Chapter 14
Dyspnea (Case 8)
Esaïe Carisma DO and Christina Migliore MD
Case: The patient is a 57-year-old forklift driver in a local warehouse. He has noticed progressive shortness of breath with exertion for the past 2 weeks. He is unable to climb one flight of stairs or walk one block on level ground without becoming short of breath. He denies any recent chest pain or lower extremity edema, but admits to a nonproductive cough. He is able to lie flat while sleeping, and he snores at night. He has a 20-year history of smoking one pack of cigarettes per day, but recently has reduced his smoking to fewer than five cigarettes daily. On physical exam, he is an obese man who does not appear short of breath or in any acute distress at rest. His respiratory rate is 18 breaths per minute, and there is no use of accessory muscles of respiration. He has a crowded oropharynx. His breath sounds are reduced bilaterally, but the chest is clear to auscultation. He has neither digital clubbing nor cyanosis. There is trace pitting edema observed at both ankles.
Differential Diagnosis
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Emphysema or chronic obstructive pulmonary disease (COPD) |
Pulmonary embolism |
Pneumothorax |
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Asthma |
Sleep apnea |
Interstitial lung disease |
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Pulmonary edema |
Pleural effusion |
Speaking Intelligently
Dyspnea is a common symptom encountered in both the inpatient and outpatient settings. It is a subjective uncomfortable sensation of breathlessness, or running out of air, that varies in intensity. Similar to patients who present with pain, it is often difficult to quantify. In certain circumstances such as during exercise or at high altitudes, dyspnea is a normal sensation. However, it is abnormal when it occurs at rest or during usual levels of activity. Cardiac and pulmonary disorders are the most common causes of dyspnea, although noncardiopulmonary causes (e.g., anemia) must be considered.
PATIENT CARE
Clinical Thinking
• Determine the onset, duration, and severity of the symptom.
• Chronic dyspnea can generally be evaluated in an ambulatory setting.
History
A detailed history should focus on:
• Environmental irritant exposure (e.g., smoke from a building fire)
• Tobacco exposure history (active or passive smoking)
• Illicit substance abuse and use of specific medications
• Past medical, occupational, and travel history
Physical Examination
• Neck: Inspect for stridor, vein distension, and goiter.
• Heart: Auscultation of the heart may reveal cardiac murmurs and/or extra heart sounds.
Tests for Consideration
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• Electrocardiogram (ECG) may demonstrate myocardial ischemia or arrhythmia. |
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| Clinical Entities | Medical Knowledge |
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Pulmonary Embolism (PE) |
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Pφ |
PE is a potentially lethal condition. It commonly occurs when a deep vein thrombus fragments and travels through the vena cava to the right side of the heart, eventually becoming lodged in the pulmonary artery or one of its branches. |
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TP |
Patients usually complain of the sudden onset of dyspnea. Pleuritic chest pain, tachypnea, and hemoptysis may also be present. Syncope may be the only presenting symptom and is usually a sign of extensive compromise of cardiac output. |
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Dx |
CT angiography (CT scan with intravenous contrast) is becoming more widely used for the diagnosis of PE; filling defects within segmental or larger pulmonary arteries are specific for the diagnosis. A ventilation/perfusion (V/Q) scan will show perfusion defects without corresponding ventilation defects; it should be ordered in patients with renal insufficiency to avoid the use of contrast. If the V/Q scan is negative, it essentially rules out the diagnosis of PE. V/Q scan results often state that there is low probability for PE or that the probability of PE is indeterminate. If the suspicion for PE remains high in such cases, further testing such as venous Doppler of the lower extremities or pulmonary angiogram should be pursued. |
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Tx |
Unfractionated heparin or low-molecular-weight heparin is the treatment of choice. In patients with massive PE and hemodynamic instability, thrombolysis or thrombectomy can be considered. See Cecil Essentials 19. |
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Pulmonary Edema |
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Pulmonary edema is usually cardiac in nature. Typical causes of pulmonary edema include myocardial infarction, acute decompensation of chronic left ventricular failure, and valvular heart disease. However, a number of other conditions such as sepsis and blood transfusion reaction may also cause pulmonary edema. |
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TP |
Patients present with severe dyspnea, production of pink frothy sputum, and diaphoresis. Tachycardia is usually observed. A third heart sound (S3 gallop) is often present. |
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Chest radiograph may reveal an enlarged cardiac silhouette and diffuse vascular congestion. An echocardiogram should be ordered to determine the cardiac function. |
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Tx |
Treatment may involve supplemental oxygen, diuretics, nitroglycerin (if angina is present), and afterload reduction along with inotropic agents to increase contractility (see Chapter 10, Congestive Heart Failure). See Cecil Essentials 6, 23. |
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Asthma |
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Asthma is a chronic inflammatory disorder of the lung characterized by reversible airway obstruction. |
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Patients present with episodic wheezing, dyspnea, cough, and chest tightness. Symptoms may worsen with exercise, upper respiratory tract infections, and emotional stress. |
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Dx |
A pulmonary function test (PFT) usually reveals a decreased FEV1/FVC ratio; reversibility of obstruction is indicated by improvement in FEV1 after administration of a short-acting β2 agonist. If PFT is nondiagnostic, a methacholine bronchial provocation test may also be ordered. A positive test is generally defined as a 20% decrease in FEV1 induced by methacholine. |
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Tx |
Treatment includes short-acting bronchodilators to relieve acute symptoms, and inhaled corticosteroids; long-acting bronchodilators are utilized for moderate to severe symptoms. Systemic corticosteroids are often used for acute and severe exacerbations. See Cecil Essentials 17. |
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COPD or Emphysema |
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COPD is a disorder with progressive airway obstruction. COPD includes an overlapping spectrum of diseases including chronic bronchitis, defined as a productive cough for 3 months or more in 2 consecutive years, and emphysema (abnormal enlargement of air spaces with destruction of alveolar walls). Emphysema is characterized by loss of elastic recoil and increased airway resistance, which lead to reduced expiratory airflow. |
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TP |
Patients usually present in their sixth decade complaining of productive cough, dyspnea on exertion, and occasional wheezing. |
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Spirometry is the recommended screening tool for COPD. FEV1/FVC ratio less than 70% is diagnostic for obstructive lung disease. PFT reveals decreased vital capacity and expiratory flow rates with increased residual volume and total lung capacity. Chest radiographs may show hyperinflation and bronchial thickening but are nonspecific and do not reflect severity of disease. |
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Tx |
Smoking cessation is necessary to slow the progression of disease. Bronchodilators including β2-adrenergic agonists and anticholinergic drugs are the mainstay of treatment. Corticosteroids are reserved for patients with severe disease. See Cecil Essentials 17. |
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Sleep Apnea |
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Sleep apnea is a disorder usually characterized by resistance to airflow in the upper airway. The patient’s airway frequently collapses while sleeping, leading to hypopnea and/or apnea. These events can lead to oxygen desaturation producing cardiovascular disease and subsequent dyspnea. |
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TP |
Patients usually have a history of loud snoring associated with a choking sensation, and excessive daytime sleepiness. Patients will usually complain of morning headache, nocturia, and waking up with dry mouth and nightmares. Patients tend to be overweight with a crowded oropharynx and large neck circumference. |
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Dx |
Nocturnal polysomnography is the gold standard for the diagnosis of sleep apnea. Apnea is defined as the cessation of airflow for at least 10 seconds. It is classified as central apnea if there is neither respiratory effort nor airflow, obstructive apnea if there is continuous respiratory effort, or mixed if there is absence of effort at the beginning followed by demonstrated effort without airflow. |
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Behavior modification is important in treating this condition; weight loss can be curative. Continuous positive airway pressure (CPAP) is the treatment of choice; it improves oxygen saturation, sleep quality, daytime alertness, and ultimately cardiac function. See Cecil Essentials 20. |
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Pleural effusion occurs when more fluid enters the pleural space than is removed. Pleural effusions are either transudative or exudative in character. |
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Dyspnea, cough, and pleuritic chest pain are the most common presenting symptoms. Fremitus and breath sounds are decreased over the effusion. |
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Dx |
Thoracentesis should be performed for diagnosis. An effusion is exudative if any one of the following three criteria is present: (1) the ratio of pleural fluid to serum protein is >0.5, (2) the ratio of pleural fluid to serum lactate dehydrogenase (LDH) is >0.6, (3) pleural fluid LDH is greater than two thirds the upper limit of the normal serum LDH. Transudates are associated with low concentrations of protein. Transudates result from imbalances of hydrostatic and oncotic forces, and are caused by limited conditions such as congestive heart failure and cirrhosis. Exudates have higher protein concentrations and tend to be inflammatory or neoplastic in origin. |
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Tx |
Treat the underlying cause. Empyema, as a complication of pneumonia, must be drained with an appropriately sized chest tube and in a timely manner to prevent complications (i.e., need for video-assisted thorascopic surgery [VATS] or thoracotomy). See Cecil Essentials 21. |
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Pneumothorax |
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Pneumothorax is the accumulation of air in the pleural space. It is classified as spontaneous or traumatic. Spontaneous pneumothorax is further classified as primary in the absence of clinical lung disease or secondary in the presence of lung disease. Trauma is the most common cause of pneumothorax. |
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TP |
Pleuritic chest pain and dyspnea are the most common symptoms. Tachycardia, decreased breath sounds, and hyper-resonance are the usual physical exam findings. |
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Dx |
A visceral pleural line on chest radiograph is diagnostic. Mediastinal shift is observed if a tension pneumothorax is present. |
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Tx |
Treatment depends on the severity of the pneumothorax. A small pneumothorax does not require therapy. Chest tube placement (i.e., tube thoracostomy) is indicated for large pneumothoraces or those demonstrating tension. See Cecil Essentials 21. |
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ILDs, or diffuse parenchymal lung diseases, are a collection of disorders that are grouped together because of their similar presenting symptoms and radiographic appearance. The pathophysiology is thought to initially center on the lung interstitium, but alveolar, pleural, and other lung structural changes may result as the disease progresses. They are classified and named primarily based on their underlying histopathology. |
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TP |
Persistent and progressive dyspnea and nonproductive cough are common initial symptoms. Crackles or “Velcro rales” are commonly auscultated with most forms of ILD but are commonly absent in granulomatous diseases including sarcoidosis. |
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Dx |
PFT will reflect a restrictive ventilatory defect. A chest radiograph may reveal diffuse reticular opacities; however, a thoracic CT scan will demonstrate interstitial changes with greater sensitivity and specificity. When the radiographic appearance is not definitive enough for diagnosis, a lung biopsy, via bronchoscopy or VATS, may be necessary. |
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Tx |
Treatment depends entirely on the histopathologic subtype. Corticosteroids are commonly prescribed as initial anti-inflammatory therapy and may be effective in sarcoidosis but are unlikely to be of any benefit for usual interstitial pneumonitis, a subtype with no known effective medical therapy. Chronic respiratory failure due to ILD is a common indication for lung transplantation. See Cecil Essentials 18. |
Practice-Based Learning and Improvement: Evidence-Based Medicine
Title
Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease
Authors
Peter MA, Calverley MD, Anderson JA, et al.
Institution
Multiple institutions
Reference
N Engl J Med 2007;356:775–789
Problem
The treatment of COPD with inhaled corticosteroids and β-adrenergic receptor agonists is well established. However, to date there had not been a trial addressing the survival benefit of combination therapy.
Intervention
Randomized, double-blind trial comparing salmeterol 50 µg plus fluticasone propionate 500 µg twice daily, with placebo, salmeterol alone, or fluticasone propionate alone for 3 years
Outcome/effect
The combination therapy did not reach the predetermined level of statistical significance.
Historical significance/comments
Although the trial did not reach its primary outcome, which was a 25% reduction in mortality, it showed that subjects receiving combination therapy had significant reduction in exacerbations, use of oral steroids, and protection against deterioration of lung function.
Interpersonal and Communication Skills
Communicate the Importance of Smoking Cessation
One of the major risk factors for chronic bronchitis, COPD, asthma, and heart disease is cigarette smoking. Studies have shown that patients are more likely to be compliant with medications and lifestyle modification when their physician has properly educated them about their condition. Patients should be provided resources to assist in their own efforts to quit smoking. Their families need to be engaged to be sources of encouragement and support, and it is essential for the physician to take the time to speak personally with family members on this point. Helpful tips for the patient include setting a quit date, informing family and friends about his or her plan to quit smoking, and joining a support group such as Nicotine Anonymous or 1-800-QUITNOW. Provide patients with a list of products that can help with the feeling of nicotine withdrawal including the nicotine patch, gum, lozenges, and medications.
Avoid Conflicts of Interest When Accepting Gifts from Patients
In caring for patients with long-standing chronic illnesses, like COPD, physicians develop relationships with patients and families that span many years. Even early in the course of a relationship, there may be clinical moments where, in the eyes of patients, their physician has literally saved their life by getting them through a serious exacerbation of the disease or working with them to alleviate significantly uncomfortable symptoms. Occasionally patients express their gratitude in the form of gifts, especially at holiday time. Hospital systems maintain specific guidelines when it comes to accepting gifts, which may even include monetary thresholds for acceptance.
Systems-Based Practice
Your patient has COPD and requires admission to the hospital. While hospitalized, his respiratory status worsens. He is transferred to the intensive care unit and requires intubation and mechanical ventilation. He later develops pneumonia and a deep venous thrombosis. How does the hospital get paid for the services provided? In the past, hospitals would assemble a list of all of the services provided, and the insurance companies would pay for them; however, this is no longer the case. Hospitals typically get paid in one of three ways. The most common is a case payment, in which the hospital receives a fixed amount of money for the patient’s entire stay; the amount is dependent on the diagnoses of the patient and does not factor in the specifics of the individual case, unless length of stay is exceptionally long. Second, hospital reimbursement can be made by per diem payments, in which the hospital receives a defined amount of money for every day that the patient is in the hospital. Third, some hospitals participate in a capitation payment structure, in which they receive a fixed amount of money per member per month to provide care for a group of patients; the hospital receives this money whether or not the patients are actually admitted to the hospital. As a result, the hospital and the entire health system have a financial incentive to keep patients healthy and out of the hospital.
