The document discusses breathlessness/dyspnoea by defining it, describing its pathophysiology, types, differential diagnosis, clinical assessment, investigations, and treatment. Breathlessness has no defined receptors or localized brain representation and can be caused by health issues like exercise or diseases of the lungs, heart, or muscles. Its assessment considers consciousness, cyanosis, breathing efforts, oxygenation, speech, and cardiovascular status. Investigations may include chest X-rays, ECGs, blood gases, and tests to identify specific causes, while treatment depends on the initial diagnosis.

1. Breathlessness/Dyspnoea
DR.MD.SELIM BABU
PHASE-A RESIDENT, PSYCHIATRY
BSMMU

2. Definition
The feeling of an uncomfortable need to breathe.
It is unusual among sensations,as it has no defined receptors,no localised
representation in the brain,
And multiple causes both in health (e.g. exercise) and in
diseases of the lungs, heart or muscles.

3. Pathophysiology

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In cardiac failure, pulmonary congestion reduces lung compliance and can
also obstruct the small airways.
Reduced cardiac output also limits oxygen supply to the skeletal muscles
during exercise, causing early lactic acidaemia and further stimulating
breathing via the central chemoreceptors.

5. Type
 Acute Severe Breathlessness
 Chronic Exertional Breathlessness

6. Differential diagnosis/Causes

7. Acute Breathlessness

8. Clinical assessment
Airway obstruction, anaphylaxis and tension pneumothorax-require
immediate identification and treatment.
In the absence of an immediately life-threatening cause, the following
should be assessed and documented:
• level of consciousness
• degree of central cyanosis
• work of breathing (rate, depth, pattern, use of accessory
muscles)
• adequacy of oxygenation (SpO2)
• ability to speak (in single words or sentences)
• cardiovascular status (heart rate and rhythm, blood pressure (BP) and
peripheral perfusion

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 Raised jugular venous pressure and bi-basal crackles or diffuse wheeze-
Pulmonary oedema
Wheez and prolonged expiration- Asthma or COPD
Hyper-resonant hemithorax with absent breath sounds-Pneumothorax
Severe breathlessness with normal breath sounds-PE
Leg swelling may suggest cardiac failure ,venous thrombosis(asymmetrical)
The presence of wheeze is not always indicative of bronchospasm.

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Rapid, shallow respiration, and wheeze (sometimes known as cardiac
asthma),Sitting upright or standing may provide some relief,may be unable to
speak and is typically distressed, agitated, sweaty and pale,recruitment of
accessory muscles, coughing and wheezing.Sputum may be profuse, frothy
and blood-streaked or pink. Extensive crepitations and rhonchi are usually
audible in the chest and there may also be signs of right heart failure-Acute
Heart Failure

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 Breathlessness with classic mid-diastolic rumbling murmur with pre-
systolic accentuation-the onset of atrial fibrillation in a patient with mitral
stenosis.Patients sometimes describe chest tightness as ‘breathlessness’.
 When breathlessness is the dominant or sole feature of myocardial
ischaemia, it is known as ‘angina equivalent’. A history of chest tightness or
close correlation with exercise should be sought.

13. Chronic Exertional Breathlessness
The cause of breathlessness is often apparent from a careful clinical history.
Key questions are detailed below-
1.How is your breathing at rest and overnight?
 In COPD-Breathlessness is apparent mainly when walking and patients
usually report minimal symptoms at rest and overnight.
 In Asthma -often woken from their sleep by breathlessness with chest
tightness and wheeze.
 Orthopnoea is common in COPD, as well as in heart disease,

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2.How much can you do on a good day?
 Variability within and between days is a hallmark of asthma; in mild
asthma, the patient may be free of symptoms and signs when well.
 Gradual,progressive loss of exercise capacity over months and years,with
consistent disability over days, is typical of COPD.
 Progressive breathlessness present at rest,accompanied by a dry cough,
suggests interstitial fibrosis.

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Chronic exertional breathlessness, cough and wheeze,history of
angina,hypertension or myocardial infarction raises the possibility of a cardiac
cause.
Confirmed by a displaced apex beat, a raised JVP and cardiac murmurs
(although these signs can occur in severe hypoxic lung disease with fluid
retention).

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3.Did you have breathing problems in childhood or at school?
 a history of childhood wheeze or atopic allergy increases the likelihood of
asthma.
4.Do you have other symptoms along with your breathlessness?
 Digital or perioral paraesthesiae and a feeling that ‘I cannot get a deep
enough breath in’ are typical features of psychogenic hyperventilation.
Additional symptoms include lightheadedness, central chest discomfort or
even carpopedal spasm. Psychogenic breathlessness rarely disturbs sleep,
frequently occurs at rest, may be provoked by stressful situations and may
even be relieved by exercise.

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Morning headache with breathlessness may signal the onset of carbon
dioxide retention and respiratory particularly significant in patients with
musculoskeletal disease impairing respiratory function (e.g.kyphoscoliosis or
muscular dystrophy).

19. Investigations
 CBC-Anaemia
 Chest X-ray
 ECG
 ABG
findings will usually indicate the primary cause of breathlessness.
 Throat swab-In cases of suspected viral infection
 Sputum for culture (If available)
 Peak expiratory fow measurement -If bronchospasm is suspected for assessment of severity.
 Procalcitonin (PCT)
 N-terminal pro-hormone brain natriuretic protein(NT-proBNP).
 CT imaging
 Echocardiography
 Troponin ,Serum Creatinine,S.Electrolytes

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Chest X-ray
a)Prominent pulmonary vasculature in upper zone:
pulmonary venous hypertension
b)Enlarged central pulmonary arteries:
pulmonary artery hypertension
c)Enlarged cardiac silhouette-
Dilated cardiomyopathy, valvular disease
d)Pleural effusion-
CHF ,TB, Pneumonia, Pulmonary embolism
e)Cosolidation- Pneumonia
f)Hyper inflation-COPD,Asthma
g) Often normal ,Prominent hilar vessels, oligaemic lung fields-Massive
PE

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ECG
 Sinus tachycardia, ischaemia*,arrhythmia –Pulmonary oedema
 Sinus tachycardia, RBBB, S1Q3T3 pattern↑T(V1–V4)-Massive PE
 signs of right ventricular strain-COPD

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 Elevated PCT is a biomarker for bacterial infection helping decide the need
for and duration of antibiotic therapy in patients with confirmed viral
respiratory disease (such as COVID-19).
 Elevated NT-proBNP is suggestive of underlying left ventricular failure. can
be elevated in other condition(renal failure, COPD, pulmonary
hypertension and pulmonary embolism).
 Individuals with suspected heart failure should undergo early
echocardiography.

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 CT imaging (with or without pulmonary angiography) is a useful
investigation in many respiratory conditions as interstitial changes,
tumours or consolidation may not be evident on chest X-ray.
 Angina equivalent-myocardial ischaemia from stress testing may help to
establish the diagnosis, although coronary artery angiography (either by
CT or cardiac catheterisation) is often performed early in the investigation
pathway.

24. Treatment
 Depending the initial aetiological clues, further diagnostic work-up is
planned and the patient is administered appropriate specific treatment
accordingly.

25. Acute Breathlessness in a Nutshell

26. Acute Breathlessness in a Nutshell

27. Thank You