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Churchill's Pocketbook of Differential Diagnosis , Fourth Edition

Andrew T. Raftery, Eric Lim, and Andrew J.K. Östör
, 114-120
© 2014 Elsevier Ltd. All rights reserved.

Dyspnoea
Dyspnoea is the uncomfortable awareness of breathing.

Causes

Sudden (Seconds to Minutes)

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Pneumothorax ( Fig. 15 )

Figure 15
A pneumothorax, visible on the right side.

Note the absence of lung markings at the periphery. The lung edge is visible (arrow).

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Chest trauma

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Aspiration

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Anxiety

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Pulmonary oedema

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Pulmonary embolism

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Anaphylaxis

Acute (Hours to Days)

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Asthma

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Respiratory tract infection

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Pleural effusion

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Lung tumours

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Metabolic acidosis

Chronic (Months To Years)

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Chronic airflow limitation (COPD)

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Anaemia

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Arrhythmia

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Valvular heart disease

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Cardiac failure

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Cystic fibrosis

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Idiopathic pulmonary fibrosis

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Chest wall deformities

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Neuromuscular disorders

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Pulmonary hypertension

History

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Many cardiac or respiratory diseases of sufficient severity produce dyspnoea. When considering chronic
respiratory causes, you may relate them anatomically to diseases of the pulmonary vasculature, airways,
interstitium and chest wall. When approaching a patient with dyspnoea, it is important to ensure that the ABC are
attended to before continuing with the diagnostic process.

Onset

The speed of onset is a useful indicator of the disease process. Classification by speed of onset narrows the
differential diagnosis in urgent clinical situations.

Precipitating factors

An obvious precipitating factor may be present, such as trauma causing either fractured ribs or a pneumothorax.
Aspiration of a foreign body may be determined from the history; however, aspiration of vomit is more difficult, as
it usually occurs in patients with decreased consciousness levels or who have lost the gag reflex. Dyspnoea on
recumbency is caused by cardiac failure; occasionally patients may complain of waking up at night gasping for
breath when they slide down the pillows (paroxysmal nocturnal dyspnoea). Dyspnoea associated with asthma
may be seasonal (grass pollen) or perennial (house-dust mite faecal proteins), depending on the precipitating
allergen. A history of severe allergy should lead to the consideration of anaphylaxis. Stressful events can
precipitate asthma attacks but may also cause anxious patients to hyperventilate.

Relieving factors

Dyspnoea resulting from cardiac failure may be relieved by sitting upright, and, when due to asthma, by beta
agonists.

Associated factors

Cough productive of (green, yellow, rusty) sputum indicates the presence of a chest infection. This may be the
primary cause or it may exacerbate dyspnoea in patients with an existing condition such as asthma, COPD or
cardiac failure. Bloodstained sputum may result from a chest infection (especially TB), pulmonary embolism or a
tumour. Wheezing may result from asthma or aspiration of a foreign body.

Examination

Inspection

Cyanosis, which is observed from the fingertips (peripheral) or in the mucous membranes (central), is an indicator
of severe underlying disease. Decreased consciousness level may indicate a life-threatening situation. However, it
may also be the presenting feature of patients with a metabolic acidosis (diabetic ketoacidosis). Kyphosis severe
enough to cause dyspnoea should be evident on general inspection. Patients with COPD may appear barrel-
chested and cyanosed or thin and tachypnoeic (with pursed-lip breathing) accompanied by the prominent use of
the accessory musculature.

The respiratory rate per se may not be very specific but extremes may be indicators of severity of the underlying
disease. The respiratory rate should be carefully counted and not just estimated.

The hands should be inspected for clubbing, as it is associated with bronchial carcinoma and idiopathic pulmonary
fibrosis (p. 64).

Pulse

A change in rate or regularity of rhythm may indicate an arrhythmia as a precipitating factor (usually in
pre-existing heart or lung disease). The rate itself is not, however, very specific to the underlying aetiology.

JVP

Acute elevation of the JVP suggests tension pneumothorax, pulmonary embolism, cardiac tamponade or tricuspid
regurgitation (prominent v waves). Chronic elevation results from congestive heart failure or any chronic lung
disease with right heart failure (cor pulmonale).

Temperature

An elevated temperature may occur with a chest infection and pulmonary embolism.

Trachea

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The trachea deviates away from the side of a tension pneumothorax, pleural effusion and any large mass. It
deviates to the side of a collapsed segment, which can result with obstruction of the bronchial lumen from tumour
or foreign bodies.

Expansion

May be reduced on the side of an area of consolidation (infection), pneumothorax and effusion. It may be
reduced bilaterally in patients with COPD.

Percussion

The area overlying consolidation, effusion or collapse is dull to percussion. Hyper-resonance is often described on
the affected side of a pneumothorax; however, a ‘relative dullness’ of the unaffected side is the usual initial
finding.

Auscultation of the precordium

Auscultation may reveal murmurs associated with valvular heart disease. The presence of a third heart sound is
consistent with cardiac failure, and quiet heart sounds may be due to an overexpanded chest from COPD.

Breath sounds

Localised reduction in the intensity of breath sounds occurs over areas with consolidation or collapse of the lung;
however, it may be reduced generally with asthma and COPD.

Added sounds

Wheezing may be appreciated in a localised area following intraluminal airway obstruction from an inhaled foreign
body or tumour. Generalised wheezing usually occurs with asthma. When a history of pre-existing asthma is not
evident, then consider anaphylaxis. Localised crepitations may be auscultated over areas of pulmonary
consolidation. Extensive bilateral crepitations occur with idiopathic pulmonary fibrosis (fine inspiratory), pulmonary
oedema and bronchopneumonia.

General Investigations

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FBC

Hb ↓ points to anaemia as the primary cause or as an exacerbating factor of underlying disease. Hb ↑

(polycythaemia) may be seen in chronic lung disease. WCC ↑ usually indicates infection, but it can also
occur with other conditions, such as pulmonary embolism.

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Peak expiratory flow rate

This simple bedside test allows you to evaluate airflow limitation. A reduced flow rate may indicate asthma
or chronic airflow limitation.

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ECG

Arrhythmias are readily appreciated on the ECG; atrial fibrillation or supraventricular tachycardia may
precipitate dyspnoea in patients with pre-existing heart or lung disease. However, an arrhythmia may be a
manifestation of the underlying cause, such as myocardial infarction, pulmonary embolism and hypoxia. ST
segment elevations occur with myocardial infarction and are also a non-specific finding in pulmonary
embolism. Right bundle-branch block may occur in the presence of longstanding lung disease.

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Pulse oximetry

Although low saturation per se is not very discriminatory, acute severe impairment of oxygen saturation is
associated with pulmonary embolus and pneumothorax. Post-exercise desaturation is helpful if
opportunistic pneumonia is suspected.

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ABGs

Useful to quantify severity of the disease and subtype of respiratory failure. Normal levels of oxygenation,
however, are not useful to exclude respiratory or cardiac disease. Low levels of bicarbonate indicate
metabolic acidosis and should lead to the investigation of the underlying cause, such as diabetic
ketoacidosis. An alkalosis (high pH) with low Pco 2 and high Po 2 points to hyperventilation. CO 2 retention
may result from chronic lung disease (type II respiratory failure) or may indicate the need for ventilation
with co-existing hypoxia in asthmatics.

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Serum cardiac markers

Cardiac troponin or CK-MB is elevated with myocardial infarction in the setting of acute left ventricular
failure.

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CXR

Hyperinflation of the lungs (if the hemidiaphragm is below the 7th rib anteriorly or the 12th rib posteriorly)
is a feature of emphysema, and may also result from asthma. Areas of consolidation are seen on a plain
film; however, radiographic changes of a chest infection may lag behind in time with the clinical findings.
The presence of cardiac failure is appreciated by cardiomegaly, upper lobe diversion of the pulmonary
veins, bilateral pleural effusions, Kerley B lines (1–2 cm horizontal lines in the periphery of the lung fields)
and patchy pulmonary oedema. A pneumothorax may be diagnosed by identifying the line of the pleura and
the absence of lung markings beyond it. Bronchial carcinoma may present as a hilar mass, peripheral
opacity or collapse and consolidation of the lung due to airways obstruction.

Specific Investigations

■
Sputum and blood cultures

Should be taken if an infective aetiology (pneumonia, lung abscess) is suspected, preferably before
antibiotics are administered.

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Respiratory function tests

Apart from physiological measurements of the lung, spirometry allows classification of restrictive or
obstructive lung defects. It can also provide information regarding severity of the disease and the
response to inhaled bronchodilators. Flow volume loops can indicate fixed airways obstruction (plateau in
the expiration phase), which can result from foreign body or intraluminal tumour. Restrictive pattern of
ventilatory impairment is characterised by a normal FEV1 to FVC ratio and a reduced vital capacity. It is
characteristic of pulmonary fibrosis, infiltrative lung disease and restriction of chest wall motion.
Obstructive pattern of ventilatory impairment is characterised by a reduced FEV1 to FVC ratio and a
normal vital capacity. It is characteristic of asthma, COPD, bronchiectasis and cystic fibrosis.

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Bronchoscopy

Bronchoscopy should be performed if aspiration of a foreign body is suspected, the procedure can be both
diagnostic and therapeutic. Intraluminal bronchial carcinomas may be visualised and biopsied.
Bronchoscopy also allows collection of specimens for culture in the diagnosis of pneumonia.

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CT thorax/pulmonary angiogram

The majority of pulmonary emboli may be diagnosed by CT pulmonary angiography. In addition, complete
visualisation of the thorax by CT is useful to evaluate masses of unknown aetiology, and for staging of
bronchial carcinoma. High-resolution CT is useful to screen for features of idiopathic pulmonary fibrosis.

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Echocardiography

An echocardiogram is indicated if cardiac failure or valvular heart disease is suspected. A large pulmonary
embolus can be diagnosed by a finding of right heart failure and elevated pulmonary artery pressures.
Elevated pulmonary artery pressures can also be caused by pulmonary hypertension causing dyspnoea.
Although a proportion are idiopathic, known causes are congenital heart disease, any severe lung disease
and recurrent pulmonary emboli.

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Cyanosis associated with dyspnoea is an ominous sign. Emergency admission and treatment is required.

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Pneumothorax is commoner in asthmatics. If an asthmatic suddenly becomes short of breath, consider
pneumothorax as a possible diagnosis.

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Sudden onset of breathlessness in an elderly patient may be due to LVF. This may be the result of a
myocardial infarction.

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Always remember an inhaled foreign body as a possible cause of acute dyspnoea.

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