Respiratory failure differential diagnosis

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

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating Respiratory Failure from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
  • [Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
  • As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].


Type of respiratory failure Causes/Etiology Onset Clinical manifestations Investigations Gold standard Other features
Symptoms Physical exam
Dyspnea Cough Fever Others findings Imaging Labs
Hypoxic respiratory failure (Type 1 respiratory failure) Cardiogenic pulmonary edema Acute decompensated heart failure[1][2] [3]
  • Acute
 + + with frothy expectoration +/-
  • nausea and anorexia
  • confusion
  • headaches
  • Pulse oximetry
  • Assays for BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro-B-type natriuretic peptide)
  • Cardiac troponin levels
  • ST and T waves abnormalities in ECG
  • Clinical diagnosis
  • History of heart disease, hypertension
Non cardiogenic pulmonary edema Adult respiratory distress syndrome (ARDS) [4]
  • Acute
 + +/- +/-
  • Diffuse, bilateral, alveolar infiltrates without cardiomegaly in chest radiograph
  • Bilateral opacities in CT
  • Clinical diagnosis with supportive test

According to Berlin definition:

  • One week of new or worse respiratory symptoms or clinical insult
  • Symptoms can not be explained by cardiac disease
  • Bilateral opacities in chest X-Ray or CT
  • Compromised oxygenation
High-Altitude Pulmonary edema (HAPE) [5]
  • Acute
 + + with frothy expectoration +
  • Chest X-ray may show patchy alveolar infiltrates, predominantly in the right central hemithorax, which become more confluent and bilateral as the illness progresses
  • Clinical diagnosis with supportive test
  • Occurrs over 2500 m
  • Descent is mandatory in >4000 m
Neurogenic pulmonary edema [6] [7]
  • Acute
 + +/- with frothy expectoration +/-
  • Diagnosis of exclusion
  • A proposed criteria is as follows
    • Bilateral infiltrates
    • PaO2/FiO2 ratio < 200
    • No evidence of left atrial hypertension
    • Presence of CNS injury
    • Absence of other common causes of acute respiratory distress or ARDS
Pulmonary embolism [8] [9]
  • Acute
  • Sub-acute
  • Chronic
 + + +/-
  • Hamptom and Westermark sign may be seen in chest X-Ray
Pneumonia[10] [11]
  • Acute
 + + with sputum production +
  • Pleuritic chest pain
  • Clinical manifestations and infiltration chest X-Ray with or without microbiological test
Idiopatic chronic lung fibrosis[12] [13] [14] [15]
  • Chronic
 + + without any sputum production +/-
  • symptoms suggestive of rheumatic diseases may be present
  • Reticular or nodular pattern in chest X-Ray
  • HRCT may show reticular opacities, including honeycomb changes and traction bronchiectasis
  • Serological tests e.g. ANA, RF for underlying rheumatological diseases
  • Clinical presentation in combinations with HRCT findings
  • Lung biopsy when lab, imaging and PFT do not yield enough evidence
  • History of cigarette smoking
Hypercapnic respiratory failure (Type 2 respiratory failure) COPD [16] [17]
  • Acute
  • Chronic
  • Acute-on-chronic
 + + +/-
  • Exercise intolerance
  • Acute exacerbation may affect CNS, ranging from irritability to decreased responsiveness
  • Clubbing
  • Tachypnea
  • Barrel shaped chest
  • Decreased breath sounds with prolonged expiration
  • Rhonchi and Wheeze
  • Use of accessory respiratory muscles
  • Increased JVP, peripheral edema may manifest with right ventricular overload during an acute exacerbation
  • Chest X-ray may show hyperinflation, flattened diaphragm, rapid tapering of vascular markings 
  • CT scan helps to correlate with COPD prognosis
  
  • PFTs: (FEV1/FVC) <70% of predicted   
  • Clinical diagnosis with supportive test
  • CNS symptoms may be the only manifestation in elderly with baseline hypercapnia
Severe Asthma/Status Asthmaticus [18] [19]
  • Acute
 + + -
  • Chest tightness
  • Audible wheeze
  • Chest X-ray not required in acute conditions, may show hyperinflation
  • PEF <40 percent predicted or personal best
  • Clinical diagnosis
Drug Overdose (opioid toxicity) [20] [21] [22]
  • Acute
 + - -
  • Nausea and vomiting
  • Constipation
  • Seizures
  • Classic triad suggesting opioid toxicity consist of respiratory depression, pinpoint pupils, and altered mental state 
  • Conjunctival injection,
  • Decreased bowel sounds
  • Euphoria
  • Urine toxicology screen: may reveal polysubstance abuse
  • Clinical diagnosis with supportive test
Myasthenic crisis [23] [24] [25] [26] [27]
  • Acute
 + +/- +/-
  • Inability to cough
  • Bulbar weakness: dysphagia, nasal regurgitation, a nasal quality to speech, staccato speech, jaw weakness, bi-facial paresis, and tongue weakness
  • Pulse Oximetry
  • ABGs
  • CBC: Infective cause precipitating the crisis may be observed
  • Tensilon (edorphonium) test
  • Clinical diagnosis with supportive test
Guillain-Barré syndrome [28] [29] [30] [31] [32] [33]
  • Acute
 + - +/-
  • Difficulty walking (ascending symmetric muscular weakness)
  • Back pain
  • Pain in extremities
  • Diminished or absent deep tendon reflexes
  • Limb weakness (first lower then upper limbs)
  • Facial droop (Facial nerve palsy)
  • Ophthalmoparesis (3rd & 6th nerve palsies)
  • Decreased breath sounds
  • Decreased bowel sounds
  • CSF analysis: Albuminocytologic dissociation
  • Nerve conduction studies may show conduction block, slowed motor conduction velocities and delayed latencies
  • PFTs: Vital Capacity, maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax) should be followed to determine appropriate timing of intubation and mechanical ventilation
  • Clinical diagnosis with supportive test
  
  • Signs depicting respiratory failure occur late, early manifestations are tachypnea, tachycardia, air hunger, broken sentences, and a need to pause between sentences
  • Use of the accessory respiratory muscles, paradoxical breathing, and orthopnea indicate severe diaphragmatic weakness
Perioperative respiratory failure (Type 3 respiratory failure) Post-operative atelectasis [34] [35] [36] [37] [38]
  • Acute
 + +/- +/-
  • Tachypnea
  • Tachycardia
  • Decreased movement in the affected lung area
  • Dullness percussion note
  • Absent breath sounds Tracheal deviation to affected side
  • Chest X-ray may show increased density and reduced volume
  • CT chest accurately shows the involved segment
  • Pulse oximetry
  • ABGs
  • Clinical diagnosis with support of radiographic findings
  • History of abdominal or thoracic surgery
Type 4 respiratory failure Shock[39] [40]
  • Acute
 + - +/-
  • Clinical diagnosis with supportive test

References

  1. ↑ Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C, Gibler WB, McCord JK, Parshall MB, Francis GS, Gheorghiade M (2010). "Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientific statement from the American Heart Association". Circulation. 122 (19): 1975–96. doi:10.1161/CIR.0b013e3181f9a223. PMID 20937981.
  2. ↑ Doust JA, Glasziou PP, Pietrzak E, Dobson AJ (2004). "A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure". Arch. Intern. Med. 164 (18): 1978–84. doi:10.1001/archinte.164.18.1978. PMID 15477431.
  3. ↑ Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C (August 2017). "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America". J. Card. Fail. 23 (8): 628–651. doi:10.1016/j.cardfail.2017.04.014. PMID 28461259.
  4. ↑ Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS (2012). "Acute respiratory distress syndrome: the Berlin Definition". JAMA. 307 (23): 2526–33. doi:10.1001/jama.2012.5669. PMID 22797452.
  5. ↑ Ma, Qing (2013). "Acute respiratory distress syndrome secondary to High-altitude pulmonary edema: A diagnostic study". Journal of Medical Laboratory and Diagnosis. 4 (1): 1–7. doi:10.5897/JMLD12.007. ISSN 2141-2618.
  6. ↑ Davison DL, Terek M, Chawla LS (2012). "Neurogenic pulmonary edema". Crit Care. 16 (2): 212. doi:10.1186/cc11226. PMC 3681357. PMID 22429697.
  7. ↑ Davison, Danielle L; Terek, Megan; Chawla, Lakhmir S (2012). "Neurogenic pulmonary edema". Critical Care. 16 (2): 212. doi:10.1186/cc11226. ISSN 1364-8535.
  8. ↑ Stein PD, Goldhaber SZ, Henry JW, Miller AC (1996). "Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism". Chest. 109 (1): 78–81. PMID 8549223.
  9. ↑ Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD (2007). "Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society". Radiology. 245 (2): 315–29. doi:10.1148/radiol.2452070397. PMID 17848685.
  10. ↑ Bauer TT, Ewig S, Rodloff AC, Müller EE (2006). "Acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data". Clin. Infect. Dis. 43 (6): 748–56. doi:10.1086/506430. PMID 16912951.
  11. ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  12. ↑ Bradley B, Branley HM, Egan JJ, Greaves MS, Hansell DM, Harrison NK, Hirani N, Hubbard R, Lake F, Millar AB, Wallace WA, Wells AU, Whyte MK, Wilsher ML (2008). "Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society". Thorax. 63 Suppl 5: v1–58. doi:10.1136/thx.2008.101691. PMID 18757459.
  13. ↑ Mittoo S, Gelber AC, Christopher-Stine L, Horton MR, Lechtzin N, Danoff SK (August 2009). "Ascertainment of collagen vascular disease in patients presenting with interstitial lung disease". Respir Med. 103 (8): 1152–8. doi:10.1016/j.rmed.2009.02.009. PMID 19304475.
  14. ↑ Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK, Colby TV, Cordier JF, Flaherty KR, Lasky JA, Lynch DA, Ryu JH, Swigris JJ, Wells AU, Ancochea J, Bouros D, Carvalho C, Costabel U, Ebina M, Hansell DM, Johkoh T, Kim DS, King TE, Kondoh Y, Myers J, Müller NL, Nicholson AG, Richeldi L, Selman M, Dudden RF, Griss BS, Protzko SL, Schünemann HJ (March 2011). "An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management". Am. J. Respir. Crit. Care Med. 183 (6): 788–824. doi:10.1164/rccm.2009-040GL. PMC 5450933. PMID 21471066.
  15. ↑ Shaw, Megan; Collins, Bridget F.; Ho, Lawrence A.; Raghu, Ganesh (2015). "Rheumatoid arthritis-associated lung disease". European Respiratory Review. 24 (135): 1–16. doi:10.1183/09059180.00008014. ISSN 0905-9180.
  16. ↑ MacIntyre N, Huang YC (May 2008). "Acute exacerbations and respiratory failure in chronic obstructive pulmonary disease". Proc Am Thorac Soc. 5 (4): 530–5. doi:10.1513/pats.200707-088ET. PMC 2645331. PMID 18453367.
  17. ↑ Calverley, P.M.A. (2003). "Respiratory failure in chronic obstructive pulmonary disease". European Respiratory Journal. 22 (Supplement 47): 26s–30s. doi:10.1183/09031936.03.00030103. ISSN 0903-1936.
  18. ↑ "Guidelines for the Diagnosis and Management of Asthma (EPR-3) | National Heart, Lung, and Blood Institute (NHLBI)".
  19. ↑ Thomson, Neil C.; Chaudhuri, Rekha; Messow, C. Martina; Spears, Mark; MacNee, William; Connell, Martin; Murchison, John T.; Sproule, Michael; McSharry, Charles (2013). "Chronic cough and sputum production are associated with worse clinical outcomes in stable asthma". Respiratory Medicine. 107 (10): 1501–1508. doi:10.1016/j.rmed.2013.07.017. ISSN 0954-6111.
  20. ↑ Hoffman RS, Goldfrank LR (August 1995). "The poisoned patient with altered consciousness. Controversies in the use of a 'coma cocktail'". JAMA. 274 (7): 562–9. PMID 7629986.
  21. ↑ Wilson, Kevin C.; Saukkonen, Jussi J. (2016). "Acute Respiratory Failure from Abused Substances". Journal of Intensive Care Medicine. 19 (4): 183–193. doi:10.1177/0885066604263918. ISSN 0885-0666.
  22. ↑ Boyer, Edward W. (2012). "Management of Opioid Analgesic Overdose". New England Journal of Medicine. 367 (2): 146–155. doi:10.1056/NEJMra1202561. ISSN 0028-4793.
  23. ↑ Mier A, Laroche C, Green M (May 1990). "Unsuspected myasthenia gravis presenting as respiratory failure". Thorax. 45 (5): 422–3. PMC 462503. PMID 2382251.
  24. ↑ Kim WH, Kim JH, Kim EK, Yun SP, Kim KK, Kim WC, Jeong HC (March 2010). "Myasthenia gravis presenting as isolated respiratory failure: a case report". Korean J. Intern. Med. 25 (1): 101–4. doi:10.3904/kjim.2010.25.1.101. PMC 2829406. PMID 20195411.
  25. ↑ Thomas CE, Mayer SA, Gungor Y, Swarup R, Webster EA, Chang I, Brannagan TH, Fink ME, Rowland LP (May 1997). "Myasthenic crisis: clinical features, mortality, complications, and risk factors for prolonged intubation". Neurology. 48 (5): 1253–60. PMID 9153452.
  26. ↑ Rabinstein AA, Wijdicks EF (March 2003). "Warning signs of imminent respiratory failure in neurological patients". Semin Neurol. 23 (1): 97–104. doi:10.1055/s-2003-40757. PMID 12870111.
  27. ↑ Wendell LC, Levine JM (January 2011). "Myasthenic crisis". Neurohospitalist. 1 (1): 16–22. doi:10.1177/1941875210382918. PMC 3726100. PMID 23983833.
  28. ↑ Wijdicks EF, Borel CO (January 1998). "Respiratory management in acute neurologic illness". Neurology. 50 (1): 11–20. PMID 9443451.
  29. ↑ Mehta S (September 2006). "Neuromuscular disease causing acute respiratory failure". Respir Care. 51 (9): 1016–21, discussion 1021–3. PMID 16934165.
  30. ↑ Gordon PH, Wilbourn AJ (June 2001). "Early electrodiagnostic findings in Guillain-Barré syndrome". Arch. Neurol. 58 (6): 913–7. PMID 11405806.
  31. ↑ "Criteria for diagnosis of Guillain-Barré syndrome". Ann. Neurol. 3 (6): 565–6. June 1978. doi:10.1002/ana.410030628. PMID 677829.
  32. ↑ Byun, W M; Park, W K; Park, B H; Ahn, S H; Hwang, M S; Chang, J C (1998). "Guillain-Barré syndrome: MR imaging findings of the spine in eight patients". Radiology. 208 (1): 137–141. doi:10.1148/radiology.208.1.9646804. ISSN 0033-8419.
  33. ↑ Iwata, F.; Utsumi, Y. (1997). "MR imaging in Guillain-Barré syndrome". Pediatric Radiology. 27 (1): 36–38. doi:10.1007/s002470050059. ISSN 0301-0449.
  34. ↑ Woodring JH, Reed JC (1996). "Types and mechanisms of pulmonary atelectasis". J Thorac Imaging. 11 (2): 92–108. PMID 8820021.
  35. ↑ "Atelectasis | National Heart, Lung, and Blood Institute (NHLBI)".
  36. ↑ Ray, Komal; Bodenham, Andrew; Paramasivam, Elankumaran (2014). "Pulmonary atelectasis in anaesthesia and critical care". Continuing Education in Anaesthesia Critical Care & Pain. 14 (5): 236–245. doi:10.1093/bjaceaccp/mkt064. ISSN 1743-1816.
  37. ↑ Sachdev, Gaurav; Napolitano, Lena M. (2012). "Postoperative Pulmonary Complications: Pneumonia and Acute Respiratory Failure". Surgical Clinics of North America. 92 (2): 321–344. doi:10.1016/j.suc.2012.01.013. ISSN 0039-6109.
  38. ↑ Massard G, Wihlm JM (August 1998). "Postoperative atelectasis". Chest Surg. Clin. N. Am. 8 (3): 503–28, viii. PMID 9742334.
  39. ↑ Vincent JL, De Backer D (2013). "Circulatory shock". N. Engl. J. Med. 369 (18): 1726–34. doi:10.1056/NEJMra1208943. PMID 24171518.
  40. ↑ Menon V, White H, LeJemtel T, Webb JG, Sleeper LA, Hochman JS (2000). "The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?". J. Am. Coll. Cardiol. 36 (3 Suppl A): 1071–6. PMID 10985707.

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