Dyspnea

Dyspnea
ICD-10	R06.8
ICD-9	786.0
DiseasesDB	15892
MedlinePlus	003075
MeSH	C08.618.326

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Synonyms or related key words: Breathlessness, DIB, difficulty breathing, dyspnoea, respiration difficult, respiratory distress, shortness of breath, SOB.

Overview

Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/), from Latin dyspnoea, from Greek dyspnoia from dyspnoos, shortness of breath) or shortness of breath (SOB) is perceived to be difficulty of breathing or painful breathing. It is a common symptom of numerous medical disorders.

Dyspnea on exertion (DOE or exertional dyspnea) indicates dyspnea that occurs (or worsens) during physical activity.

Conditions That Dyspnea Should be Distinguished From

• 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.

Life Threatening Causes of Dyspnea Requiring Urgent Evaluation and Management

• Acute heart failure
• Acute papillary muscle rupture
• Cardiac tamponade
• Foreign body aspiration
• Spontaneous pneumothorax
• H. influenza epiglottitis
• Bronchospasm
• Pulmonary edema

Complete Differential Diagnosis of Causes of Dyspnea

In alphabetical order.

• Abdominal masses
• Abnormality of thoracic vessels
• use of bleomycin in ABVD
• Acute bronchitis
• Acute Chest Syndrome
• Acute Coronary Syndromes
• Acute myeloid leukemia
• Acute promyelocytic leukemia
• Acute tracheobronchitis
• AIDS
• Air pollution
• Air-conditioner lung
• Allergy
• Alpha 1-antitrypsin deficiency
• Altitude sickness
• Amniotic fluid embolism
• Amphotericin B
• Amyl nitrite
• Amyotrophic Lateral Sclerosis (ALS)
• Anaphylactoid reactions
• Anaphylaxis
• Anemia
• Angina Pectoris
• Anthrax
• Anxiety
• Aortic Arch Anomalies
• Aortic regurgitation
• Aortic stenosis
• Arrhythmia
• Asbestosis
• Aspergillus clavatus
• Aspiration
• Asthma
• Atelectasis
• Atrial Fibrillation
• Atrioseptal defect
• Atypical pneumonia
• Barium
• Beriberi Heart Disease
• Beta-blockers
• Betazole
• Bird breeder's lung
• Bird fancier's lung
• Biventricular heart failure
• Bland-White-Garland Syndrome
• Blood transfusion
• Brain stem infarction
• Bronchial asthma
• Bronchial tumors
• Bronchiolitis
• Bronchiolitis obliterans
• Bronchiolitis obliterans organizing pneumonia
• Bronchitis
• Bronchogenic carcinoma
• Bronchoscopy
• Cardiac diseases
• Cardiac Disease in Pregnancy
• Cardiac failure
• Cardiomegaly
• Cardiomyopathy
• Caspofungin
• Cheese worker's lung
• Chemical worker's lung
• Chest trauma
• Chest tube
• Cholesterol pericarditis
• Chronic bronchitis
• Chronic fatigue syndrome
• Chronic Obstructive Pulmonary Disease (COPD)
• Chylothorax
• Cirrhosis
• Cladosporium
• CMV Pneumonitis
• Community-acquired pneumonia
• Complex cyanotic defect
• Complex defects
• Congestive Heart Failure
• Continuous murmur
• Cor Pulmonae
• Coronary Artery Disease
• Coronary Artery Fistula
• Croup
• Cystic Fibrosis
• Daptomycin
• Decompression sickness
• Decreased thoracic or diaphragmatic excursions
• Diabetic coma
• Diffuse panbronchiolitis
• Diverticulosis
• Drugs
• Ebstein's Anomaly of the Tricuspid Valve
• Ehrlichiosis (canine)
• Empty nose syndrome
• Empyema, pleural
• Encephalitis
• Endocarditis
• Endomyocardial fibrosis
• Eosinophilic pneumonia
• Ephedrine
• Epidemic dropsy
• Erdheim-Chester disease
• Esophageal cancer
• Esophageal diseases with tracheal compression
• Exercise-induced asthma
• Extrinsic allergic alveolitis
• Fat embolism
• Fibrosing alveolitis, cryptogenic
• Gamma-Hydroxybutyric acid
• Gastroesophageal reflux
• Gemeprost
• Glatiramer acetate
• Glottal edema
• Goiter
• Goodpasture syndrome
• Grain handler's lung
• Gram-negative sepsis
• Guillain-Barre Syndrome
• Heart failure
• Hematochlyothorax
• Histiocytosis X
• Hydrochlyothorax
• Hypertension
• Hypoxia
• Hysteria
• Intermittent dyspnea
• Interstitial lung disease
• Intoxication (carbon monoxide, cyanide)
• Intrapulmonary receptor stimulation
• Kyphoscoliosis
• Laryngeal/bronchospasm
• Loeffler's Endocarditis
• Lymphangitic metastases
• Mediastinal tumors
• Metabollic acidosis
• Miliary tuberculosis
• Mitral Regurgitation
• Mitral Stenosis
• Multiple rib fractures
• Myasthenia Gravis
• STEMI
• Neuromuscular diseases
• Obesity
• Patent Ductus Arteriosus
• Pericardial effusion/pericardial constriction
• Perimyocarditis
• Phrenic nerve paresis
• Physiologic dyspnea
• Pleural callosity
• Pneumoconiosis
• Pneumonia
• Pneumochlyothorax
• Pneumothorax
• Pleural Effusion
• Pleural fibrosis
• Polyradiculitis
• Pulmonary arteriovenous malformation
• Pulmonary Edema
• Pulmonary Embolism
• Pulmonary Emphysema
• Pulmonary fibrosis
• Pulmonary hypertension
• Pulmonary stenosis
• Quincke's Edema
• Radiation pneumonitis
• Respiratory muscle fatigue with severely lowered cardiac output
• Respiratory tract infection
• Right ventricular failure
• Sarcoidosis
• Shock
• Shock lung
• Sleep Apnea Syndrome
• Stenosis of aortic isthmus
• Tetralogy of Fallot
• Trauma
• Tracheal stenosis
• Tracheal tumors
• Tracheomalacia
• Tracheobronchial collapse
• Tricuspid stenosis
• Tumors of the myocardium
• Uremia
• Valvular heart disease
• Ventricular septal defect

Complete Differential Diagnosis of the Causes of Dyspnea

(By organ system)

Cardiovascular	Aortic dissection, Cardiomyopathy, Congenital heart disease, Heart failure, Ischaemic heart disease, Malignant hypertension, Diseases of the pericardium such as Cardiac tamponade, Constrictive pericarditis or Pericardial effusion, Pulmonary edema, Pulmonary embolism, Valvular heart disease
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	Hypothyroidism
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	Anemia, Leukemia
Iatrogenic	No underlying causes
Infectious Disease	Sepsis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Amyotrophic lateral sclerosis, Guillain-Barré syndrome, Multiple sclerosis, Myasthenia gravis, Parsonage-Turner syndrome, Eaton-Lambert syndrome
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Lung cancer
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Anxiety disorders and panic attacks
Pulmonary	Obstructive lung diseases Asthma Bronchitis Chronic obstructive pulmonary disease Cystic fibrosis Emphysema Hookworm disease Laryngeal edema due to allergies Tuberculosis Diseases of lung parenchyma and pleura Contagious Anthrax through inhalation of Bacillus anthracis Pneumonia Non-contagious Fibrosing alveolitis Atelectasis Hypersensitivity pneumonitis Interstitial lung disease Lung cancer Pleural effusion Pneumoconiosis Pneumothorax Non-cardiogenic pulmonary edema or acute respiratory distress syndrome Sarcoidosis Pulmonary vascular diseases Acute or recurrent pulmonary emboli Pulmonary hypertension, primary or secondary Pulmonary veno-occlusive disease Superior vena cava syndrome Obstruction of the airway Cancer of the larynx or pharynx Empty nose syndrome Pulmonary aspiration Epiglottitis Immobilization of the diaphragm Lesion of the phrenic nerve Polycystic liver disease Tumor in the diaphragm Restriction of the chest volume Ankylosing spondylitis Broken ribs Kyphosis Obesity Pregnancy Pectus excavatum Scoliosis
Renal / Electrolyte	Metabolic acidosis
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Diagnosic Evaluation

• History
• Physical examination: All patients should be evaluated for underlying diseases (especially heart and lung diseases). Detecting of following symptoms and signs are important:

• Heart murmurs
• S3, S4
• Crackles, rales
• Jugular venous distension
• Peripheral edema
• Wheezing
• Palpation of peripheral arteries
• Leg swelling / leg pain / tenderness
• Chest pain / chest tightness
• Fever

• Complete blood count
• Thyroid function tests
• Chest x-ray
• Electrocardiography
• Echocardiography
• Spirometry
• Pulse oximetry
• Exercise stress test (Treadmill test)
• Arterial blood gases
• Pulmonary function tests
• Cardiopulmonary exercise testing

Treatment of the Patient with Dyspnea

Oxygen Supply

Oxygen supply is the essential part of acute dyspnea management.

Exercise Training

Controlled studies have shown that dyspnea upon exertion decreases and exercise tolerance improves in response to exercise training, even in patients with advanced disease. It is now well established that for patients with COPD who remain breathless despite optimal drug therapy, exercise training can confer significant symptomatic benefits.

Pharmacologic Therapy

Two types of medications have proven useful in alleviating dyspnea: opiates and drugs that reduce anxiety. A number of studies have shown that opiates acutely relieve dyspnea and improve exercise performance in patients with COPD.

The drugs to reduce anxiety have the potential to relieve ventilatory response related to the available amounts of oxygen in the blood, as well as by lowering the emotional response to dyspnea.

Fans

The movement of cool air with a fan has been observed to reduce dyspnea in pulmonary patients. A decrease in the temperature of the facial skin alters feedback to the brain and modifies the perception of dyspnea. Cool air has been shown in normal volunteers to reduce dyspnea in response to excess carbon dioxide in the blood.

Altered Breathing Patterns

Breathing retraining including diaphragmatic breathing and pursed lip breathing has been advocated to relieve dyspnea in COPD patients. During a breathing retraining period, many patients adopt slower, deeper breathing techniques; however, they often resort to spontaneous, fast, shallow breathing patterns when the training ends.

Continuous Positive Airway Pressure (CPAP)

In various studies, CPAP has been shown to relieve dyspnea during asthma attacks, when patients are being weaned from ventilators, and during exercise sessions for patients with advanced COPD.

Nutrition

Several investigators have shown improvement in respiratory muscle function in response to short-term use of nutritional repletion by an intravenous route.

Positioning

Patients with COPD often change body position to improve dyspnea. They tend to lean forward to improve overall respiratory muscle strength and to reduce their symptoms.

Steroids

Steroid use can be beneficial to pulmonary patients by reducing airway inflammation and by increasing vital capacity in chronic lung inflammation. However, steroids have adverse effects, including muscle wasting and weakness. These potential problems need to be balanced against possible gains in lung function associated with this drug.

Cognitive-behavioral Approaches In patients with different pain syndromes, distraction, relaxation, and education about symptoms have modified the intensity of pain, increased tolerance, and decreased distress. Improvements in dyspnea and anxiety have been shown to follow distractions such as music during exercise, although long-term effects have been minimal. However, exercise in a monitored, supportive environment has been shown to be a powerful method of overcoming apprehension, anxiety, and/or fear associated with exertional dyspnea.

See also

• Air hunger
• Tachypnea
• Bradypnea
• Eupnea
• Orthopnea
• Trepopnea
• Paroxysmal nocturnal dyspnea

Additional Resources

• Julie K. Stegman, Stedman's Medical Dictionary, 28th Edition, pages=601, Lippincott Williams & Wilkins, Baltimore, Maryland ISBN 0781733901

External links

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