Dyspnea and Cyanosis or Clubbing

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]


Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

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[1] - - - - - +/- - +/- - + Normal Normal ↓O2, ↑CO2 Normal N/A Physical exam Generalized edema
Anaphylaxis[2] +/- + - +/- - - +/- - - - Scattered wheezing Normal Normal Normal N/A Vital sign Type 1 hypersensitivity
Aspiration[3] - + - - +/- + + - - - Diminished breath sounds Normal Normal Atelectasis ↓Vt, ↑RV Bronchoscopy Choking
Croup[4] - + - +/- - + + - - - Stridor ↑WBC Normal Steeple sign Normal Physical exam Barking cough
Chest and Pleura,

Lower airway

Asthma attack[5] - + - - +/- + + - - - Wheeze ↑ Eosinophil Respiratory alkalosis Normal ↓ FEV1, PEF Physical exam and

Spirometry

Chest pain
Bronchospasm[6] +/- + - - + +/- + - - - Wheeze Normal ↓O2, ↑CO2 Normal ↓Vt, ↑RV Physical exam Allergic reaction
COPD exacerbation[7] - + - + + + + +/- +/- +/- Wheeze, Rhonchi, and Crackles ↑WBC, ↑RBC Respiratory alkalosis Hyperexpansion ↓ FEV1/FVC Clinical assessment Acute exacerbations of chronic bronchitis (AECB)
Lung carcinoma[8] - - + - - + + + - - Wheeze and Crackles Normal Normal Mass lesion, hilar lymphadenopathy ↓Vt, ↑RV Bronchoscopy  Paraneoplastic syndromes, such as SIADH and lambert-Eaton
Cardiovascular system Acute heart failure[9] +/- + - - +/- + + - + + S3 Normal Respiratory alkalosis ↑ Cardiothoracic ratio ↓Vt B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) Excessive sweating, high blood pressure
Pulmonary edema[10] +/- + - + + + + + + + Basal crackle Normal Respiratory alkalosis Bat wing pattern, air bronchograms ↓Vt, ↑RV Cardiac Catheterization Tachypnea
Toxic/Metabolic Salicylate poisoning[11] + - - - - - + - - - Normal Normal Metabolic acidosis, Respiratory alkalosis Normal Normal Blood test Vomiting, Tinnitus, Confusion, Hyperthermia
Carbon monoxide poisoning[12] + - - - + + + - - - Wheeze Carboxyhemoglobin ↓O2, ↑CO2 Normal N/A Carboxyhemoglobin (HbCO) level Headache, Dizziness, Weakness, Vomiting, 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

Tracheal stenosis[13] - - - - +/- +/- + + - - 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[5] - + +/- - +/- + + + - - Wheeze ↑ Eosinophil Respiratory alkalosis, Metabolic acidosis Pulmonary hyperinflation,

Bronchial wall thickening

↓ FEV1/FVC Spirometry before and after bronchodilator Paroxysmal respiratory distress
Bronchiectasis[14] - - - + + + + + - - Rhonchi, Wheezing, Crackles ↑WBC, neutrophilia ↓O2, ↑CO2 Tram-track opacities ↑ FEV1/FVC High resolution computed tomography (HRCT) Chronic productive cough
COPD[7] - - +/- - - + + + + +/- Expiratory wheeze ↑ RBC Respiratory alkalosis, Metabolic acidosis ↑ Bronchovascular markings, Cardiomegaly ↓ FEV1/FVC Physical exam and

Spirometry

Heavy smoking history
Emphysema[15] - - - - - +/- + + - - Expiratory wheeze, Hyperinflation Normal Respiratory alkalosis, Metabolic acidosis Flattening of diaphragm, vertical heart ↓ FEV1/FVC Physical exam and

Spirometry

Barrel chest
Pulmonary hypertension[16] - - - - +/- +/- +/- +/- + + Accentuated S2 Normal Hypoxia and acidosis Enlarged pulmonary arteries ↑Physiologic RV Cardiac catheterization Syncope,

Ascites, Pleural effusion

Interstitial lung disease[17] - - - - + + + + - - Rhonchi, Wheezing, Crackles Normal ↓O2, ↑CO2 Peripheral pulmonary infiltrative opacification ↑ FEV1/FVC High resolution computed tomography (HRCT) Pneumoconiosis
Sarcoidosis[18] - - +/- - +/- + + - - - Crackles Normal ↓O2, ↑CO2 Hilar adenopathy ↑ FEV1/FVC High resolution computed tomography (HRCT) Hypercalcemia, high ACE
Bronchiolitis obliterans[19] - - - + + + + + - - Expiratory wheeze ↑WBC ↓O2, ↑CO2 Hyperinflation, Reticulonodular opacities ↓ FEV1/FVC Lung biopsy Complication of allogeneic hematopoietic stem cell transplantation
Cystic fibrosis[20] - - + + - +/- + + - - Rhonchi, Wheezing, Crackles Normal Metabolic alkalosis Thick-walled bronchiectasis ↓ FEF75%/FVC Sweat test Absent vas deferens
Pulmonary right-to-left shunt[21] - - - - +/- + + + - - Diminished breath sounds Normal ↓O2, ↑CO2, Respiratory acidosis Normal ↓Vt, ↑RV

(physiological)

Pulmonary CT angiography Chronic hypoxemia
Tuberculosis[22] - - + + + + +/- - - - Rhonchi, Wheezing, Crackles ↑WBC ↓O2, ↑CO2 Patchy consolidation or poorly defined linear and nodular opacities Restrictive, obstructive, or mixed IFN-γ release assay (IGRA)

Acid-fast staining

Night sweat
Cardiovascular system Intracardiac shunt[23] - - - - +/- - + + - - Cardiac continuous murmur Normal ↓O2 Dilatation of heart chambers Normal Echocardiography Syncope, Palpitation

References

  1. ↑ Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J (2017). "Angioedema in the emergency department: a practical guide to differential diagnosis and management". Int J Emerg Med. 10 (1): 15. doi:10.1186/s12245-017-0141-z. PMC 5389952. PMID 28405953.
  2. ↑ Bjornsson HM, Graffeo CS (2010). "Improving diagnostic accuracy of anaphylaxis in the acute care setting". West J Emerg Med. 11 (5): 456–61. PMC 3027438. PMID 21293765.
  3. ↑ O'Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J, Safdar N (2015). "Bedside diagnosis of dysphagia: a systematic review". J Hosp Med. 10 (4): 256–65. doi:10.1002/jhm.2313. PMC 4607509. PMID 25581840.
  4. ↑ Bjornson CL, Johnson DW (2013). "Croup in children". CMAJ. 185 (15): 1317–23. doi:10.1503/cmaj.121645. PMC 3796596. PMID 23939212.
  5. ↑ 5.0 5.1 Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA (2010). "Management of acute asthma in adults in the emergency department: nonventilatory management". CMAJ. 182 (2): E55–67. doi:10.1503/cmaj.080072. PMC 2817338. PMID 19858243.
  6. ↑ Molis MA, Molis WE (2010). "Exercise-induced bronchospasm". Sports Health. 2 (4): 311–7. doi:10.1177/1941738110373735. PMC 3445098. PMID 23015953.
  7. ↑ 7.0 7.1 Qureshi H, Sharafkhaneh A, Hanania NA (2014). "Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications". Ther Adv Chronic Dis. 5 (5): 212–27. doi:10.1177/2040622314532862. PMC 4131503. PMID 25177479.
  8. ↑ Dela Cruz CS, Tanoue LT, Matthay RA (2011). "Lung cancer: epidemiology, etiology, and prevention". Clin Chest Med. 32 (4): 605–44. doi:10.1016/j.ccm.2011.09.001. PMC 3864624. PMID 22054876.
  9. ↑ Gaggin, Hanna K.; Januzzi, James L. (2013). "Biomarkers and diagnostics in heart failure". Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 1832 (12): 2442–2450. doi:10.1016/j.bbadis.2012.12.014. ISSN 0925-4439.
  10. ↑ Martindale, Jennifer L.; Noble, Vicki E.; Liteplo, Andrew (2013). "Diagnosing pulmonary edema". European Journal of Emergency Medicine. 20 (5): 356–360. doi:10.1097/MEJ.0b013e32835c2b88. ISSN 0969-9546.
  11. ↑ Chin RL, Olson KR, Dempsey D (2007). "Salicylate toxicity from ingestion and continued dermal absorption". Cal J Emerg Med. 8 (1): 23–5. PMC 2859737. PMID 20440389.
  12. ↑ Lane TR, Williamson WJ, Brostoff JM (2008). "Carbon monoxide poisoning in a patient with carbon dioxide retention: a therapeutic challenge". Cases J. 1 (1): 102. doi:10.1186/1757-1626-1-102. PMC 2533003. PMID 18710551.
  13. ↑ Conti V, Calia N, Pasquini C, Zardi S, Finetti C, Stomeo F, Ravenna F (April 2013). "[Chronic cough and worsening dyspnea: a case of idiopathic tracheal stenosis]". Recenti Prog Med (in Italian). 104 (4): 156–8. doi:10.1701/1271.14026. PMID 23748638.
  14. ↑ Cantin, Luce; Bankier, Alexander A.; Eisenberg, Ronald L. (2009). "Bronchiectasis". American Journal of Roentgenology. 193 (3): W158–W171. doi:10.2214/AJR.09.3053. ISSN 0361-803X.
  15. ↑ Sharafkhaneh A, Hanania NA, Kim V (2008). "Pathogenesis of emphysema: from the bench to the bedside". Proc Am Thorac Soc. 5 (4): 475–7. doi:10.1513/pats.200708-126ET. PMC 2645322. PMID 18453358.
  16. ↑ Sajkov D, Petrovsky N, Palange P (June 2010). "Management of dyspnea in advanced pulmonary arterial hypertension". Curr Opin Support Palliat Care. 4 (2): 76–84. doi:10.1097/SPC.0b013e328338c1e0. PMID 20407377.
  17. ↑ Baughman RP, Shipley RT, Loudon RG, Lower EE (1991). "Crackles in interstitial lung disease. Comparison of sarcoidosis and fibrosing alveolitis". Chest. 100 (1): 96–101. PMID 2060395.
  18. ↑ Moher D, Cole CW, Hill GB (November 1992). "Epidemiology of abdominal aortic aneurysm: the effect of differing definitions". Eur J Vasc Surg. 6 (6): 647–50. PMID 1451823.
  19. ↑ Holbro A, Lehmann T, Girsberger S, Stern M, Gambazzi F, Lardinois D, Heim D, Passweg JR, Tichelli A, Bubendorf L, Savic S, Hostettler K, Grendelmeier P, Halter JP, Tamm M (2013). "Lung histology predicts outcome of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation". Biol. Blood Marrow Transplant. 19 (6): 973–80. doi:10.1016/j.bbmt.2013.03.017. PMID 23562737.
  20. ↑ Ziegler, Bruna; Rovedder, Paula Maria Eidt; Dalcin, Paulo de Tarso Roth; Menna-Barreto, Sérgio Saldanha (2009). "Padrões ventilatórios na espirometria em pacientes adolescentes e adultos com fibrose cística". Jornal Brasileiro de Pneumologia. 35 (9): 854–859. doi:10.1590/S1806-37132009000900006. ISSN 1806-3713.
  21. ↑ Vodoz JF, Cottin V, Glérant JC, Derumeaux G, Khouatra C, Blanchet AS; et al. (2009). "Right-to-left shunt with hypoxemia in pulmonary hypertension". BMC Cardiovasc Disord. 9: 15. doi:10.1186/1471-2261-9-15. PMC 2671488. PMID 19335916.
  22. ↑ Campbell IA, Bah-Sow O (2006). "Pulmonary tuberculosis: diagnosis and treatment". BMJ. 332 (7551): 1194–7. doi:10.1136/bmj.332.7551.1194. PMC 1463969. PMID 16709993.
  23. ↑ Vodoz JF, Cottin V, Glérant JC, Derumeaux G, Khouatra C, Blanchet AS; et al. (2009). "Right-to-left shunt with hypoxemia in pulmonary hypertension". BMC Cardiovasc Disord. 9: 15. doi:10.1186/1471-2261-9-15. PMC 2671488. PMID 19335916.
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