Key Clinical Updates in Dyspnea
Point-of-care ultrasonography (POCUS) consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, PE, pleural effusion, or pneumothorax. Specificities increased in most, but not all, studies; in-hospital mortality and length of hospital stay, however, did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests.
Gartlehner G et al. Ann Intern Med. [PMID: 33900798]
Fever, cough, risk of COVID-19, and chest pain.
Vital sign measurements; pulse oximetry.
Cardiac and chest examination.
Chest radiography and arterial blood gas measurement in selected patients.
Dyspnea is a subjective experience or perception of uncomfortable breathing. There is a lack of empiric evidence on the prevalence, etiology, and prognosis of dyspnea in general practice. The relationship between level of dyspnea and the severity of underlying disease varies widely among individuals. The prevalence of dyspnea increases with age, and undifferentiated dyspnea is multifactorial in older adults and may be associated with obesity. Dyspnea can result from conditions that increase the mechanical effort of breathing (eg, asthma, COPD, restrictive lung disease, respiratory muscle weakness, Parkinson disease, obesity hypoventilation syndrome), alveolar lung disease (pulmonary edema, pneumonia, alveolar proteinosis), interstitial lung disease (such as hypersensitivity pneumonitis), conditions that produce compensatory tachypnea (eg, hypoxemia, acidosis), primary pulmonary vasculopathy (pulmonary hypertension), or psychogenic conditions. Obese patients may have an increased perception of dyspnea associated with systemic inflammation and excessive ventilation for metabolic demands during exercise. Dyspnea may be underdiagnosed and undertreated in critically ill patients. Dyspnea during episodes of acute coronary syndrome (ACS) without signs of HF is an independent predictor of mortality at 1-year (9% vs. 4%).
The duration, severity, and periodicity of dyspnea influence the tempo of the clinical evaluation. Rapid onset or severe dyspnea in the absence of other clinical features should raise concern for pneumothorax, PE, or increased left ventricular end-diastolic pressure (LVEDP).
Spontaneous pneumothorax is usually accompanied by chest pain and occurs most often in thin, young males and in those with underlying lung disease. PE should always be suspected when a patient with new dyspnea reports a recent history (previous 4 weeks) of prolonged immobilization or surgery, estrogen therapy, or other risk factors for DVT (eg, previous history of thromboembolism, cancer, obesity, lower extremity trauma) and when the cause of dyspnea is not apparent. Silent MI, which occurs more frequently in persons with diabetes and women, can result in increased LVEDP, acute HF, and dyspnea.
Although no symptom description is adequately sensitive or specific for identifying a condition, chest "tightness" was found in a study to be unique for asthma and "shallow breathing" was unique for interstitial lung disease. Accompanying symptoms provide important clues to causes of dyspnea. When cough and fever are present, ...