Dyspnea

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Contents 1 More Specific Terms 2 Introduction 3 Classification 4 Etiology 5 Pathology 6 History 7 Clinical-manifestations 8 Laboratory 9 Diagnostic-procedures 10 Radiology 11 Management 12 More General Terms 13 Additional Terms 14 References

More Specific Terms

• exertional dyspnea; dyspnea on exertion (DOE)
• orthopnea
• paroxysmal nocturnal dyspnea (PND)
• platypnea
• trepopnea

Introduction

• The sensation of shortness of breath, difficulty breathing, labored breathing. Alternatively, the uncomfortable awareness of breathing [6].

Classification

• Severity grading: ( New York Heart Association Classification)
• 0. No dyspnea except with strenuous exercise
• 1. Slight dyspnea while walking uphill or rapidly on a flat surface.
• 2. Dyspnea while walking on a flat surface; unable to keep up with peers, having to stop to catch breath
• 3. Dyspnea on walking 100 yards or after a few minutes & having to stop to catch breath
• 4. Dyspnea with minimal exertion, i.e. dressing or undressing
• 5. Dyspnea at rest.

Etiology

• heart disease

• increased pulmonary capillary pressure
• left atrial hypertension
• increased airway resistance
• decreased lung compliance
• myocardial ischemia, myocardial infarction

• obstructive airway disease

• upper airway obstruction
• bronchitis
• asthma
• chronic obstructive pulmonary disease

• pulmonary parenchymal disease

• pneumonia
• pneumoconiosis
• sarcoidosis

• pulmonary vascular disease - pulmonary embolism
• chest wall or respiratory muscle disorder

• severe kyphoscoliosis
• paralysis of diaphragm
• respiratory muscle weakness

• other

• pregnancy
• drugs
• psychogenic
• deconditioning
• obesity
• esophageal reflux disease

Pathology

• generally the result of increased work of breathing
• other mechanisms

• abnormal activation of respiratory centers
• voluntary hyperventilation
• Cheyne-Stokes respirations
• stimulation of pressure receptors in pulmonary vasculature or right atrium ( pulmonary embolus)

• underlying factors

• hypoxia
• hypercarbia

History

• rate of onset, orthopnea, paroxysmal nocturnal dyspnea, effect of physical exertion, history of myocardial infarction, history of syncope, prior episodes of dyspnea, aggravating or relieving factors, edema, weight gain, cough, sputum, fever, nausea, HIV risk factors, history of asthma, occupational exposure

Clinical-manifestations

• response to dyspnea is both physiologic & psychologic

• tachycardia, tachynea
• pain, anxiety, fear

• heart disease

• dyspnea on exertion
• orthopnea
• paroxysmal nocturnal dyspnea
• dyspnea at rest
• S3, S4
• murmurs
• cardiomegaly
• jugular venous distention
• hepatomegaly
• peripheral edema

• obstructive airway disease

• upper airway obstruction

• acute dyspnea with difficulty inhaling
• inspiratory stridor
• retraction of supraclavicular fossa

• asthma

• acute intermittent dyspnea
• expiratory wheezes

• chronic obstructive pulmonary disease

• slowly progressive exertional dyspnea

• pulmonary parenchymal disease

• exertional dyspnea early
• tachypnea
• inspiratory rales

• pulmonary embolism

• multiple discrete episodes of dyspnea with recurrent pumonary embolism
• may be progressive dyspnea without abrupt worsening
• tachypnea
• deep venous thrombosis may or may not be present

• chest wall or respiratory muscle disorder

• severe kyphoscoliosis

• must be severe before respiratory function is compromised

• paralysis of diaphragm

• appears normal standing
• severe orthopnea

Laboratory

• serum BNP useful in distinguishing cardiac from pulmonary source of dysnea (high serum BNP suggests cardiac source) [8]

Diagnostic-procedures

• fiberoptic exam of upper airway if suspecting upper airway obstruction
• pulmonary function tests
• peak flow rate
• arterial blood gas
• electrocardiogram
• exercise tolerance testing
• other tests depend on specific etiology

Radiology

• lateral neck films if suspecting upper airway obstruction
• chest X-ray
• high-resolution computed tomography ( CT) if suspecting:

• interstitial lung disease
• malignant infiltrate
• bronchiectasis
• emphysema

Management

• specific measures for specific etiologies

• corticosteroids particularly useful for bronchospasm
• diuretics may be useful for hypervolemia

• general measures

• exercise training program

• improves physical well-being, endurance & breathlessness without improving lung function or gas exchange

• breathing techniques reduce sense of respiratory effort

• purse-lipped breathing
• diaphragmatic breathing

• cool air moving across the face from a fan or open window stimulates the maxillary nerve ( cranial nerve V-2) which has a central inhibitory effect on the sensation of breathlessness [3]
• supplemental oxygen

• benefit in patients with significant dyspnea & only mild hypoxia
• not beneficial in the absence of hypoxia [5]

• opiates reduce sense of breathlessness

• oral [7]
• nebulized/ aerosolized morphine

• adjunct for patients already receiving oral opiate
• may be combined with bronchodilator ( albuterol)

• haloperidol reduces sense of breathlessness [5]
• theophylline use to improve diaphragmatic contractility is controversial
• anxiolytic agents are generally not effective
• respiratory muscle training of little value

• pneumonectomy (bilateral)

More General Terms

• sign/symptom

Additional Terms

• orthopnea
• platypnea
• respiratory distress syndrome (RDS)
• respiratory urgency
• trepopnea

References

1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
2. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill NY, 1995, pg 43-44
3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
4. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 720
5. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
6. Bruera E, Neumann CM. Management of specific symptom complexes in patients receiving palliative care. Canadian Medical Assoc. J (CAMJ):158:1717, 1998
7. Journal Watch 23(22):176, 2003 Abernathy AP et al, Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 327:523, 2003 <PubMed> PMID: [1] <Internet> [2]
8. Green SM, Martinez-Rumayor A, Gregory SA, Baggish AL, O'Donoghue ML, Green JA, Lewandrowski KB, Januzzi JL Jr. Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea. Arch Intern Med. 2008 Apr 14;168(7):741-8. PMID: &dopt=Abstract
9. National Guideline Clearinghouse ACR Appropriateness Criteria for dyspnea - suspected cardiac origin. (American College of Radiology) ngc-guideline: [3]
   - ACR Appropriateness Criteria for chronic dyspnea - suspected pulmonary origin. (American College of Radiology) ngc-guideline: [4]
   - (1) Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). (2) Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD) 2010 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [5]

dyspnea (shortness of breath {SOB})