicious use of laboratory investigations
breathing”,14 “sensation of feeling breathless or
including imaging is essential for rational, scientific
experiencing air hunger”.15 The American Thoracic society
evaluation and management of patients presenting with
(ATS) defined dyspnoea11,12 as “subjective experience
dyspnoea.
of breathing discomfort that consists of qualitatively
INTRODUCTION distinct sensations that vary in intensity. The experience
Dyspnoea is one of the most common presenting symptoms derives from interactions among multiple physiological,
encountered by clinicians.1,2 The causes of dyspnoea can psychological, social, and environmental factors and
be several and range from cardiac, pulmonary, anemia, may induce secondary physiological and behavioral
obesity, hysterical/psychogenic, physical deconditioning, responses.” The ATS statement11,12 also reiterates that
among others. As these causes are varied, it is essential to dyspnoea per se can only be perceived by the person
differentiate life-threatening causes causes from benign, experiencing it. Therefore, adequate assessment of
self-limiting conditions. dyspnoea depends on self-report . Further, it is important
to distinguish dyspnoea from the signs of increased work
EPIDEMIOLOGY of breathing.
Dyspnoea has been reported in 50% of patients admitted
to acute, tertiary care hospitals3 and in 25% of patients MEASUREMENT OF DYSPNOEA
in ambulatory settings.4,5 Data from population-based Dyspnoea has to be measured to assess it adequately.
studies have shown that the prevalence of mild to Instruments pertaining to dyspnoea measurement are
moderate dyspnoea ranged from 9%-13% in adults.6-8 This classified as pertaining to domains of sensory–perceptual
figure ranged from 15%-18% in adults aged 40 years or experience (e.g., visual analogue scale, Borg scale), affective
older; and 25%-27% in persons aged 70 years or more.7,9,10 distress (single- / multi-item ratings), or symptom/disease
impact or burden [unidimensional rating of disability or
PATHOPHYSIOLOGICAL CORRELATES activity limitation like Medical Research Council (MRC)
A given disease/condition may result in dyspnoea scale, multidimensional scales of quality of life/health
by one or more mechanisms. The respiratory motor status].11,12
system is unique in having both automatic (brainstem)
and voluntary (cortical) sources of motor command. DIAGNOSTIC APPROACH
Respiratory sensations are thought to be the consequence Dyspnoea is a usual symptom related to disturbances in
of interactions between the efferent motor output from cardiovascular and respiratory systems; other potential
the brain to the muscles of ventilation (feed-forward) causes that can cause dyspnoea include metabolic,
and the afferent sensory input from chemoreceptors, infectious, traumatic, neuromuscular, haematological and
mechanoreceptors and metaboreceptors (feedback) as other conditions (Table 1). Patients describe dyspnoea in
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Table 1: Some of the common causes of acute onset dyspnoea Table 2: Causes of paroxysmal nocturnal dyspnoea
in adults Left heart failure
Cardiac Nocturnal episodes of asthma
Heart failure with reduced ejection fraction Nocturnal episodes of recurrent minute pulmonary
Coronary artery disease, acute coronary syndromes emboli
Arrhythmias Postnasal discharge with attendant severe cough
Pericarditis Sleep apnea with arousal
Valvular heart disease Nocturnal angina with dyspnoea (angina equivalent)
Respiratory Nocturnal aspiration in gastro-oesophageal reflux
disease
Chronic obstructive pulmonary disease
RESPIRATORY

Bronchial asthma History

Pneumonia, other respiratory infections (e.g., SARS) While evaluating a patient with dyspnoea, the following
should be meticulously recorded: onset, duration, pattern,
Acute respiratory distress syndrome progression, severity, diurnal variation, relation to
Pneumothorax exercise, exertion, aggravating and relieving factors. The
Pulmonary embolism terminology used by the patient can sometimes give a clue
to the cause of dyspnoea: chest tightness or constricted
Pleural effusion
breathing (bronchial asthma); smothering or suffocating
Lung cancer, metastatic lung disease sensation (heart failure, acute coronary syndromes); need
Pulmonary oedema to sigh (heart failure).
Gastro-oesophageal reflux disease with aspiration Onset
Restrictive lung disease In adult patients presenting with sudden onset dyspnoea
Interstitial lung disease (e.g., acute interstitial (Table 1), acute pulmonary thromboembolism, acute
pneumonitis) coronary syndrome or spontaneous pneumothorax, acute
respiratory distress syndrome (ARDS), foreign body
Upper airway obstruction
aspiration, psychogenic causes should be high in the list
Epiglottitis of differential diagnosis.
Foreign body
Duration
Croup Common causes of dyspnoea that is slowly progressing
Central over hours or days include bronchial asthma, chronic
Neuromuscular disease obstructive pulmonary disease (COPD), pleural effusion,
pneumonia, congestive heart failure, small pulmonary
Pain emboli, interstitial lung disease or malignancy;
Others psychogenic acuses; and cardiac diseases like coronary
Anaphylactic reaction artery disease, congestive heart failure.16
Laryngeal spasm, laryngeal tumours Pattern
Anaemia Prolonged bed rest prior to acute onset dyspnoea may
indicate acute pulmonary embolism. Orthopnoea
Metabolic acidosis
(dysnoea in supine position, relieved on assuming upright
Drugs (e.g., aspirin overdosage) position) is classically seen in left heart failure but can also
SARS = severe acute respiratory sndrome occur in COPD, bilateral diaphragmatic palsy, asthma
their own phrases and a focussed diagnostic approach is triggered by gastric reflux, among others. Paroxysmal
necessary for a clinician for ascertaining diagnosis and nocturnal dyspnea (PND) is not always diagnostic of
providing treatment. left heart failure as nocturnal episodes of dyspnoea
occur in variety of conditions (Table 2). Dyspnoea and
Immediate evaluatoin deoxygenation upon assuming upright position is termed
Patients presenting with acute dyspnoea should be platypnoea-orthodeoxia and is seen in right-to-left
immediately evaluated and triaging should be done for shunting of blood (e.g., large patent foramen of ovale,
signs of clinical instability, such as: (i) suspected upper hepatopulmonary syndrome). Dyspnoea in upright
airway obstruction (e.g., stridor); (ii) tachypnoea (> 24 position, relieved in supine position is called platypnoea
breaths/minute) or apnoea; (iii) gasping or breathing and it seen in left atrial myxoma or hepatopulmonary
effort without movement of air; (iv) chest retractions or syndrome. Trepopnoea is dyspnoea in lateral decubitus
use of accessory muscles of respiration; (v) presence of position and is seen in unilateral pleural effusion.
hypotension; (vi) presence of hypoxaemia; (vii) unilateral
or absent breath sounds; and (viii) altered consciousness.
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Table 3: Differential diagnosis for some common presenting Table 4: Some of the common causes of chronic dyspnoea
symptoms Respiratory
Symptom Differential Diagnosis Bronchial asthma
Wheeze COPD/emphysema, asthma, Chronic obstructive pulmonary disease
allergic reaction, CHF (cardiac
wheeze) Interstitial lung disease
Pleuritic chest pain Pneumonia, pulmonary Chronic pulmonary thromboembolism
embolism, pneumothorax, Pulmonary hypertension
COPD, asthma Occupational lung disease
Fever Pneumonia, bronchitis, TB, Cardiovascular
malignancy
Coronary artery disease

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Cough Pneumonia, asthma, COPD/
emphysema Congestive heart failure
Haemoptysis Pneumonia, TB, pulmonary Valvular heart disease
embolism, malignancy Haematological
Oedema Acute heart failure, pulmonary Anaemia
embolism (unilateral)
Others
Pulmonary oedema Acute and chronic heart failure,
Psychogenic conditions
end-stage renal and liver
diseases, ARDS Gastro-oesophageal reflux disease
Tachypnoea Pulmonary embolism, acidosis Neuromuscular
(including aspirin toxicity), Thyroid disease
anxiety
COPD= chronic obstructive pulmonary disease; CHF= some of the commonly encountered physical examination
congestive heart failure; TB = tuberculosis; ARDS = acute clues are described below.
respiratory distress syndrome.
Whether the patient is able to complete full sentences
Variations while talking is carefully observed. In acute severe
Intermittent episodes of dyspnoea may be seen with asthma, patients cannot complete full sentences while
bronchial asthma, heart failure, pleural effusion, recurrent talking. Use of accessory muscles of respirations,
pulmonary embolism, gastro-oesophageal reflux disease; paradoxical breathing or sitting in tripod position, signs
aspiration. In addition to ardivascular diseases, exercise- of pallor, cyanosis, clubbing and pedal oedema are looked
induced dyspnoea is seen in exercise-induced asthma as for. Haemodynamic stability of the patient is checked by
well. Seasonal or diurnal dyspnoea is seen in bronchial assessing the vital signs. Further, whether the patient
asthma. Aggravation of dyspnoea during winter months is able to maintain saturation on room air is assessed
may occur with COPD. using pulse oximetry. On measuring blood pressure
pulsus paradoxus should be watched for as its presence
Other associated symptoms points to pericardial disease, restrictive heart disease. On
Dyspnoea presenting with other associated symptoms respiratory system examination, the symmetry of chest
may help in localizing the system involved and wall movements with respiration is observed. Percussion
understanding the nature of disease. Dyspnoea associated (e.g., dull note in pleural effusion, hyperresonant in tension
with central chest pain, points to aortic dissection, pneumothorax) and auscultation (wheeze, crepitations,
pulmonary embolism or acute coronary syndrome. If the decreased or hyperreasonant sounds, bronchial breath
pain is sharp and aggrevated by cough or deep breathing sounds) give valuable clue to the aetiological diagnosis.
it could be due to pleural irritation. Fever indicates an On cardiovascular system examination signs of heart
infectious cause. If anxiety precedes dyspnoea it could be failure should be looked for. Elevated jugular venous
a panic attack or pychogenic dyspnea. When dyspnoea pressure (JVP), peripheral oedema, S3 gallop rhythm,
is associated with cough, haemoptysis, pedal oedema, or presence of murmurs are valuable clues to the aetiological
wheeze most probable aetiological causes are shown in cause. indicate that patient is in fluid over load secondary
Table 3. Some of the common causes of chronic dyspnoea to heart failure. Paradoxical inward movement of
are shown in Table 4.1,11,12 abdominal muscles indicate weakness of diaphragm.
Physical examination Laboratory testing
A thorough physical examination helps the clinician to Electrocardiogram should be obtained immediately if
assess the severity, diagnose the cause and in prompt history and physical examination are in favour of heart
management of the patient. While a detailed account failure, acute coronary syndrome, cardiac arrhythmias,
of physical examination findings and their clues to the pulmonary embolism or pulmonary hypertension.
origin of dyspnoea is beyond the scope of this chapter,
Chest imaging consisting of chest radiograph,
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RESPIRATORY

Fig. 1: Algorithm for evaluating an adult patient presenting with acute dyspnoea. CXR = chest X-ray; NT-proBNP = N-terminal
pro-brain natriuretic peptide; ACS = acute coronary syndrome; ECG = electrocardiogram; ABG = arterial blood gas; A-a = alveolar-
arterial; CT = computed tomography; PE = pulmonary embolism; RR = respiratory rate; V/Q = ventilation-perfusion ratio; ACE =
angiotensin-converting enzyme; BiPAP = biphasic positive airway pressure; CPAP = continuous positive airway pressure. Adapted
from reference 19
computed tomography of the chest, and bedside tests that are useful include cardiac biomarkers like
thoracic ultrasonography are helpful in diagnosing troponin, D-dimer, N-terminal pro-brain natriuretic
pleural effusions, pulmonary oedema, pneumothorax peptide (NT-proBNP), exercise testing, pulmonary
or consolidation. Thoracic ultrasonography is emerging function testing including spirometry, reversibility
as a point-of-care diagnostic test recently. It has been testing, diffusion capacity of lung for carbon monoxide,
reported that lung ultrasonography improves diagnostic among others are useful in appropriate situations. The
accuracy of acute dyspnoea when performed within 1 diagnostic approach to an adult patient presenting with
hour of admittance to emergency room (ER).17 Further, acute dyspnoea is shown in Figure 1.19
it has also been observed that combination of lung
ultrasonography with or without testing for N-terminal TREATMENT
pro-brain natriuretic peptide (NT-proBNP) has high Depending the initial aetiological clues, further diagnostic
diagnostic accuracy for differentiating acute dyspnoea work-up is planned and the patient is administered
due to heart failure from COPD/bronchial asthma-related appropriate specific treatment accordingly.
acute dyspnoea in prehospital/ER setting.18
CONCLUSIONS
Complete haemogram (anaemia) renal functions and A detailed history, thorough clinical examination,
serum electrolytes help in identifying kidney disease. appropriate “triage”, judicious use of laboratory
Arterial blood gas (ABG) analysis will help in knowing investigations including imaging is essential for rational,
the type of respiratory failure and also gives information scientific evaluation and management of patients
about the acid-base state of the patient. Other laboratory presenting with dysponea.
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