This presentation tries to help a clinician reach the diagnosis when a patient of dyspnoea/breathlessness visits him/her.

1. An Approach to the patient of
DYSPNOEA
Presented by:
Dr. Narendra Prasad Giri
MD Kayachikitsa
Final Year Resident
TUATH, Kirtipur
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 1

2. Definitions:
 Dyspnoea:
1. “A subjective experience of breathing discomfort that
consists of qualitatively distinct sensations that vary in
intensity. The experience derives from interactions
among multiple physiological, psychological, social, and
environmental factors, and may induce secondary
physiological and behavioral responses.”-American
thoracic society
2. Difficulty in breathing/ Shortness of breath
3. Undue awareness of unpleasant breathing
4. Experienced as ‘cannot get enough air’, ‘air does not go
all the way down’, smothering feeling or tightness or
tiredness of chest’, ‘choking sensation’ etc. Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 2

3. Definitions..
 Orthopnoea:- Dyspnoea in supine position, usually seen in
CCF but may also be seen in Asthma and chronic Bronchitis
and is a regular finding in the rare occurrence of bilateral
diaphragmatic paralysis.
 Trepopnoea:-Dyspnoea in lateral decubitus position most
oftenly seen in patients with heart disease.
 Platypnoea: Dyspnoea in upright position. Possible causes
are intracardiac shunt, pulmonary parenchymal
ventilation/perfusion mismatch, and pulmonary
arteriovenous shunts.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 3

4. Pathophysiology:
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 4

5. Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 5

6. Approach to the patient
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 6

7. Triage: Rapid assessment of patient according to the
severity for prioritizing the treatment
 RED FLAGS in Dyspnoea:
(i) suspected upper airway obstruction (e.g. stridor);
(ii) tachypnoea (> 24 breaths/minute) or apnoea;
(iii) gasping or breathing effort without movement of air;
(iv) chest retractions or use of accessory muscles of respiration;
(v) presence of hypotension;
(vi) presence of hypoxaemia/ Cyanosis;
(vii) unilateral or absent breath sounds; and
(viii) altered consciousness.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 7

8. Acute Dyspnoea
 New onset or abruptly worsening dyspnea within the preceeding 2 weeks.
 Causes:
Upper Airway Obstruction Lower Airway Disease Parenchymal Lung disease
Inhaled foreign body Acute Bronchitis Pneumonia
Anaphylaxis Asthma Lobar collapse
Epiglotitis Acute exacerbation of COPD Acute respiratory distress
Syndrome (ARDS)
Extrinsic compression eg.
Rapidly expanding
haematoma
Acute exacerbation of
Bronchiectasis
Anaphylaxis Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 8

9. Acute Dyspnoea causes contd…
Other Respiratory Causes Cardiovascular Causes Other causes
Pneumothorax Acute cardiogenic
Pulmonary Oedema
Metabolic Acidosis
Pleural Effusion Acute coronary syndrome Psychogenic
Breathlessness
Pulmonary Embolism (PE) Cardiac tamponade
Acute Chest wall Injury Arrhythmia
Acute Valvular Heart
disease
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 9

10. Chronic Dyspnoea
 Breathlessness of more than 2 weeks duration
 Common Causes
Respiratory Causes
Asthma Bronchiectasis
COPD Cystic fibrosis
Pleural Effusion Pulmonary Hypertension
Ca Lungs eg. Bronchial ca Pulmonary Vasculitis
Interistitial Lung Disease e.g
sarcoidosis
TB
Chronic pulmonary Thromboembolism Laryngeal/tracheal stenosis eg.
extrinsic compression, malignancy
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 10

11. Chronic Dyspnoea Causes contd..
Cardiovascular causes Other causes
Chronic Heart Failure Severe Anaemia
Coronary artery disease Obesity
Valvular Heart disease Chest wall disease eg Khyphoscoliosis
Paroxymal Arrythmia Physical deconditioning
Constrictive pericarditis Diaphragmatic Paralysis
Pericardial effusion Psychogenic hyperventilation
Cyanotic Heart disease Neuromuscular disease eg. Myasthenia
gravis, muscular dystrophy
Cirrhosis (Hepato-pulmonary syndrome)
Tense ascites
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 11

12. Stepwise approach
1. History:
The terminology used by the patient can sometimes give a clue to the
cause of dyspnoea:
 chest tightness or constricted breathing -bronchial asthma;
 smothering or suffocating sensation-heart failure, acute coronary
syndromes;
 need to sigh- heart failure ( ‘sigh’ dictionary meaning:-emit a long, deep
audible breath expressing sadness, relief, tiredness, or similar)
The followings should be recorded during History taking:-onset,
duration, pattern, progression, severity, diurnal variation, relation to
exercise, exertion, aggravating and relieving factors etc.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 12

13. Onset
Within Minutes
• Pneumothorax
• Pulmonary oedema
• Major pulmonary embolism
• Foreign body
• Laryngeal oedema
Within Hours
• Asthma
• Left heart failure
• Pneumonia
Within Days
• Pneumonia
• ARDS
• Left heart failure
• Repeated pulmonary embolism
Within Weeks
• Pleural effusion
• Anaemia
• Muscle weakness
• Tumours
Within Months
• Pulmonary fibrosis
• Thyrotoxicosis
• Muscle weakness
Within Years
• Muscle weakness
• COPD
• Chest wall disorder
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 13

14. Position
Orthopnoea (dyspnea in
supine position)
Platypnoea (Dyspnoea in
assuming upright
position )
Trepopnoea (dyspnoea
in lateral decubitus
position )
• CCF
• LVF
• COPD
• Bronchial asthma
• Massive pleural
effusion
• Bilateral diaphragm
palsy.
• Ascites
• GERD
• Left atrial myxoma
• Massive pulmonary
Embolism
• Pulmonary Atriovenous
fistula
• Paralysis of intercostal
muscles
• Hepato pulmonary
syndrome
• Large foramena ovale
• Disease of one lung or
bronchus like
unilateral pleural
effusion
• CCF
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 14

15. Timing
Nocturnal onset
Dyspnoea
Paroxymal Nocturnal Dyspnoea Post Prandial
Dyspnoea
• CHF
• COPD
• BRONCHIAL ASTHMA
• SLEEP APNOEA
• NOCTURNAL
ASPIRATION IN GERD
• Left heart failure
• Nocturnal episodes of asthma
• Nocturnal episodes of
recurrent minute pulmonary
emboli
• Postnasal discharge with
attendant severe cough
• Sleep apnea with arousal
• Nocturnal angina with
dyspnoea (angina equivalent)
• Nocturnal aspiration in gastro-
oesophageal reflux disease
• GERD
• ASPIRATION
• FOOD ALLERGY
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 15

16. Severity
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 16

17. Precipitating and Relieving Factors
Precipitating Factors Relieving Factors
• exercise
• exposure – cigarette,
allergens
• occupational exposure
• obesity
• Medication like Aspirin,
Beta Blockers etc
• rest
• Medication
• Expectoration of sputum
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 17

18. Associated Symptoms
Symptoms Differential Diagnosis
Wheeze COPD/emphysema, asthma, allergic reaction, CHF
(cardiac wheeze)
Pleuritic chest pain Pneumonia, pulmonary embolism, pneumothorax,
COPD, asthma
Fever Pneumonia, bronchitis, TB, malignancy
Cough Pneumonia, asthma, COPD/ emphysema
Haemoptysis Pneumonia, TB, pulmonary embolism, malignancy
Peripherial Oedema Acute heart failure, pulmonary embolism (unilateral)
Pulmonary oedema
(pink frothy sputum)
Acute and chronic heart failure, end-stage renal and
liver diseases, ARDS
Tachypnoea Pulmonary embolism, acidosis (including aspirin
toxicity), anxiety Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 18

19. Past History
CCF HTN, DM, Dyslipidaemia, Obstructed sleep
apnoea
Acute exacerbation
of COPD
COPD
Acute exacerbation
of Bronchial Asthma
Asthma
PE DVT, Prolonged immobilization, Long travel,
recent surgery, long bone fracture
Respiratory muscle
weakness
Myasthenia gravis, Muscular Dystrophies
Acute Angina/ MI Coronary Heart disease
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 19

20.  Family History
 Occupational History
 Drug History
 Travel History
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 20

21. 2. Physical Examination
 General condition of the patient
 The breathing pattern-
 Shallow rapid breathing as in ILD
 Deep Rapid breathing eg Kussmaul’s breathing
 Irregular breathing eg Chyne strokes breathing
 Use of Accessory muscles of respiration
 General body Built-
 Lin and thin-COPD
 Obse/ oedamatous- CCF
 Decubitus- Orthopnoea, Trepopnoea, Platypnoea, Tripod
position in COPD Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 21

22.  Pallor
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Thyroid gland
 Speech- Can the patient complete a sentence in one breath?
 Vitals
 BP-Hypotention- poor prognosis,
Hypertension-hypertension-related diastolic heart failure with
pulmonary oedema, hyperthyroidism, or phaeochromocytoma
 Pulsus Paradoxus- asthma, COPD, cardiac tamponade
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 22

23.  Pulse- Rate, Rhythm, Volume, Force
 Respiratory rate- Tachypnoea
 Temperature- Fever
 Pupilary Reaction
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 23

24. Systemic Examination
Respiratory System
 Insepection- Inspect the nose, nasal cavity, pharynx and
chest
 Purpsed lips and Prolonged expiration-COPD
 Foreign body in the respiratory tract,
 Anaphylaxis/ Angiodemia-swelling of mouth, tongue,
pharynx
 Epiglottitis
 URTI
 Barrel shaped chest-Emphysema and Cystic Fibrosis
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 24

25.  Tracheal Deviation-In contralateral side-Pleural effusion,
lung mass, Pneumothorax
 Ipsilateral deviation in lobar/lung collapse, lung
fibrosis
 Voice-Hoarseness-in laryngitis, laryngeal tumours, vocal
cord paralysis.
 JVP- raised in Right heart failure and in conditions which
increases blood pressure in superior Vena cava
 Kyphosis/Scoliosis
 Chest movement-Symmetry, Intercostal recession ( in
upper airway obstruction), Inward movement of lower ribs
during inspiration (COPD)
 etc
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 25

26. Palpation
 Lymph nodes-cervical, supraclavicular, axillary
 Position of the trachea
 Measurement of chest expansion
 Reduced in obstructive disorder
 Unilateral reduction in pneumothorax, pleural
effusion, lung collapse, fibrosis
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 26

27. Percussion
 Unilateral dullness to percussion - pleural effusion (stony
dullness), atelectasis, foreign body aspiration, pleural
tumours, or pneumonia.
 Hyper-resonance - pneumothorax or severe emphysema.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 27

28. Ascultation
 Reduced Breath sounds-COPD
 Bronchial breathing sounds in peripheral region- Consolidation
 Wheese-Asthma, COPD
 Crackles-
 Crackles in the beginning of inspiration-COPD
 Localized loud and coarse crackles-area of bronchiectasis
 Fine and late inspiratory crackles-Diffuse interistitial
fibrosis
 Absent Breath sounds unilaterally- lung collapse,
pneumothorax
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 28

29. Cardiovascular System
 Inspection
 Anaemia
 Cyanosis
 Clubbing
 Oedema
 JVP
 Palpation
 Pulse
 BP
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 29

30. Auscultation
 Heart sounds
 S3 gallop in adults in LVF, less commonly seen in Mitral
regurgitation, Constrictive pericarditis. Can also be found
in Thyrotoxicosis, pregnancy, fever, anaemia.
 Murmurs- Stenosis and Regurgitations
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 30

31. Investigations:
1. Blood tests:
 CBC-for assessing infections eg. Pneumonia, URTI, Acute
infective exacerbation of COPD
 Hb level to assess anaemia
 ESR and CRP to assess inflammation
 Renal Function test for occult renal disease
 Thyroid Function test
 Arterial Blood Gas (ABG)-to assess the cause of acidosis,
state of ventilation and perfusion and type of respiratory
failure.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 31

32. Blood tests contd..
 Biomarkers:
a. Natriuretic peptides-
Brain Natriuretic peptides (BNP) and N terminal Pro-hormone Brain
Natriuretic peptide (NT proBNP)-Released from ventricle myocytes
in response to increased pressure to the ventricles.
Increased in clinically relevant congestive heart failure.
b. Troponins-
If the clinical evidence points to an acute coronary syndrome as
the cause of dyspnea, serial determination of cardiac troponin
(troponin I or troponin T) is helpful. This can be used to rule out
acute myocardial ischemia with a high degree of certainty.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 32

33. Biomarkers contd…
c. D-dimers
D-dimers are fibrin degradation products generated by
fibrinolysis; they are found in higher concentrations after
thrombotic events.
They have a high negative predictive value in the
diagnostic evaluation of pulmonary embolism.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 33

34. Investigations contd..
2. Chest X-ray:
 Can assess Pulmonary consolidation
(Pneumonia), Hyperinflation (COPD)
Fluid collection (Pleural effusion),
Pulmonary oedema (Bat’s wing
pattern), lung collapse, fibrosis,
etc.
 Size of heart etc.
3. ECG and Echocardiogram:
 Can assess Cardiac pathology
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 34

35. Investigations contd..
 Pulmonary Function test:
 FEV1/FVC should be more than 70% if low suggests
Obstructive pathology eg. COPD
 If FVC is less than 80% of the previous baseline of the
same patient suggests Restrictive pathology eg.
Reduced compliance ( Fibrosis etc)
 CT scan of Pulmonary Artery if Pulmonary embolism is
suspected
 Sputum examination: In suspected TB, Pneumonia and
infected COPD cases
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 35

36. Some specific conditions of Dyspnoea:
1. Acute exacerbation of Asthma:
 Past History of Bronchial Asthma
 Tachypnea, wheezes, and a prolonged expiratory phase
are typical clinical findings
 Spirometry shows a decrease in both the forced
expiratory volume at one second (FEV1) and the peak
expiratory flow (PEF) .
 The obstruction, and the symptoms, improve markedly
after the inhalation of a bronchodilator drug (β2-
agonist or anticholinergic drug).
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 36

37. 2. Acute Exacerbation of COPD
 Past History of COPD
 barrel shaped chest
 Purpsed lips and prolonged expiration
 Use of accessory muscle of respiration
 Current or past smoking history
 Reduced breath sounds with prolonged expiration,
expiratory wheeze, Hyper-resonant percussion note
 CXR- Hyperinflated lungs with flat diaphragms
 Sputum Production
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 37

38. CXR of a COPD patient
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 38

39. 3. Pneumonia:
 Dyspnoea, Pleuritic pain, fever, and cough are typical
accompanying symptoms.
 Examination reveals tachypnea, inspiratory crackles, and
sometimes bronchial breathing.
 Laboratory testing (inflammatory parameters), chest x-ray,
and in some cases chest CT are diagnostically helpful.
4. Interistitial Lung Diseases (ILD):
 Patients report chronic shortness of breath and
nonproductive cough, and they are often smokers.
 Examination reveals crackling rales at the bases, and
sometimes also digital clubbing and hourglass nails.
 Pulmonary function testing reveals low vital capacity (VC)
and total lung capacity (TLC). Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 39

40. Right Middle lobe Pneumonia
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 40

41. 5. Pulmonary Embolism:
 Often characterized by dyspnea of acute onset with pleuritic
pain and sometimes have hemoptysis.
 Examination reveals shallow breathing and tachycardia,
Tachypnoea, hypotension.
 History of DVT, recent Surgery, Long bone fracture or
prolonged immobilization or recent long travel.
 D-dimer test or CT of pulmonary artery are used for
diagnosis
6. Pneumothorax:
 Sudden-onset dyspnoea associated with unilateral chest pain
may indicate acute pneumothorax.
 On examination, breath sounds are unilaterally absent, and
percussion of the ipsilateral chest may reveal tympany.
 The trachea may also be deviated away from the lesionThursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 41

42. 7. Anaphylaxis:
 Exposed to a medication, food product, or insect bite.
 Sudden-onset dyspnoea is accompanied by cutaneous
manifestations , voice changes, a choking sensation, tongue
and facial oedema, wheezing, tachycardia, and hypotension.
8. Acute myocardial infarction:
 Presents with central chest pain radiating to the shoulders
and neck frequently accompanied by dyspnoea.
 O/E patient may be clammy and hypotensive.
 S3 or S4 gallop rhythm
 pulmonary rales.
 characteristic ECG changes,
 elevated cardiac enzymes
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 42

43. 9. Acute valvular insufficiency
 Acute dyspnoea,
 systolic murmur and signs of acute cardiovascular collapse
with hypotension, tachycardia, and pulmonary rales.
 An echocardiogram is typically required to establish the
diagnosis.
10. Aortic dissection
 Dyspnoea
 severe chest pain that may radiate to the back.
 hypotension and absent peripheral pulses.
 Emergency echocardiogram or a CT chest is used for
diagnosis. Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 43

44. 11. Congestive heart failure
 Presents with dyspnoea worsened by exertion,
 orthopnoea and paroxysmal nocturnal dyspnoea, elevated
neck veins, peripheral fluid retention, an S3 gallop
rhythm, and pulmonary congestion (fine bibasal rales) .
 The CXR shows characteristic signs of pulmonary venous
congestion with cardiomegaly.
 Echocardiography.
 Brain natriuretic peptide >100 pg/ml
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 44

45. CXR of CCF
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 45

46. 12. Pericardial tamponade
 Dyspnoea accompanied by neck vein and facial
engorgement, shock, peripheral cyanosis, and
tachycardia.
 An enlarged cardiac silhouette on CXR and a low-voltage
ECG, echocardiography.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 46

47. Pericardial Tamponade
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 47

48. 13. Psychogenic Breathlessness and Hyperventilation Syndrome
 Reach to this Diagnosis after excluding all the serious causes
of dyspnea
 Patient complain of ‘inability to take a deep enough breath’
leading to extra deep sighs being taken.
 Other symptoms-digital and perioral paresthesia, light
headedness, central chest discomfort or even carpo-pedal
spasm due to acute respiratory alkalosis
 Rarely disturbs sleep and frequently occurs at rest
 Provoked by stressful situation
 Can even be relieved by exercise
 ABG shows normal PaO2, low PaCO2 and alkalosis.
Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 48

49. Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 49

50. Any Querries???Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 50

51. Thursday,
September
12, 2019
Dr. Narendra P. Giri/An approachto the patient of Dyspnoea 51