Dyspnea

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Dyspnea
ICD-10	R06.8
ICD-9	786.0
DiseasesDB	15892
MedlinePlus	003075
MeSH	C08.618.326

Dyspnea Microchapters
Patient Information
Overview
Pathophysiology
Causes
Differentiating Dyspnea from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Breathlessness; DIB; difficulty breathing; dyspnoea; respiration difficult; respiratory distress; shortness of breath; SOB;

Overview

Dyspnea is perceived to be difficulty of breathing or painful breathing. It is a common symptom of numerous medical disorders.

Dyspnea on exertion (DOE or exertional dyspnea) indicates dyspnea that occurs (or worsens) during physical activity.

Causes

Common Causes

• Acute heart failure
• Acute papillary muscle rupture
• Cardiac tamponade
• Foreign body aspiration
• Spontaneous pneumothorax
• H. influenza epiglottitis
• Bronchospasm
• Pulmonary edema

Causes by Organ System

Cardiovascular	Aortic dissection, Cardiomyopathy, Congenital heart disease, Heart failure, Ischaemic heart disease, Malignant hypertension, Diseases of the pericardium such as Cardiac tamponade, Constrictive pericarditis or Pericardial effusion, Pulmonary edema, Pulmonary embolism, Valvular heart disease
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	Hypothyroidism
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	Anemia, Leukemia
Iatrogenic	No underlying causes
Infectious Disease	Sepsis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Amyotrophic lateral sclerosis, Guillain-Barré syndrome, Multiple sclerosis, Myasthenia gravis, Parsonage-Turner syndrome, Eaton-Lambert syndrome
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Lung cancer
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Anxiety disorders and panic attacks
Pulmonary	No underlying causes
Renal / Electrolyte	Metabolic acidosis
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

Abdominal masses Acute bronchitis Acute Chest Syndrome Acute Coronary Syndromes Acute myeloid leukemia Acute promyelocytic leukemia Acute tracheobronchitis AIDS Air pollution Air-conditioner lung Allergy Alpha 1-antitrypsin deficiency Altitude sickness Amniotic fluid embolism Amphotericin B Amyl nitrite Amyotrophic Lateral Sclerosis (ALS) Anaphylactoid reactions Anaphylaxis Anemia Angina Pectoris Anthrax Anxiety Aortic Arch Anomalies Aortic regurgitation Aortic stenosis Arrhythmia Asbestosis Aspergillus clavatus Aspiration Asthma Atelectasis Atrial Fibrillation Atrioseptal defect Atypical pneumonia Barium Beriberi Heart Disease Beta-blockers Betazole Bird breeder's lung Bird fancier's lung Biventricular heart failure Bland-White-Garland Syndrome Bleomycin in ABVD Blood transfusion Brain stem infarction Bronchial asthma Bronchial tumors Bronchiolitis Bronchiolitis obliterans Bronchiolitis obliterans organizing pneumonia Bronchitis Bronchogenic carcinoma Bronchoscopy Cardiac Disease in Pregnancy Cardiac failure Cardiomegaly Cardiomyopathy Caspofungin Cheese worker's lung Chemical worker's lung Chest trauma Chest tube Cholesterol pericarditis Chronic bronchitis Chronic fatigue syndrome Chronic Obstructive Pulmonary Disease (COPD) Chylothorax

Cirrhosis Cladosporium CMV Pneumonitis Community-acquired pneumonia Congenital heart disease Congestive Heart Failure Continuous murmur Cor Pulmonae Coronary Artery Disease Coronary Artery Fistula Croup Cystic Fibrosis Daptomycin Decompression sickness Decreased thoracic or diaphragmatic excursion Diabetic coma Diffuse panbronchiolitis Diverticulosis Drugs Ebstein's Anomaly of the Tricuspid Valve Ehrlichiosis (canine) Empty nose syndrome Empyema, pleural Encephalitis Endocarditis Endomyocardial fibrosis Eosinophilic pneumonia Ephedrine Epidemic dropsy Erdheim-Chester disease Esophageal cancer Esophageal diseases with tracheal compression Exercise-induced asthma Extrinsic allergic alveolitis Fat embolism Fibrosing alveolitis, cryptogenic Gamma-Hydroxybutyric acid Gastroesophageal reflux Gemeprost Glatiramer acetate Glottal edema Goiter Goodpasture syndrome Grain handler's lung Gram-negative sepsis Guillain-Barre Syndrome Heart failure Hemochlyothorax Hemothorax Histiocytosis X Hoose (disease) Humidifier lung Hydrochlyothorax Hypersensitivity Pneumonitis Hypertension Hypertensive heart disease Hyperthyroidism Hypertrophic cardiomyopathy Hypoxia Hysteria Idiopathic pulmonary fibrosis Iloprost Inappropriate sinus tachycardia Interstitial lung disease Intoxication (carbon monoxide, cyanide) Intrapulmonary receptor stimulation Intussusception (medical disorder) Iron deficiency anemia Irregular Heart Rhythms Ketorolac Kyphoscoliosis

Laryngeal/bronchospasm Leukemia Levo-Transposition of the great arteries Loeffler's Endocarditis Lung cancer Lymphangitic metastases Lymphocytic interstitial pneumonia Lymphoma Malignant hypertension Malignant Mesothelioma Malt worker's lung Mediastinal tumors Megaloblastic Anemias Mercury (element) Metabolic acidosis Methyl isocyanate Micropolyspora faeni Miliary tuberculosis Mitral Regurgitation Mitral Stenosis Mollusk shell hypersensitivity Mucor stolonifer Multiple rib fractures Myasthenia Gravis Myocardial infarction Myxoma STEMI Neuromuscular disease Obesity Patent Ductus Arteriosus Pericardial effusion/pericardial constriction Perimyocarditis Phrenic nerve paralysis Pleural callosity Pneumoconiosis Pneumonia Pneumochlyothorax Pneumothorax Pleural Effusion Pleural fibrosis Polyradiculitis Pulmonary arteriovenous malformation Pulmonary Edema Pulmonary Embolism Pulmonary Emphysema Pulmonary fibrosis Pulmonary hypertension Pulmonary stenosis Quincke's Edema Radiation pneumonitis Respiratory tract infection Right ventricular failure Sarcoidosis Shock Shock lung Sleep Apnea Syndrome Tetralogy of Fallot Trauma Tracheal stenosis Tracheal tumors Tracheomalacia Tracheobronchial collapse Tricuspid stenosis Tumors of the myocardium Uremia Valvular heart disease Ventricular septal defect

Obstructive lung diseases

• Asthma
• Bronchitis
• Chronic obstructive pulmonary disease
• Cystic fibrosis
• Emphysema
• Hookworm disease
• Laryngeal edema due to allergies
• Tuberculosis

Diseases of lung parenchyma and pleura

Contagious

• Anthrax through inhalation of Bacillus anthracis
• Pneumonia

Non-contagious

• Fibrosing alveolitis
• Atelectasis
• Hypersensitivity pneumonitis
• Interstitial lung disease
• Lung cancer
• Pleural effusion
• Pneumoconiosis
• Pneumothorax
• Non-cardiogenic pulmonary edema or acute respiratory distress syndrome
• Sarcoidosis

Pulmonary vascular diseases

• Acute or recurrent pulmonary emboli
• Pulmonary hypertension, primary or secondary
• Pulmonary veno-occlusive disease
• Superior vena cava syndrome

Obstruction of the airway

• Cancer of the larynx or pharynx
• Empty nose syndrome
• Pulmonary aspiration
• Epiglottitis

Immobilization of the diaphragm

• Lesion of the phrenic nerve
• Polycystic liver disease
• Tumor in the diaphragm

Restriction of the chest volume

• Ankylosing spondylitis
• Broken ribs
• Kyphosis
• Obesity
• Pregnancy
• Pectus excavatum
• Scoliosis

Differentiating Dyspnea from other Conditions

• Air hunger the sensation of an urgent need to breathe, sensation that you cannot take in a full breath
• Tachypnea breathing rapidly
• Bradypnea breathing slowly
• Eupnea normal unlabored breathing
• Orthopnea dyspnea that occurs with lying flat
• Trepopnea an abnormal awareness of one's own breathing that is seen in one lateral position but not in the other
• Paroxysmal nocturnal dyspnea sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

Diagnosic Evaluation

• History
• Physical examination: All patients should be evaluated for underlying diseases (especially heart and lung diseases). Detecting of following symptoms and signs are important:

• Heart murmurs
• S3, S4
• Crackles, rales
• Jugular venous distension
• Peripheral edema
• Wheezing
• Palpation of peripheral arteries
• Leg swelling / leg pain / tenderness
• Chest pain / chest tightness
• Fever

• Complete blood count
• Thyroid function tests
• Chest x-ray
• Electrocardiography
• Echocardiography
• Spirometry
• Pulse oximetry
• Exercise stress test (Treadmill test)
• Arterial blood gases
• Pulmonary function tests
• Cardiopulmonary exercise testing

Treatment of the Patient with Dyspnea

Oxygen Supply

Oxygen supply is the essential part of acute dyspnea management.

Exercise Training

Controlled studies have shown that dyspnea upon exertion decreases and exercise tolerance improves in response to exercise training, even in patients with advanced disease. It is now well established that for patients with COPD who remain breathless despite optimal drug therapy, exercise training can confer significant symptomatic benefits.

Pharmacologic Therapy

Two types of medications have proven useful in alleviating dyspnea: opiates and drugs that reduce anxiety. A number of studies have shown that opiates acutely relieve dyspnea and improve exercise performance in patients with COPD.

The drugs to reduce anxiety have the potential to relieve ventilatory response related to the available amounts of oxygen in the blood, as well as by lowering the emotional response to dyspnea.

Fans

The movement of cool air with a fan has been observed to reduce dyspnea in pulmonary patients. A decrease in the temperature of the facial skin alters feedback to the brain and modifies the perception of dyspnea. Cool air has been shown in normal volunteers to reduce dyspnea in response to excess carbon dioxide in the blood.

Altered Breathing Patterns

Breathing retraining including diaphragmatic breathing and pursed lip breathing has been advocated to relieve dyspnea in COPD patients. During a breathing retraining period, many patients adopt slower, deeper breathing techniques; however, they often resort to spontaneous, fast, shallow breathing patterns when the training ends.

Continuous Positive Airway Pressure (CPAP)

In various studies, CPAP has been shown to relieve dyspnea during asthma attacks, when patients are being weaned from ventilators, and during exercise sessions for patients with advanced COPD.

Nutrition

Several investigators have shown improvement in respiratory muscle function in response to short-term use of nutritional repletion by an intravenous route.

Positioning

Patients with COPD often change body position to improve dyspnea. They tend to lean forward to improve overall respiratory muscle strength and to reduce their symptoms.

Steroids

Steroid use can be beneficial to pulmonary patients by reducing airway inflammation and by increasing vital capacity in chronic lung inflammation. However, steroids have adverse effects, including muscle wasting and weakness. These potential problems need to be balanced against possible gains in lung function associated with this drug.

Cognitive-behavioral Approaches In patients with different pain syndromes, distraction, relaxation, and education about symptoms have modified the intensity of pain, increased tolerance, and decreased distress. Improvements in dyspnea and anxiety have been shown to follow distractions such as music during exercise, although long-term effects have been minimal. However, exercise in a monitored, supportive environment has been shown to be a powerful method of overcoming apprehension, anxiety, and/or fear associated with exertional dyspnea.

See also

• Air hunger
• Tachypnea
• Bradypnea
• Eupnea
• Orthopnea
• Trepopnea
• Paroxysmal nocturnal dyspnea

Additional Resources

• Julie K. Stegman, Stedman's Medical Dictionary, 28th Edition, pages=601, Lippincott Williams & Wilkins, Baltimore, Maryland ISBN 0781733901

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