Dyspnea

Diagnosis/Definition

Symptoms of difficult, labored, uncomfortable breathing, often associated with various diseases (of respiratory, cardiac, endocrine, renal, neurologic, hematologic or rheumatologic origin) or from psychologic disturbances.

Initial Diagnosis and Management

Made from history, with clarifying features to include timing, place and position at onset, relationship to physical activity, aggravating or precipitating factors, ameliorating factors, presence of related conditions, and changes in overall health status.
Physical exam: assess respiratory rate, technique of breathing (i.e., pursed lip, accessory muscle use), lung auscultation with forced exhalation, cardiac exam, clubbing, and peripheral edema. Cyanosis is an insensitive sign.
Laboratory: chest radiograph, pulmonary spirometry, ECG may be helpful.
Consider for acute dyspnea: airway obstruction, pneumothorax, pulmonary embolus, pulmonary edema, pneumonia or pulmonary hemorrhage.
Consider for chronic dyspnea: airways disease, lung parenchymal disease, pneumonia, pulmonary vascular disease, pleural process, chest wall abnormality, anemia, deconditioning, cardiac disease, thyroid disease or neuromuscular process.
If patient is active but symptoms of dyspnea always occur with nonexertion, the etiology of dyspnea is much less likely from organic disease. This symptom complex can be approached with more reassurance and primary care follow-up.

Ongoing Management and Objectives

Persisting dyspnea associated with organic lung disease can be troublesome to treat. Treatment of the underlying process (beta agonists and controller medication for asthma, diuresis and after load reduction for CHF, oxygen for the patient with COPD and significant desaturation) does not always alleviate dyspnea. Consider codeine or adjustments in activities of daily living.

Indications for Specialty Care Referral

Cause of dyspnea not apparent after thorough evaluation for etiology.

Etiology is clearly related to pulmonary process (asthma, pneumonia, interstitial lung process) and/or when diagnosis or treatment requires specialty activities (bronchoscopy, bronchoalveolar lavage or long term immunosuppressives, etc.)

Criteria for Return to Primary Care

Resolution of the illness.