Approach to the patient with dyspnea
- Richard M Schwartzstein, MD
Richard M Schwartzstein, MD
- Professor of Medicine
- Harvard Medical School
A consensus statement of the American Thoracic Society defined dyspnea in the following way :
"Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses."
The American Thoracic Society (ATS) statement on the mechanisms, assessment, and management of dyspnea, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.
Dyspnea, or breathing discomfort, is a common symptom that afflicts millions of patients with pulmonary disease and may be the primary manifestation of myocardial ischemia or dysfunction. Examination of the language of dyspnea suggests that this symptom represents a number of qualitatively distinct sensations, and that the words utilized by patients to describe their breathing discomfort may provide insight into the underlying pathophysiology of the disease.
The key elements in the evaluation of the patient with acute and chronic dyspnea will be reviewed here with a pathophysiologic construct to guide thinking about a differential diagnosis for the patient with dyspnea. The basic physiology of dyspnea is discussed separately. (See "Physiology of dyspnea".)
- Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435.
- Pratter MR, Curley FJ, Dubois J, Irwin RS. Cause and evaluation of chronic dyspnea in a pulmonary disease clinic. Arch Intern Med 1989; 149:2277.
- Martinez FJ, Stanopoulos I, Acero R, et al. Graded comprehensive cardiopulmonary exercise testing in the evaluation of dyspnea unexplained by routine evaluation. Chest 1994; 105:168.
- Simon PM, Schwartzstein RM, Weiss JW, et al. Distinguishable sensations of breathlessness induced in normal volunteers. Am Rev Respir Dis 1989; 140:1021.
- Banzett RB, Lansing RW, Reid MB, et al. 'Air hunger' arising from increased PCO2 in mechanically ventilated quadriplegics. Respir Physiol 1989; 76:53.
- Banzett RB, Lansing RW, Brown R, et al. 'Air hunger' from increased PCO2 persists after complete neuromuscular block in humans. Respir Physiol 1990; 81:1.
- Brack T, Jubran A, Tobin MJ. Dyspnea and decreased variability of breathing in patients with restrictive lung disease. Am J Respir Crit Care Med 2002; 165:1260.
- Simon PM, Schwartzstein RM, Weiss JW, et al. Distinguishable types of dyspnea in patients with shortness of breath. Am Rev Respir Dis 1990; 142:1009.
- Elliott MW, Adams L, Cockcroft A, et al. The language of breathlessness. Use of verbal descriptors by patients with cardiopulmonary disease. Am Rev Respir Dis 1991; 144:826.
- Mahler DA, Harver A, Lentine T, et al. Descriptors of breathlessness in cardiorespiratory diseases. Am J Respir Crit Care Med 1996; 154:1357.
- O'Donnell DE, Bertley JC, Chau LK, Webb KA. Qualitative aspects of exertional breathlessness in chronic airflow limitation: pathophysiologic mechanisms. Am J Respir Crit Care Med 1997; 155:109.
- Moy ML, Lantin ML, Harver A, Schwartzstein RM. Language of dyspnea in assessment of patients with acute asthma treated with nebulized albuterol. Am J Respir Crit Care Med 1998; 158:749.
- Killian KJ, Gandevia SC, Summers E, Campbell EJ. Effect of increased lung volume on perception of breathlessness, effort, and tension. J Appl Physiol Respir Environ Exerc Physiol 1984; 57:686.
- Taguchi O, Kikuchi Y, Hida W, et al. Effects of bronchoconstriction and external resistive loading on the sensation of dyspnea. J Appl Physiol (1985) 1991; 71:2183.
- Moy ML, Woodrow Weiss J, Sparrow D, et al. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med 2000; 162:451.
- Clark AL, Piepoli M, Coats AJ. Skeletal muscle and the control of ventilation on exercise: evidence for metabolic receptors. Eur J Clin Invest 1995; 25:299.
- Clark A, Volterrani M, Swan JW, et al. Leg blood flow, metabolism and exercise capacity in chronic stable heart failure. Int J Cardiol 1996; 55:127.
- Killian KJ, Leblanc P, Martin DH, et al. Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation. Am Rev Respir Dis 1992; 146:935.
- Melzack R, Torgerson WS. On the language of pain. Anesthesiology 1971; 34:50.
- Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1:277.
- Hunter M, Philips C. The experience of headache pain--an assessment of the qualities of tension headache pain. Pain 1981; 10:209.
- Melzack R, Terrence C, Fromm G, Amsel R. Trigeminal neuralgia and atypical facial pain: use of the McGill Pain Questionnaire for discrimination and diagnosis. Pain 1986; 27:297.
- Scano G, Stendardi L, Grazzini M. Understanding dyspnoea by its language. Eur Respir J 2005; 25:380.
- Banzett RB, Pedersen SH, Schwartzstein RM, Lansing RW. The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort. Am J Respir Crit Care Med 2008; 177:1384.
- Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax 2010; 65:21.
- Williams M, Cafarella P, Olds T, et al. The language of breathlessness differentiates between patients with COPD and age-matched adults. Chest 2008; 134:489.
- Gui P, Ebihara S, Kanezaki M, et al. Gender differences in perceptions of urge to cough and dyspnea induced by citric acid in healthy never smokers. Chest 2010; 138:1166.
- Hardie GE, Janson S, Gold WM, et al. Ethnic differences: word descriptors used by African-American and white asthma patients during induced bronchoconstriction. Chest 2000; 117:935.
- Phankingthongkum S, Daengsuwan T, Visitsunthorn N, et al. How do Thai children and adolescents describe asthma symptoms? Pediatr Allergy Immunol 2002; 13:119.
- Han J, Zhu Y, Li S, et al. The language of medically unexplained dyspnea. Chest 2008; 133:961.
- Manning HL, Shea SA, Schwartzstein RM, et al. Reduced tidal volume increases 'air hunger' at fixed PCO2 in ventilated quadriplegics. Respir Physiol 1992; 90:19.
- Binks AP, Moosavi SH, Banzett RB, Schwartzstein RM. "Tightness" sensation of asthma does not arise from the work of breathing. Am J Respir Crit Care Med 2002; 165:78.
- Lam LL, Cameron PA, Schneider HG, et al. Meta-analysis: effect of B-type natriuretic peptide testing on clinical outcomes in patients with acute dyspnea in the emergency setting. Ann Intern Med 2010; 153:728.
- Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347:161.
- Maisel A. B-type natriuretic peptide levels: diagnostic and prognostic in congestive heart failure: what's next? Circulation 2002; 105:2328.
- Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139:1140.
- Epler GR, McLoud TC, Gaensler EA, et al. Normal chest roentgenograms in chronic diffuse infiltrative lung disease. N Engl J Med 1978; 298:934.
- Wells AU, Hansell DM, Rubens MB, et al. The predictive value of appearances on thin-section computed tomography in fibrosing alveolitis. Am Rev Respir Dis 1993; 148:1076.
- Klein JS, Gamsu G, Webb WR, et al. High-resolution CT diagnosis of emphysema in symptomatic patients with normal chest radiographs and isolated low diffusing capacity. Radiology 1992; 182:817.
- Penicka M, Bartunek J, Trakalova H, et al. Heart failure with preserved ejection fraction in outpatients with unexplained dyspnea: a pressure-volume loop analysis. J Am Coll Cardiol 2010; 55:1701.
- Rosser R, Guz A. Psychological approaches to breathlessness and its treatment. J Psychosom Res 1981; 25:439.
- Bredin M, Corner J, Krishnasamy M, et al. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 1999; 318:901.
- Burns BH, Howell JB. Disproportionately severe breathlessness in chronic bronchitis. Q J Med 1969; 38:277.
- Dales RE, Spitzer WO, Schechter MT, Suissa S. The influence of psychological status on respiratory symptom reporting. Am Rev Respir Dis 1989; 139:1459.
- Nishino T, Shimoyama N, Ide T, Isono S. Experimental pain augments experimental dyspnea, but not vice versa in human volunteers. Anesthesiology 1999; 91:1633.
- Livermore N, Butler JE, Sharpe L, et al. Panic attacks and perception of inspiratory resistive loads in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2008; 178:7.
- - Controller
- - Ventilatory pump
- - Gas exchanger
- - Heart failure
- - Anemia
- - Deconditioning
- LANGUAGE OF DYSPNEA
- Using questionnaires
- EVALUATION OF ACUTE DYSPNEA
- Plasma BNP
- Chest ultrasonography
- EVALUATION OF CHRONIC DYSPNEA
- History and physical examination
- Laboratory testing
- Pulmonary function testing
- Cardiopulmonary exercise testing
- BEHAVIORAL CONSIDERATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS