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The Differential Diagnosis of Dyspnea Dominik Berliner, Nils Schneider, Tobias Welte, and Johann Bauersachs

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The Differential Diagnosis of Dyspnea Dominik Berliner, Nils Schneider, Tobias Welte, and Johann Bauersachs MEDICINE CONTINUING MEDICAL EDUCATION The Differential Diagnosis of Dyspnea Dominik Berliner, Nils Schneider, Tobias Welte, and Johann Bauersachs SUMMARY yspnea (shortness of breath) is a common D symptom affecting as many as 25% of patients Background: Dyspnea is a common symptom affecting as seen in the ambulatory setting. It can be caused by many as 25% of patients seen in the ambulatory setting. It many different underlying conditions, some of can arise from many different underlying conditions and is which arise acutely and can be life-threatening (e.g., sometimes a manifestation of a life-threatening disease. pulmonary embolism, acute myocardial infarction). Methods: This review is based on pertinent articles Thus, rapid evaluation and targeted diagnostic retrieved by a selective search in PubMed, and on studies are of central importance. Overlapping pertinent guidelines. clinical presentations and comorbid diseases, e.g., Results: The term dyspnea refers to a wide variety of congestive heart failure and chronic obstructive pul- subjective perceptions, some of which can be influenced monary disease (COPD), can make the diagnostic by the patient’s emotional state. A distinction is drawn evaluation of dyspnea a clinical challenge, all the between dyspnea of acute onset and chronic dyspnea: the more so as the term “dyspnea” covers a wide variety latter, by definition, has been present for more than four of subjective experiences. The presence of this weeks. The history, physical examination, and observation symptom is already a predictor of increased mortal- of the patient’s breathing pattern often lead to the correct ity. diagnosis, yet, in 30–50% of cases, more diagnostic studies are needed, including biomarker measurements Learning goals and other ancillary tests. The diagnosis can be more This article should enable the reader to: difficult to establish when more than one underlying ● be familiar with the problems that lead adult disease is present simultaneously. The causes of dyspnea patients to complain of shortness of breath include cardiac and pulmonary disease (congestive heart (dyspnea), failure, acute coronary syndrome; pneumonia, chronic ● name the main steps in the diagnostic evaluation obstructive pulmonary disease) and many other conditions of dyspnea, and (anemia, mental disorders). ● identify the main elements in the differential diag- Conclusion: The many causes of dyspnea make it a nosis of dyspnea of non-traumatic origin. diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of dis- Methods ease. This review is based on pertinent articles retrieved by a selective search in PubMed, on the current guidelines ►Cite this as: of the European Society of Cardiology (ESC), the Ger- Berliner D, Schneider N, Welte T, Bauersachs J: The man Society of Cardiology (Deutsche Gesellschaft für differential diagnosis of dyspnoea. Dtsch Arztebl Int Kardiologie, DGK), and the German Society for Pneu- 2016; 113: 834–45. DOI: 10.3238/arztebl.2016.0834 monology and Respiratory Medicine (Deutsche Gesell schaft für Pneumologie und Beatmungsmedizin, DGP), and on information contained in textbooks of gen- eral and internal medicine. The search terms included the following, among others: “dyspnea”; “dyspnea, epidemiology”; “dyspnea, primary care, prevalence”; Department of Cardiology and Angiology, Hannover Medical School: Dr. med. Berliner, Prof. Dr. med. Bauersachs Prevalence Institute for General Practice, Hannover Medical School: Prof. Dr. med. Schneider Dyspnea (shortness of breath) is a common Department of Respiratory Medicine, Hannover Medical School: symptom affecting as many as 25% of patients Prof. Dr. med. Welte seen in the ambulatory setting. 834 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 834–45 MEDICINE “dyspnea, prevalence”; “dys pnea, guidelines”; “dyspnea, Epidemiology pathophysiology”; “dys pnea, causes”; “dyspnea, general Dyspnea is a common symptom both in general practitioner”; “dyspnea, primary care”; “dyspnea, acute practice and in hospital emergency rooms. It has coronary syndrome”; “PLATO trial”; “dyspnea, side been reported that 7.4% of patients presenting to effect”; “EMS, dyspnea”; “ED, dyspnea.” emergency rooms complain of dyspnea (4); among patients in general practice, 10% complain of Illustrative case study dyspnea when walking on flat ground and 25% A 64-year-old woman presents to her family doctor complain of dyspnea on more intense exertion, e.g., complaining of progressive shortness of breath on exer- climbing stairs (5). For 1–4% of patients, dyspnea tion. She can climb no more than two flights of stairs is their main reason for consulting a doctor (6, 7). without stopping; recently, she has been able to walk no In specialty practice, patients with chronic dyspnea longer than 5 minutes on flat ground without becoming account for 15–50% of those seen by cardiologists “exhausted.” She has, in fact, been experiencing short- and just under 60% of those seen by pneumonol - ness of breath for some time now, but has noticed a ogists (2). 12% of patients seen by emergency marked worsening in the last few days. medical rescue teams have dyspnea, and half of them need to be hospitalized; those who are hospi- The definition of dyspnea talized have an in-hospital mortality of ca. 10% (8). In a consensus paper (1), the American Thoracic The distribution of underlying diagnoses varies Society defines dyspnea as “a subjective experience of from one care situation to another, as shown in breathing discomfort that consists of qualitatively dis- Table 1. tinct sensations that vary in intensity. [it] derives A more precise classification of the patient’s symp- from interactions among multiple physiological, psy- toms is helpful in the differential diagnosis. There are chological, social, and environmental factors, and may multiple criteria to be considered (3): induce secondary physiological and behavioral ● temporal responses.” – acute onset, vs. chronic (present for more than Dyspnea is an umbrella term for a number of distin- four weeks), vs. acute worsening of pre- guishable subjective experiences including effortful existing symptoms respiration, a feeling of choking or asphyxiation, and – intermittent vs. permanent hunger for air. The subjectivity of dyspnea is one of the – episodic (attacks) main difficulties confronting the clinician whose task it ● situational is to determine the diagnosis and judge the severity of – at rest the underlying condition. The pathogenesis of dyspnea is – on exertion still not fully clear and is now under investigation. – accompanying emotional stress Current explanatory hypotheses are based on the concept – depending on body position of a regulatory circuit that consists of afferent in- – depending on special exposure(s) formation relayed centrally (from chemoreceptors for ● pathogenetic pH, CO2, and O2 , as well as from mechanoreceptors in – problems relating to the respiratory system the musculature and the lungs [C fibers in the parenchy- (central control of breathing, airways, gas ma, J fibers in the bronchi and pulmonary vessels]) and a exchange) corresponding ventilatory response (2). – problems relating to the cardiovascular system Various instruments are used to assess dyspnea, – mixed cardiac and pulmonary causes ranging from simple descriptions of intensity (visual – other causes, e.g., anemia, thyroid disease, analog scale, Borg scale) to multidimensional question- poor physical condition (i.e., muscle decondi- naires (e.g., the Multidimensional Dyspnea Profile). tioning) These instruments have been validated and are useful – mental causes for communication. There are other, disease-specific The diagnosis and treatment of dyspnea are some- classifications, including the New York Heart Associ- times made more difficult by the simultaneous presence ation (NYHA) classification of chronic congestive of more than one underlying disease, particularly in heart failure (2, 3). elderly, multimorbid patients. Diagnostic evaluation Dyspnea The diagnostic assessment of dyspnea is a Dyspnea is a common symptom: challenge in routine practice, particularly because 7% of patients in hospital emergency rooms and the term “dyspnea”/“shortness of breath” covers as many as 60% of those in ambulatory pulmono- a variety of subjective experiences. logical practice complain of dyspnea. Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 834–45 835 MEDICINE TABLE 1 Acute dyspnea Dyspnea of acute onset may be a manifestation of a The more common causes of dyspnea in emergency medical rescue situa - life-threatening condition. Alarm signs include con- tions, in hospital emergency rooms, and in general medical practice* fusion, marked cyanosis (as a new finding), dyspnea Rescue service Emergency room General practice while speaking, and insufficient respiratory effort or Heart failure (15–16%) COPD (16.5%) Acute bronchitis (24.7%) respiratory exhaustion. The potential threat to life should be assessed at once. Measurement of the vital Pneumonia (10–18%) Heart failure (16.1%) Acute upper respiratory infection (9.7%) signs (heart reate, blood pressure, oxygen saturation of the blood) is obligatory for timely decision-making COPD (13%) Pneumonia (8.8%) Other airway infection (6.5%) about what to do next, in particular whether the patient acutely needs to be treated in an intensive care unit or Bronchial asthma (5–6%) Myocard. infarction (5.3%) Bronchial asthma (5.4%) to receive invasive assisted ventilation.
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