Dyspnea differential diagnosis

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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[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

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 - - - + + + + + - - Expiratory wheeze ↑WBC ↓O2, ↑CO2 Hyperinflation, Reticulonodular opacities ↓ FEV1/FVC Lung biopsy Complication of allogeneic hematopoietic stem cell transplantation
Cystic fibrosis - - + + - +/- + + - - Rhonchi, Wheezing, Crackles Normal Metabolic alkalosis Thick-walled bronchiectasis ↓ FEF75%/FVC Sweat test Absent vas deferens
Pleural effusion - +/- + - + - - - +/- +/- Egophony ("E-to-A" change) Normal Normal Blunting of the costophrenic and cardiophrenic angle ↓Vt, ↑RV Light's criteria ↓Tactile fremitus, Asymmetrical chest expansion
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 - - - - -

References

  1. ↑ 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.
  2. ↑ van Steijn JH, Sleijfer DT, van der Graaf WT, van der Sluis A, Nieboer P (2002). "How to diagnose cardiac tamponade". Neth J Med. 60 (8): 334–8. PMID 12481882.
  3. ↑ 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.
  4. ↑ Debiasi RL, Tyler KL (2004). "Molecular methods for diagnosis of viral encephalitis". Clin Microbiol Rev. 17 (4): 903–25, table of contents. doi:10.1128/CMR.17.4.903-925.2004. PMC 523566. PMID 15489354.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.

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