ASSESSMENT OF DYSPNOEA

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Introduction

Dyspnoea, or shortness of breath, is a subjective sensation of breathing discomfort that patients often describe as difficulty in breathing, air hunger, or chest tightness. It is a prevalent symptom in emergency and general medicine, affecting up to half of all patients admitted to tertiary care hospitals. The clinical evaluation of dyspnoea can be complex, as its etiology spans a wide spectrum of diseases across various organ systems, including respiratory, cardiovascular, and neuromuscular conditions.

Etiology of Dyspnoea

The causes of dyspnoea can be broadly categorized based on the acuity of onset: acute, subacute, and chronic.

• Acute Dyspnoea: Common causes include asthma, exacerbations of COPD, pulmonary embolism (PE), acute coronary syndromes (ACS), and pneumothorax. Acute dyspnoea is often associated with life-threatening conditions that require rapid diagnosis and intervention.

• Subacute Dyspnoea: Typically develops over hours to days. Common causes include worsening asthma, acute exacerbation of heart failure, and pleural effusion.

• Chronic Dyspnoea: Develops over weeks to months and is frequently associated with chronic conditions such as COPD, congestive heart failure, interstitial lung disease, and pulmonary hypertension.

Table 1: Common Causes of Dyspnoea by Acuity

Onset

Common Causes

Acute

Asthma, COPD exacerbation, PE, ACS, pneumothorax

Subacute

Acute asthma, COPD exacerbation, myocarditis

Chronic

COPD, congestive heart failure, idiopathic pulmonary fibrosis

Diagnostic Approach

The initial approach to a patient with dyspnoea involves a thorough clinical history, physical examination, and the use of the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) to assess the severity. The history should focus on identifying the acuity of symptoms, associated features like chest pain or wheezing, and risk factors such as smoking or cardiovascular disease.

Key elements in the evaluation include:

• Time Course: Acute vs. chronic symptoms.

• Associated Symptoms: Fever, cough, chest pain, wheezing, and fatigue.

• Positionality: Conditions such as orthopnoea (dyspnoea when supine) and platypnoea (worsening on standing) help narrow the differential.

• Physical Examination: Cyanosis, tachycardia, tachypnoea, use of accessory muscles, and auscultation findings (e.g., wheezing, crackles) guide further investigation.

Table 2: Differential Diagnosis Based on Symptoms and Physical Exam Findings

Symptom/Exam Finding

Possible Conditions

Wheezing

Asthma, COPD, foreign body aspiration

Chest Pain

ACS, PE, pneumothorax

Fever

Pneumonia, acute bronchitis, sepsis

Orthopnoea

Congestive heart failure, asthma, COPD

Management of Dyspnoea

The management of dyspnoea is directed by the underlying cause. Immediate interventions focus on airway management, oxygen supplementation, and stabilization. For instance:

• Acute Asthma: Treated with high-dose inhaled bronchodilators, corticosteroids, and possibly magnesium sulfate if unresponsive to initial therapy.

• Pulmonary Embolism: Anticoagulation therapy is initiated, and thrombolytic therapy may be considered in hemodynamically unstable patients.

• Congestive Heart Failure: Management includes diuretics, nitrates, and positive pressure ventilation in cases of acute pulmonary edema.

Emergencies Associated with Dyspnoea

Several emergencies present with dyspnoea and require urgent intervention:

• Acute Coronary Syndrome (ACS): May present with or without chest pain, especially in diabetic patients. ECG and cardiac biomarkers are critical for diagnosis.

• Acute Pulmonary Embolism (PE): Presents with sudden dyspnoea, chest pain, and tachycardia. CT pulmonary angiography is the gold standard for diagnosis.

• Pneumothorax: Requires rapid decompression via needle thoracostomy if tension pneumothorax is suspected.