Dyspnea

Dyspnea
ICD-10	R06.8
ICD-9	786.0
DiseasesDB	15892
MedlinePlus	003075
MeSH	C08.618.326

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Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/), from Latin dyspnoea, from Greek dyspnoia from dyspnoos, shortness of breath) or shortness of breath (SOB) is perceived to be difficulty of breathing or painful breathing. It is a common symptom of numerous medical disorders.

Dyspnea on exertion (DOE or exertional dyspnea) indicates dyspnea that occurs (or worsens) during physical activity.

Causes of Acute Dyspnea

• Acute heart failure
• Acute papillary muscle rupture
• Cardiac tamponade
• Foreign body aspiration
• Spontaneous pneumothorax
• H. influenza epiglottitis
• Bronchospasm
• Pulmonary edema

Diagnosic Evaluations

• History
• Physical examination: All patients should be evaluated for underlying diseases (especially heart and lung diseases). Detecting of following symptoms and signs are important:

• Heart murmurs
• S3, S4
• Crackles, rales
• Jugular venous distension
• Peripheral edema
• Wheezing
• Palpation of peripheral arteries
• Leg swelling / leg pain / tenderness
• Chest pain / chest tightness
• Fever

• Complete blood count
• Thyroid function tests
• Chest x-ray
• Electrocardiography
• Echocardiography
• Spirometry
• Pulse oximetry
• Exercise stress test (Treadmill test)
• Arterial blood gases
• Pulmonary function tests
• Cardiopulmonary exercise testing

Complete Differential Diagnosis of Causes of Dyspnea

In alphabetical order.

Obstructive lung diseases

• Asthma
• Bronchitis
• Chronic obstructive pulmonary disease
• Cystic fibrosis
• Emphysema
• Hookworm disease
• Laryngeal edema due to allergies
• Tuberculosis

Diseases of lung parenchyma and pleura

Contagious

• Anthrax through inhalation of Bacillus anthracis
• Pneumonia

Non-contagious

• Fibrosing alveolitis
• Atelectasis
• Hypersensitivity pneumonitis
• Interstitial lung disease
• Lung cancer
• Pleural effusion
• Pneumoconiosis
• Pneumothorax
• Non-cardiogenic pulmonary edema or acute respiratory distress syndrome
• Sarcoidosis

Pulmonary vascular diseases

• Acute or recurrent pulmonary emboli
• Pulmonary hypertension, primary or secondary
• Pulmonary veno-occlusive disease
• Superior vena cava syndrome

Obstruction of the airway

• Cancer of the larynx or pharynx
• Empty nose syndrome
• Pulmonary aspiration
• Epiglottitis

Immobilization of the diaphragm

• Lesion of the phrenic nerve
• Polycystic liver disease
• Tumor in the diaphragm

Restriction of the chest volume

• Ankylosing spondylitis
• Broken ribs
• Kyphosis
• Obesity
• Pregnancy
• Pectus excavatum
• Scoliosis

Disorders of the cardiovascular system

• Aortic dissection
• Cardiomyopathy
• Congenital heart disease
• Heart failure
• Ischaemic heart disease
• Malignant hypertension
• Diseases of the pericardium
  • Cardiac tamponade
  • Constrictive pericarditis
  • Pericardial effusion
• Pulmonary edema
• Pulmonary embolism
• Valvular heart disease

Disorders of the blood and metabolism

• Anemia
• Hypothyroidism
• Metabolic acidosis
• Sepsis
• Leukemia

Disorders affecting breathing nerves and muscles

• Amyotrophic lateral sclerosis
• Guillain-Barré syndrome
• Multiple sclerosis
• Myasthenia gravis
• Parsonage-Turner syndrome
• Eaton-Lambert syndrome

Psychological conditions

• Anxiety disorders and panic attacks

Management of Patients with Dyspnea

Oxygen Supply

Oxygen supply is the essential part of acute dyspnea management.

Exercise Training

Controlled studies have shown that dyspnea upon exertion decreases and exercise tolerance improves in response to exercise training, even in patients with advanced disease. It is now well established that for patients with COPD who remain breathless despite optimal drug therapy, exercise training can confer significant symptomatic benefits.

Pharmacologic Therapy

Two types of medications have proven useful in alleviating dyspnea: opiates and drugs that reduce anxiety. A number of studies have shown that opiates acutely relieve dyspnea and improve exercise performance in patients with COPD.

The drugs to reduce anxiety have the potential to relieve ventilatory response related to the available amounts of oxygen in the blood, as well as by lowering the emotional response to dyspnea.

Fans

The movement of cool air with a fan has been observed to reduce dyspnea in pulmonary patients. A decrease in the temperature of the facial skin alters feedback to the brain and modifies the perception of dyspnea. Cool air has been shown in normal volunteers to reduce dyspnea in response to excess carbon dioxide in the blood.

Altered Breathing Patterns

Breathing retraining including diaphragmatic breathing and pursed lip breathing has been advocated to relieve dyspnea in COPD patients. During a breathing retraining period, many patients adopt slower, deeper breathing techniques; however, they often resort to spontaneous, fast, shallow breathing patterns when the training ends.

Continuous Positive Airway Pressure (CPAP)

In various studies, CPAP has been shown to relieve dyspnea during asthma attacks, when patients are being weaned from ventilators, and during exercise sessions for patients with advanced COPD.

Nutrition

Several investigators have shown improvement in respiratory muscle function in response to short-term use of nutritional repletion by an intravenous route.

Positioning

Patients with COPD often change body position to improve dyspnea. They tend to lean forward to improve overall respiratory muscle strength and to reduce their symptoms.

Steroids

Steroid use can be beneficial to pulmonary patients by reducing airway inflammation and by increasing vital capacity in chronic lung inflammation. However, steroids have adverse effects, including muscle wasting and weakness. These potential problems need to be balanced against possible gains in lung function associated with this drug.

Cognitive-behavioral Approaches In patients with different pain syndromes, distraction, relaxation, and education about symptoms have modified the intensity of pain, increased tolerance, and decreased distress. Improvements in dyspnea and anxiety have been shown to follow distractions such as music during exercise, although long-term effects have been minimal. However, exercise in a monitored, supportive environment has been shown to be a powerful method of overcoming apprehension, anxiety, and/or fear associated with exertional dyspnea.

See also

• Air hunger
• Tachypnea
• Bradypnea
• Eupnea
• Orthopnea
• Trepopnea
• Paroxysmal nocturnal dyspnea

Additional Resources

• Julie K. Stegman, Stedman's Medical Dictionary, 28th Edition, pages=601, Lippincott Williams & Wilkins, Baltimore, Maryland ISBN 0781733901

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