Assessing the
Breathless Patient
Dr Rodney Hughes
Locum Respiratory Physician
Overview
• What is breathlessness?
• Causes and patho-physiology
• Assessing severity
• Assessing the cause
• Approach to acute breathlessness
• Approach to chronic breathlessness
Defining Breathlessness
• Dictionary (Oxford and Free Online)
– “Difficulty breathing or altered sensation of
breathing”
– “Air Hunger”
– “Laboured respiration”
• Variety of qualifying medical terms
– Dyspnoea
– SOBOE, DOE, “DOA”
– Tachypnoea
– Orthopneoa
– Platypnoea
– Paroxysmal nocturnal dyspnoea
Simon PM et al Am Rev Respir Dis 1989;140:1021
Simon PM et al Am Rev Respir Dis 1989;140:1021
Simon PM et al Am Rev Respir Dis 1989;140:1021
Simon PM et al Am Rev Respir Dis 1989;140:1021
ATS Consenus Statement
“A subjective experience of breathing
discomfort that consists of
qualitatively distinct sensations that
vary in intensity.”
ATS Dyspnea Consensus, ARJCCM, 1999
Breathlessness
• Altered perception of normal pattern of breathing for an
individual
• Complex interaction of mechanical, neural and chemo-
tactic pathways
• A desirable physiological response
• Components of the description may indicate the
underlying cause but these are not specific
• Impairing this response may have undesirable
consequences
Causes of breathlessness
• Cardiac
– Myocardial / pump
dysfunction
– Valvular abnormalities
– Arrhythmia
• Pulmonary • Non-cardiopulmonary
– Upper airways – Haematological
obstruction – Acidosis, metabolic
– Impaired ventilation – Neuromuscular
– Impaired gas exchange – Functional
• Mixed
– Pulmonary vascular
disease
– De-conditioning
Triaging acute dyspneoa
Zoorob, Amer Fam Phys, 2003
Assessing acute dyspnoea
• Determine urgency of assessment
– Assess airway patency and listen to the lungs.
– Observe breathing pattern, including use of
accessory muscles.
– Monitor cardiac rhythm.
– Measure vital signs and pulse oximetry
– Obtain any history of cardiac or pulmonary
disease, or trauma.
– Evaluate mental status.
Immediate considerations
• Unstable patients requiring emergency care:
– Hypotension, altered mental status, hypoxia, or
unstable arrhythmia, central chest pain
– Stridor and breathing effort without air movement
(suspect upper airway obstruction).
– Unilateral tracheal deviation, hypotension, and
unilateral breath sounds (suspect tension
pneumothorax)
– Respiratory rate above 40 breaths per minute,
cyanosis, low oxygen saturation, signs of
respiratory distress.
Refer immediately
Immediate considerations
• Unstable patients requiring emergency care:
– Hypotension, altered mental status, hypoxia, or
unstable arrhythmia, central chest pain
– Stridor and breathing effort without air movement
(suspect upper airway obstruction).
– Unilateral tracheal deviation, hypotension, and
unilateral breath sounds (suspect tension
pneumothorax)
– Respiratory rate above 40 breaths per minute,
cyanosis, low oxygen saturation, signs of
respiratory distress.
Refer immediately
Immediate considerations
• Unstable patients requiring emergency care:
– Hypotension, altered mental status, hypoxia, or
unstable arrhythmia, central chest pain
– Stridor and breathing effort without air movement
(suspect upper airway obstruction).
– Unilateral tracheal deviation, hypotension, and
unilateral breath sounds (suspect tension
pneumothorax)
– Respiratory rate above 40 breaths per minute,
cyanosis, low oxygen saturation, signs of
respiratory distress.
Refer immediately
Immediate considerations
• Unstable patients requiring emergency care:
– Hypotension, altered mental status, hypoxia, or
unstable arrhythmia, central chest pain
– Stridor and breathing effort without air movement
(suspect upper airway obstruction).
– Unilateral tracheal deviation, hypotension, and
unilateral breath sounds (suspect tension
pneumothorax)
– Respiratory rate above 40 breaths per minute,
cyanosis, low oxygen saturation, signs of
respiratory distress.
Refer immediately
Differential diagnosis of stable
semi-acute patient
• Cardiac:
– Congestive heart failure, coronary artery disease, pericardial
effusion, arrhythmia, peri-myocarditis, sub-acute myocardial
infarction
• Pulmonary:
– Chronic obstructive pulmonary disease, asthma, pneumonia,
pneumothorax, pulmonary embolism, pleural effusion,
pulmonary oedema, gastroesophageal reflux disease with
aspiration, CO inhalation
– Upper airway obstruction: epiglottitis, foreign body, tracheitis,
Epstein-Barr virus, angio-oedema
• Non-cardiopulmonary
– Psychogenic: panic attacks, hyperventilation, pain, anxiety
– Endocrine: metabolic acidosis, medications
– Central: neuromuscular disorders, pain, aspirin overdose
Clues of Symptoms or history Possible diagnosis
Nocturnal Cough Asthma, GORD
Severe sore throat Epiglottitis
Pleuritic chest pain Pericarditis, pulmonary embolism,
pneumothorax, pneumonia, empyema
Orthopneoa, nocturnal paroxysmal Congestive heart failure
dyspneoa, oedema
Recent trauma, surgery, pregnancy or Pulmonary embolism
prolonged immobility
Haemoptysis Pulmonary embolism, malignancy,
bronchiectasis, pulmonary vasculitis / AVM
Orthopnoea, weakness, hoarseness of voice Neuro-muscular weakness, daiphragmatic
dysfunction
Tobacco use Chronic obstructive pulmonary disease,
congestive heart failure
Indigestion, dysphagia, cough after eating GORD, aspiration (foreign body)
Barking cough Croup, tracheo-bronchitis
Physical Exam Finding Clues Possible diagnosis
Wheezing, pulsus paradoxus, accessory muscle use Acute asthma, COPD
exacerbation
Wheezing, clubbing, barrel chest, decreased breath sounds, COPD exacerbation (+/- acute
flap, peripheral vasodilation CO2 retention)
Fever, crackles, increased fremitus, bronchial breathing Pneumonia
Oedema, neck vein distension, S3 or S4, hepatojugular Congestive heart failure,
reflux, murmurs, crackles, hypertension, wheezing pulmonary oedema
Pleuritic rub, tachycardia, lower extremity swelling Pulmonary embolism
Absent breath sounds, hyper-resonance Pneumothorax
Inspiratory stridor, rhonchi, tracheal tug Croup, tracheitis
Stridor, drooling, fever Epiglottitis
Stridor, wheezing, persistent pneumonia Foreign body aspiration
Wheezing, flaring, intercostal retractions Bronchiolitis
Sighing, peripheral or peri-oral paraesthesia Hyperventilation
Suggested Investigations
• First Line
– ECG
– Chest Xray
– Blood tests: Full blood count, CRP
– PEFR / Spirometry
• Consider
– D-dimer
– Plasma BNP (if available)
Refer if cause not immediately obvious
Zoorob, Amer Fam Phys, 2003
Chronic dyspnoea
• Breathlessness lasting more than 1 month
• Broader differential diagnosis
• Key components of history:
– Duration
– Pattern of deterioration
– Loss of function / activity
– Associated symptoms
Assessing severity of chronic
dyspnoea
What you test differs with the question:
• End –exercise dyspneoa: Borg/VAS
• Dyspneoa limiting daily activity: NYHA/MRC
• Presence of dyspneoa in the day: Diary
• Impact of dyspneoa on well being:
SGRQ/CRQ/MLWHF
Modified MRC Score
0 None Not troubled by breathlessness
1 Slight Troubled by shortness of breath when hurrying on
the level or walking up a slight hill
2 Moderate Walks slower than people of the same age on the
level because of breathlessness
3 Moderate- Has to stop because of breathlessness when
severe walking at own pace on the level
4 Severe Stops for breath after walking about 100 yards or a
few minutes on the level
5 Very severe Too breathless to leave the house or breathless
when dressing or undressing
MRC score in COPD
Bestell, Thorax 1999
NYHA Classification
I Patients with impaired cardiac function but no limitation of
activities; they suffer no symptoms from ordinary activities.
II Patients with slight, mild limitation of activity; they are
comfortable with rest or with mild exertion.
III Patients with marked limitation of activity; they are
comfortable only at rest.
IV Patients who should be at complete rest, confined to bed or
chair; any physical activity brings on discomfort and
symptoms occur at rest.
Differential diagnoses in
chronic dyspneoa
• Cardiac:
– Congestive heart failure, coronary artery disease, arrhythmia, restrictive
cardiomyopathy, recent myocardial infarction
• Pulmonary:
– Chronic obstructive pulmonary disease, asthma, bronchiectasis, interstitial lung
disease, sarcoidosis, malignancy, pulmonary embolism, pleural effusion, chronic
pulmonary oedema
– Upper airway obstruction: Tracheal stenosis, vocal cord dysfunction
• Mixed:
– Chronic thrombo-embolic pulmonary hypertension, pulmonary arterial hypertension
• Non-cardiopulmonary
– Obesity
– Metabolic: uraemia, hypothyroidism, cirrhosis
– Psychogenic: panic attacks, hyperventilation, pain, anxiety
– Central: neuromuscular disorders, pain
– Haematological: anaemia, malignancy
Findings Clinical conditions
Intermittent breathlessness; triggering Asthma
factors; allergic rhinitis; nasal polyps;
prolonged expiration; wheezing
Significant tobacco consumption; barrel Chronic obstructive pulmonary disease
chest; prolonged expiration; wheezing
History of hypertension, coronary artery Congestive heart failure
disease, or diabetes; orthopneoa; PND;
pedal oedema; jugular vein distension; S 3
gallop; bibasilar crackles; wheezing
History of generalized anxiety disorder, panic Anxiety disorder; hyperventilation
disorder; intermittent symptoms; sighing
breathing
Postprandial dyspnea Gastroesophageal reflux disease;
aspiration; food allergy; coronary
artery disease
Haemoptysis Lung neoplasm; pneumonia;
bronchiectasis; mitral stenosis;
arteriovenous malformation
Findings Clinical conditions
Recurrent pneumonia Lung cancer; bronchiectasis; aspiration;
organising pneumonia
Drug exposure Beta blockers aggravating airways disease
Amiodarone / nitrofurantoin / Methotrexate
lung fibrosis
Illicit drugs (e.g., heroin): talcosis
History of immunosuppressive disease Opportunistic infections: Pneumocystis carinii
or therapy; acquired pneumonia; bacterial (tuberculosis;
immunodeficiency syndrome Legionella); viral (cytomegalovirus); or
fungal (Aspergillus)
Exposure to inorganic dust, asbestos, Pneumoconiosis; silicosis; berylliosis; coal
or volatile chemicals workers lung; asbestosis
Organic exposure to dust (birds, Hypersensitivity pneumonitis (bird fancier's
laboratory workers) lung)
Abnormal inspiratory or expiratory Central airway obstruction; vocal cord
sounds heard over the trachea paralysis; tracheal stenosis
Accentuated P2; right ventricular Pulmonary hypertension
heave; murmurs
Suggested Investigations
• First line
– ECG
– Chest Xray
– Spirometry with reversibility
– Blood testing: Full blood count, chemistry, CRP
and viscosity / ESR / ANA
• Consider
– Echocardiography, plasma BNP
– Full pulmonary function tests
– Exercise assessment- 6MWT, Step test, CPET
– HRCT chest
Karnani, Amer Fam Phys,
2005
Summary
• Breathlessness is a complex subjective experience that
varies significantly between individuals
– Determining specific aspects of their experience may aid
diagnosis
• Cardiopulmonary disease is the most common cause
• Patients with acute breathlessness requiring urgent
attention are usually recognisable
• The differential diagnosis of acute and chronic
breathlessness is varied and requires a systematic
approach
