Approach to a patient

with breathlessness

Definition

difficult, laboured,
uncomfortable breathing; it is an
unpleasant type of breathing.

Medical Research Council (MRC)

breathlessness scale
Grade

Degree of breathlessness related to activities

Breathlessness when hurrying on the level or walking

up a slight hill

Breathlessness when walking with people of own age

or on level ground

Walks slower than peers, or stops when walking on the

flat at own pace

Stops after walking 100 meters, or a few minutes, on

the level

Too breathless to leave the house

5b

Too breathless to wash or dress

Cause of
breathlessness
Condition
associated with an
increased chemical
or neurological
drive to breath

Condition
associated with an
increase work of
breathing

Obstructiv
e

Restrictiv
e

Condition
associated with
decreased
neuromascular
power

Condition associated with an

increased chemical or neurological
drive to breathe
Common causes:
Pulmonary edema
Pulmonary embolus
Pneumothorax
Pneumonia
Lobar collapse
Pulmonary fibrosis
Anemia

Uncommon causes:
Acidosis
Pregnancy
Cyanotic congenital heart disease
High altitude
Arteriovenous fistula

Condition associated with an

increased work of breathing
A. Obstructive ventilatory defects
Common causes:
Chronic obstructive airways disease
Emphysema
Asthma
Bronchiectasis
Cystic fibrosis
Byssinosis

Uncommon causes:
Upper airways obstruction

B. Restrictive ventilatory defects

Common causes:
Sarcoidosis
Fibrosing alveolitis
Extrinsic allergic alveolitis
Pneumoconiosis
Large pleural effusion
Extensive lung resection
Chest wall deformities
Pulmonary edema
Left ventricular dysfunction

Uncommon causes:
Large tumours
Large hiatus hernia
Lymphangitis carcinomatosa
Connective tissue diseases
Aspiration pneumonitis
Infections

Condition associated with decreased

neuromascular power
Common causes:
Myasthenia gravis
Polyneuritis
Muscular dystrophies
Uncommon causes:
Poliomyelitis
Motor neurone disease

History taking in a patient

with breathlessness

Personal history
Name, Age, Sex, Occupation, Address, Date
of Admission
Chief complaint
Nature and duration of complaint
Breathlessness / dyspnea / shortness of
breath / difficulty in breathing
Other related complaints: cough with
expectoration, chest pain, fever,
palpitation

History of presenting illness

Onset, duration, description, progression,
aggravating and relieving factors, current
treatment
Questions regarding positions, timings,
conditions, activities that lead to
breathlessness
Grade the severity of the breathlessness
Past history
Asthma, TB, allergy, chest trauma / surgery,
IHD (angina, MI), HT, diabetes

Personal history
Smoking, loss of weight and appetite, alcohol,
sleep
Family history
Genetic disorders, relatives with similar
problems, history of TB, asthma, IHD, allergy
Social history
Income, house, electricity, water source
Treatment history
Summary

Abnormalities on physical
examination in
breathlessness
General Examination

GENERAL EXAMINATION
1. Face
. Visible Distress
. Swollen Facial Tissue
(in the case of anaphylaxis)

2. Hand
Palm: Cold and sweaty (due to peripheral
vasoconstriction)
Nails: Bluish discoloration (Cyanosis)

3. Mouth
Lips: bluish discoloration (Cyanosis)
Tip of tongue: bluish
discoloration(Cyanosis)
Tongue: Oral leukoplakia , Oral candidiasis
(signify immunosuppression, high chance of
pneumocystis jirovecci infection with HIV)

4. Eyes
Palpebral conjunctiva: pallor
5. Pulse
High pulse rate
Abnormal volume
Pulsus paradoxus (due to cardiac
tamponade)

6. Respiratory rate
High
7. Blood Pressure
Hypertensive (due to peripheral
vasoconstriction)
Hypotensive (due to shock)

8. Leg
Swelling (if symmetrical, cardiac failure;
if asymmetrical, venous thrombosis)

Respiratory System
InspectionExamination
1. Thoracic deformity (any scars for
thoracic surgery)
2. Abnormal shape of chest
Kyphoscoliosis
Barrel chest
3. Excessive usage of accessory muscle
of respiration
4. Presence of Kussmauls Respiration
(Rapid, deep and labored pattern of
breathing)

Palpation
1. Trachea deviation (e.g. in pneumothorax,
pleural effusion)
2. Significant Asymmetry in chest expansion
and vocal fremitus
Percussion
Significant asymmetry in percussion
. Dull: Total lung collapse
(tumor, foreign body, mucus plug)
. Stony dull: Pleural effusion
. Hyper resonance: Pneumothorax

Auscultation
1. Abnormal breath sounds
Bronchial breath sound heard over
lung parenchyma
Aegophony
2. Diminished vesicular breath sounds
Pleural effusion
Pneumothorax
3. Added sounds
Wheezing
Crepitation

CVS System Examination

Inspection
Visible JVP (Cardiac tamponade)
Palpation and Auscultation
Murmur of mitral stenosis in rest
(MI/Congestive Heart Failure)
Cardiac arrhythmia

Differential diagnosis
of breathlessness

Breathlessness presents
either as:
Chronic exertional breathlessness
Acute severe breathlessness

Chronic exertional
breathlessness
Careful history taking
Key questions:
How is you breathing at rest?
COPD : bad during exercise, better at
rest/overnight\
Asthma : woken up at night

How much can you do on a good day?

Grading of dyspnea (note the distance and
the level)

Association with history of

angina/HTN/MI?

Cont
Breathing problems during
childhood/history of atopy?
Suggestive of asthma

Other symptoms along with

breathlessness
Pleuritic chest pain + breathlessness ->
thromboembolism
Morning headache + breathlessness
-> onset of CO2 retention/ respiratory
failure

Acute severe breathlessness

Most common and dramatic medical
emergencies
History and rapid but careful examination
can suggest cause
Supplemented with CXR and ABG
History :
Rate of onset
Severity
Any CVS ass.
Any respiratory symptom

Cont
Clinical assessment :
Level of consciousness
Degree of central cyanosis
Evidence of anaphylaxis
Patency of the upper airway
Ability to speak
CVS status

Investigations of
dyspnoea
1. Pulse oximetry
2.
3.
4.
5.
6.

Spirometry
Arterial Blood Gas (ABG)
Peak Expiratory Flow Rate
Full Blood Count
Electrolytes, B-type natriuretic peptide
(BNP), N-terminal pro-BNP (NT-proBNP)
7. Kidney function tests
8. Cardiac enzymes- elevated troponin I/T,
myoglobin & CK-MB
9. CXR
10. ECG & Echocardiogram
11. D-dimer
12. High resolution CT & lung biopsy

MANAGEMENT

BRONCHODILATORS
CORTICOSTEROIDS
ANTI-ANXIETY DRUGS
OXYGEN THERAPY
EXPOSURE TO IRRITANTS
MUCOLYTICS
PULMONARY REHABILITATION
SURGICAL INTERVENTION