Dyspnea differential diagnosis

Dyspnea Microchapters
Patient Information
Overview
Pathophysiology
Causes
Differentiating Dyspnea from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differential Diagnosis

• Air hunger - the sensation of an urgent need to breathe, sensation that you cannot take in a full breath
• Tachypnea - breathing rapidly
• Bradypnea - breathing slowly
• Eupnea - normal unlabored breathing
• Orthopnea - dyspnea that occurs with lying flat
• Trepopnea - an abnormal awareness of one's own breathing that is seen in one lateral position but not in the other
• Paroxysmal nocturnal dyspnea - sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

 Shortness of breath/Dyspnea

Differential diagnosis

Organ system			Diseases	Clinical manifestations											Diagnosis					Other features
				Symptoms						Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Acute Dyspnea	Respiratory system	Head and Neck, Upper airway	Angioedema	-	-	-	-	-	+/-	-	+/-	-	++	Normal	Normal	↓O2, ↑CO2	Normal	↓Vt, ↑RV	Physical exam	Generalized edema
			Anaphylaxis	+	+	-	+/-	-	-	+/-	-	-	-	Scattered wheeze	Normal	Normal	Normal	↓Vt, ↑RV	Vital sign	Type 1 hypersensitivity
			Aspiration	-	+	-	-	+/-	+	+	-	-	-	Diminished breath sounds	Normal	Normal	Atelectasis	↓Vt, ↑RV	Bronchoscopy	Choking
			Croup	-	+	-	+/-	-	+	+	-	-	-	Stridor	↑WBC	Normal	Steeple sign	Normal	Physical exam	Barking cough
			Epiglottitis	-	+	-	+	-	+	-	-	-	-	Stridor	↑WBC	Normal	Thumb sign	Normal	Laryngoscopy	Drooling
			Rhinosinusitis	-	-	-	+	-	+/-	-	-	-	-	Normal	↑WBC	Normal	Sinus inflammation	Normal	Physical exam	Headache
			Vocal cord dysfunction	-	-	-	-	-	+/-	-	-	-	-	Stridor	Normal	Normal	Normal	↓ FVC	Laryngoscopy	Choking sensation
		Chest and Pleura, Lower airway	Asthma attack	-	+	-	-	+/-	+	+	-	-	-	Wheeze	↑ Eosinophil	Respiratory alkalosis	Normal	↓ FEV1/FVC	Physical exam and Spirometry	Chest pain
			Bronchitis	-	-	-	+	+	+	-	-	-	-	Rhonchi	↑WBC	Normal	Normal	Normal	Physical exam	Rhonchi relieved by cough
			Bronchospasm	+/-	+	-	-	+	+/-	+	-	-	-	Wheeze	Normal	↓O2, ↑CO2	Normal	↓Vt, ↑RV	Physical exam	Allergic reaction
			Bronchiolitis	-	-	-	+	+/-	+	-	-	-	-	Wheeze and Crackles	↑WBC	Normal	Bronchovascular markings	↓Vt	Clinical assessment	Respiratory syncytial virus (RSV)
			COPD exacerbation	-	+	-	+	+	+	+	-	-	-	Wheeze, Rhonchi, and Crackles	↑WBC, ↑RBC	Respiratory alkalosis	Hyperexpansion	↓ FEV1/FVC	Clinical assessment	Acute exacerbations of chronic bronchitis (AECB)
			Lung carcinoma	-	-	+	-	-	+	+	+	-	-	Wheeze and Crackles	Normal	Normal	Mass lesion, hilar lymphadenopathy	↓Vt, ↑RV	Bronchoscopy	SIADH
			Pneumonia	-	-	-	+	+	+	-	-	-	-	Wheeze, Rhonchi, and Crackles	↑WBC, neutrophilia	Normal	Lobar consolidation	Normal	Chest X-ray	productive cough
			Pneumothorax	-	-	-	-	+	-	-	-	+/-	-	Diminished breath sounds	Normal	↓O2, ↑CO2	Radiolucency without lung marking	↓Vt	Chest CT scan	Tracheal deviation
			Pulmonary embolism	-	-	-	-	+	-	-	-	-	-	Normal	Normal	Respiratory alkalosis	Normal	Normal	Pulmonary CT angiography	Pleuritic chest pain
			Rib fractures (flail chest)	-	+	-	-	+	-	-	-	-	-	Normal	Normal	Respiratory acidosis	Broken rib	Normal	Chest X-ray	Pneumothorax
	Cardiovascular system		Acute myocardial ischemia	+/-	+	-	+/-	+	-	-	-	-	-	Normal	Normal	Normal	Normal	Normal	Cardiac troponin I	Nausea and vomiting
			Acute heart failure	+/-	+	-	-	+/-	+	+	-	+	+	S3	Normal	Respiratory alkalosis	↑ Cardiothoracic ratio	↓Vt	B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)	Excessive sweating, high blood pressure
			Pericardial tamponade	+/-	-	-	-	+	-	-	-	+	-	Muffled heart sounds	Normal	Normal	Water bottle appearance enlarged heart	Normal	Echocardiography	Fluid accumulation in pericardium
			Tachyarrhythmia	-	+	-	-	+/-	-	-	-	-	-	High pulse rate	Normal	Normal	Normal	Normal	ECG	Palpitation
			Pulmonary edema	+/-	+	-	+	+	+	+	+	+	+	Basal crackle	Normal	Respiratory alkalosis	Bat wing pattern, air bronchograms	↓Vt, ↑RV	Lung ultrasound	Tachypnea
	Central nervous system		Stroke	+	-	-	+/-	-	-	-	-	-	-	Normal	Normal	Normal	Intracranial infarct or hemorrhage	Normal	Brain MRI	Paralysis or paresthesia
			Encephalitis	+	+	-	+	-	-	-	-	-	-	Normal	↑WBC, neutrophilia	Normal	Normal	Normal	CSF PCR	Confusion
			Traumatic brain injury	+	+/-	-	-	-	-	-	-	-	-	Normal	Normal	Respiratory acidosis	Intracerebral hemorrhage	Normal	Brain CT scan	Lucid interval
	Toxic/Metabolic		Organophosphate poisoning	+	-	-	+	-	-	-	-	-	-	Wheeze	Normal	↓O2, ↑CO2	Normal	Normal	Blood test	Salivation, Lacrimation, Emesis, Miosis
			Salicylate poisoning	+	-	-	-	-	-	+	-	-	-	Normal	Normal	Metabolic acidosis, Respiratory alkalosis	Normal	Normal	Blood test	Vomiting, Tinnitus, Confusion, Hyperthermia
			Carbon monoxide poisoning	+	-	-	-	+	+	+	-	-	-	Wheeze	Carboxyhemoglobin	↓O2, ↑CO2	Normal	↓Vt, ↑RV	Carboxyhemoglobin (HbCO) level	Headache, Dizziness, Weakness, Vomiting, Confusion
			Diabetic ketoacidosis	+	+/-	-	-	-	-	-	-	-	-	Scattered wheeze	↑WBC	Metabolic acidosis	Normal	Normal	Blood test (acidosis, hyperglycemia, ketonemia)	Vomiting, Abdominal pain, Weakness, Confusion
	Systemic		Panic attack	+/-	+	-	-	-	-	-	-	-	-	Normal	Normal	Normal	Normal	Normal	Clinical assessment	Severe anxiety
			Pregnancy	-	-	-	-	+/-	-	-	-	-	+	Normal	↑WBC, RBC	↓O2, ↑CO2	Normal	↓Vt, ↑RV	βhCG	Hyperemesis
			Sepsis	+/-	-	-	+	-	-	-	-	-	-	Normal	↑WBC, neutrophilia	↓O2, ↑CO2	Normal	Normal	SIRS criteria	Chills, Confusion
Organ system			Diseases	Clinical manifestations											Diagnosis					Other features
				Symptoms						Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Chronic Dyspnea	Respiratory system	Head and Neck, Upper airway	Goiter	-	-	-	-	-	-	-	-	-	+	Normal	Normal	Normal	Normal	Normal	Blood test (TSH, T4)	Weight gain
			Laryngeal adenocarcinoma	-	-	+	-	-	+/-	-	-	-	-	Stridor	Normal	↓O2, ↑CO2	Retropharyngeal tissue thickness	Normal	Laryngoscopy	Choking sensation
			Vocal cord paralysis	-	-	-	-	-	+/-	-	-	-	-	Stridor	Normal	Normal	Pharyngeal constrictor muscles thinning, uvular deviation	Normal	Laryngoscopy	Choking sensation
			Tracheal stenosis	-	-	-	-	+/-	+/-	+	+	-	-	Stridor, Stertorous	Normal	↓O2, ↑CO2	Soft tissue thickening internal to normal-appearing tracheal cartilage	Normal	Bronchoscopy	Respiratory distress
		Chest and Pleura, Lower airway	Bronchial asthma	-	+	+/-	-	+/-	+	+	+	-	-	Wheeze	↑ Eosinophil	Respiratory alkalosis, Metabolic acidosis	Pulmonary hyperinflation, Bronchial wall thickening	↓ FEV1/FVC	Spirometry before and after bronchodilator	Paroxysmal respiratory distress
			Bronchiectasis	-	-	-	+	+	+	+	+	-	-	Rhonchi, Wheezing, Crackles	↑WBC, neutrophilia	↓O2, ↑CO2	Tram-track opacities	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Chronic productive cough
			COPD	-	-	+/-	-	-	+	+	+	+	+/-	Expiratory wheeze	↑ RBC	Respiratory alkalosis, Metabolic acidosis	↑ Bronchovascular markings, Cardiomegaly	↓ FEV1/FVC	Physical exam and Spirometry	Heavy smoking history
			Emphysema	-	-	-	-	-	+/-	+	+	-	-	Expiratory wheeze, Hyperinflation	Normal	Respiratory alkalosis, Metabolic acidosis	Flattening of diaphragm, vertical heart	↓ FEV1/FVC	Physical exam and Spirometry	Barrel chest
			Pulmonary hypertension	-	-	-	-	+/-	+/-	+/-	+/-	+	+	Accentuated S2	Normal	Hypoxia and acidosis	Enlarged pulmonary arteries	↑Physiologic RV	Cardiac catheterization	Syncope, Ascites, Pleural effusion
			Interstitial lung disease	-	-	-	-	+	+	+	+	-	-	Rhonchi, Wheezing, Crackles	Normal	↓O2, ↑CO2	Peripheral pulmonary infiltrative opacification	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Pneumoconiosis
			Sarcoidosis	-	-	+/-	-	+/-	+	+	-	-	-	Crackles	Normal	↓O2, ↑CO2	Hilar adenopathy	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Hypercalcemia, high ACE
			Alveolitis	-	-	-	+	+	+	-	-	-	-	Basal crackle	↑WBC, neutrophilia	Normal	Basal reticulonodular opacification	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Dry cough
			Bronchiolitis obliterans
			Cystic fibrosis
			Pleural effusion
			Pulmonary right-to-left shunt
			Phrenic nerve palsy
			Tuberculosis
	Cardiovascular system		Constrictive pericarditis
			Restrictive cardiomyopathy
			Valvular heart disease
			Bradyarrhythmia
			Pericardial effusion
			Coronary heart disease
			Intracardiac shunt
	Neuromuscular disease		Amyotrophic lateral sclerosis
			Polymyositis/dermatomyositis
			Mitochondrial diseases
			Glycolytic enzyme defects (e.g., McArdle)
	Toxic/Metabolic		Metabolic acidosis
			Renal failure
	Systemic		Anemia
			Anxiety
			Ascites
			Depression
			Kyphoscoliosis
			Obesity
	Autoimmune		Churg-Strauss syndrome
			Microscopic polyangiitis
			Wegener's granulomatosis
			Goodpasture's disease