An approach to a

patient with
breathlessness
Contents:
 Definition
 Grades of breathlessness
 Common causes
 History taking
 Physical examination
 Differential diagnosis
 Investigations
 Basic management
Definition:

Dyspnea may be defined as 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.
Or
Breathlessness or dyspnoea can be defined as the feeling of
an uncomfortable need to breathe.
The Modified Medical Research Council
Dyspnea Scale:
Grade Description
0 Not troubled by breathlessness, except with strenuous
exercise
1 Shortness of breath walking on level ground or with walking
up a slight hill
2 Walks slower than people of similar age on level ground due
to breathlessness, or has to stop to rest when walking at own
pace on level ground
3 Stops to rest after walking 100 m or after walking a few
minutes on level ground
4 Too breathless to leave the house, or breathless with activities
of daily living (e.g., dressing/ undressing)
Causes of breathlessness:
system Acute dyspnea
Cardiovascular Acute pulmonary oedema
Respiratory Acute severe asthma
Acute exacerbation of COPD
Pneumothorax
Pneumonia
Pulmonary embolus
ARDS
Inhaled foreign body (especially in children)
Lobar collapse
Laryngeal oedema (e.g. anaphylaxis)

others Metabolic acidosis (e.g. diabetic ketoacidosis, lactic

acidosis, uraemia, overdose of salicylates, ethylene glycol
poisoning)
Psychogenic hyperventilation (anxiety- or panic-related)
Causes of breathlessness:
system Chronic exertional dyspnea
Cardiovascular Chronic heart failure
Myocardial ischaemia (angina equivalent)
Respiratory COPD
Chronic asthma
Lung cancer
Interstitial lung disease (sarcoidosis, fibrosing alveolitis,
extrinsic allergic alveolitis, pneumoconiosis)
Chronic pulmonary thromboembolism
Lymphatic carcinomatosis (may cause intolerable
breathlessness)
Large pleural effusion(s)
others Severe anaemia
Obesity
Deconditioning
History taking:

 Particulars of patient:
 Name
 Age
 Sex
 Occupation
 Address
 Date of admission
 Chief complaints:
1. Shortness of breath for how many days or weeks

 History of presenting illness:

onset: sudden or gradual
progression: worsen or better
severity: MRCA grading
diurnal variability: worsen at night/morning-asthma
postural variability: orthopnoea, paroxysmal nocturnal dyspnea-CVD
aggravating factor: pollen, dust,cold climate-asthma
relieving factor: rest, medication
Associated symptoms:
 Cough: yes/no
o >if yes: onset,duration, progression
o Frequency, severity
o Diurnal variation: might indicate asthma
o Postural variation: might indicate bronchiectasis
o productive or dry cough
 Sputum:
o How much? Frequency?- copious amount suggestive of bronchiectasis
o Colour? White(viral), yellowish( bacteria), rusty( pneumonia)
o Consistency? Smell?
 Haemoptysis:
o Duration, onset, progression
o Amount of blood?
o Associated with malena or epistaxis?

 Chest pain:
o Onset, duration, progression
o Site? Central or peripheral; unilateral or bilateral?
o Type of pain
o Radiation: CVS pathology
o Relieving factors
o Grading
 Fever: onset, duration, progression, high/low grade, associated with
Chills and rigor, night sweat
(Evening rise of temperature-TB)
 Weight loss: TB, malignancy
 Palpitation: CVS pathology
 Past history:
History of TB, asthma, IHD, chest trauma, surgery,similar complaints, DM,HTN
 Personal history:
o Diet, addiction
o Smoking- highly associated with COPD
 Family history:
o Asthma, TB , malignancy
o Anyone with similar complaints
General examination:

Initial vital signs might be helpful in pointing toward an underlying etiology in the
context of the remainder of the evaluation. The physical examination should begin
during the interview of the patient.
 Appearance
 Body build & nutritional status (BMI-obesity/under weight)
 Co-operation
 Decubitus ( propped up- COPD, LVF)
 Anaemia
 Jaundice
 cyanosis: cardiac failure, COPD, pulmonary edema, Massive pulmonary emolus
General examination:

 Vital sign:
 Pulse rate: bradycardia-MI, tachycardia-pneumonia,
 Blood pressure: hypotension-MI, pnuemothorax, HTN- cardiac failure
 Temperature: high-TB, pneumonia
 Respiratory rate: tachypnea- pulmonary embolism, anxiety bradypnea-MI,
pulsus paradoxus
 Clubbing: carcinoma, bronchiectasis, lung abscess
 JVP: increased in right heart failure caused by pulmonary hypertension in severe
lung disease such as COPD
General examination:
 Pedal edema: bilateral in CCF
 Lymph node
 Flapping Tremor & bounding pulse: Acute exacerbation of COPD
 Acetone breath with air hunger & dehydration – Metabolic acidosis
Systemic examination
 Respiratory:
 INSPECTION
 Shape of chest-
Barrel chest- COPD
 Suprasternal & supraclavicular excavation- COPD
 Use of accessory muscles-COPD, Ashtma
 Movement- may be restricted
Unilateral: pleural effusion , pneumothorax, consolidation
Bilateral: COPD
 PALPATION:
 Tracheal Deviation:
Same side- Massive lung collapse
Fibrosis
Opposite side- Pneumothorax
Massive pleural effusion
 Shifted apex beat: Right sided pleural effusion
Right sided pneumothorax
 Reduced expansibility: Emphysema
Collapse
Fibrosis
Consolidation
 Vocal fremitus: Increased in- Consolidation
Fibrosis
Collapse with patent bronchus
Cavitation
 Decreased vocal fremitus in- Pleural effusion
Pneumothorax
Collapse with obstructed bronchus
 Percussion:
 Hyperresonant- Pneumothorax, Emphysema
 Dull- consolidation, collapse, fibrosis
 Stony dull- pleural effusion
 Auscultation:
 Breath sound: vesicular with prolong expiration- COPD, Asthma
Bronchial- consolidation, collapse, fibrosis
 Added sound:
Crepitation-Pulmonary edema due to LVF
End inspiratory fine crepitation in ILD
Rhonchi- Bronchial asthma
COPD
 Vocal resonance:
Increased in- Decreased in-
Consolidation Pneumothorax
Fibrosis Pleural effusion
Collapse with patent bronchus Collapse with
Cavitation obstructive bronchus
 Cardiovascular system:
 Inspection: Cheyne- Stocks Respiration
 PALPATION: Apex beat : shifted downward & outwards with heaving
character in CCF
 AUSCULTATION:
 Loud P₂- Pulmonary HTN
 Gallop rhythm – LVF
 Bilateral basal crepitation- Pulmonary oedema due to LVF
 Murmurs- Vulvular Heart disease
 Abdominal examination:
 Paradoxical movement of abdomen –
Diaphragmatic weakness
 Tender Hepatomegaly- CCF
Metastasis
 Huge Ascites may causes mechanical breathlessness
 Rounding of the abdomen during exhalation-
Pulmonary oedema
Differential diagnosis
Investigation:
 Routine investigations:
 CBC ( Hb%, TC, DC, ESR)
 Chest X-ray
 Blood glucose
 Serum creatinine
 ECG
 Others investigations:
 Arterial blood gases
 Lung function test: Spiromerty with reversibility test, PEFR, Exercise test
 Skin prick test
 Serum IgE
 CRP
 Sputum for eosinophil count
 Serum electrolytes
 Blood urea
Management:

The first goal is to correct the underlying condition(s) driving dyspnea and address
potentially reversible causes with appropriate treatment for the particular condition.
 STABILIZATION OF VITAL SIGN-
 O₂ Inhalation- High flow high concentration is used except in COPD patients.
Low flow low concentration
 Opioids have been shown to reduce symptoms of dyspnea, largely through reducing air
hunger, thus, likely suppressing respiratory drive and influencing cortical activity.
 Bronchodilators help in relaxing muscles and improving muscle tone in the airways
 Acute Breathlessness

No important findings on

auscultation

May be Metabolic acidosis or

psychogenic
 Sudden onset of breathlessness at rest

 Orthopnea ,bilateral basal crepitation with leg oedema,

inappropriate bradycardia or excessive tachycardia

 ALVF
 Acute Breathlessness

Absent breath sound, hyper resonant

percussion note

 Pneumothorax
  Chronic breathlessness & dry cough

Clubbing & end inspiratory creps on

auscultation

 Interstitial Lung disease