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Dyspnea is a sensation, a symptom, a complaint on the part of the patient of not being

able to breathe enough or having to breathe too much, or, simply, an abnormal, uncomfortable
feeling during breathing (Wasserman, 1982)
While shortness of breath is generally caused by disorders of the cardiac or respiratory
system, other systems such as neurological, musculoskeletal, endocrine, hematologic, and
psychiatric may be the cause. DiagnosisPro, an online medical expert system, listed 497 distinct
causes in October 2010. The most common cardiovascular causes are acute myocardial infarction
and congestive heart failure while common pulmonary causes include chronic obstructive
pulmonary disease, asthma, pneumothorax, pulmonary edema and pneumonia. On a
pathophysiological basis the causes can be divided into: (1) an increased awareness of normal
breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3) an
abnormality in the ventilator system.
Dyspnea that is greater than expected with the degree of exertion is a symptom of
disease. Most cases of dyspnea result from asthma, heart failure and myocardial ischemia,
chronic obstructive pulmonary disease, interstitial lung disease, pneumonia, or psychogenic
disorders. The etiology of dyspnea is multi - factorial in about one-third of patients. The clinical
presentation alone is adequate to make a diagnosis in 66 percent of patients with dyspnea.
Patients descriptions of the sensation of dyspnea may be helpful, but associated symptoms and
risk factors, such as smoking, chemical exposures, and medication use, should also be
considered. Examination findings (e.g., jugular venous distention, decreased breath sounds or
wheezing, pleural rub, clubbing) may be helpful in making the diagnosis. Initial testing in
patients with chronic dyspnea includes chest radiography, electrocardiograph, spirometer,
complete blood count, and basic metabolic panel. Measurement of brain natriuretic peptide levels
may help exclude heart failure, and D -dimer testing may help rule out pulmonary emboli.
Pulmonary function studies can be used to identify emphysema and interstitial lung diseases.
Computed tomography of the chest is the most appropriate imaging study for diagnosing
suspected pulmonary causes of chronic dyspnea. To diagnose pulmonary arterial hypertension or
certain interstitial lung diseases, right heart catheterization or bronchoscopy may be needed
(WAHLS, 2012 Jul 15).
Acute dyspnea is most commonly caused by respiratory and cardiac disorders. Other
causes may be upper airway obstruction, metabolic acidosis, a psychogenic disorder, or a
neuromuscular condition. Differential diagnoses in children include bronchiolitis, croup,
epiglottitis, and foreign body aspiration. Pertinent history findings include cough, sore throat,
chest pain, edema, and orthopnea. The physical examination should focus on vital signs and the
heart, lungs, neck, and lower extremities. Significant physical signs are fever, rales, wheezing,
cyanosis, stridor, or absent breath sounds.
Acute dyspnea has multiple causes. Dyspnea can be the first manifestation of a life
threatening disease or it can have a functional cause. The most common causes of acute dyspnea
are pulmonary and cardiac diseases, as well as acute blood loss, metabolic acidosis, anxiety, poor
physical condition. Acute dyspnea has multifactorial causes so that additional medical history
findings such as the presence of fever, night sweats, chills, weight loss, chest pain, and recent

trauma, history of a recent proximal deep venous thrombosis or symptoms of gastro-esophageal


reflux disease can help the practitioner to make the right diagnosis (Lighezan et al, 2006)
Chronic dyspnea is defined as dyspnea lasting more than one month. In approximately
two thirds of patients presenting with dyspnea, the underlying cause is cardiopulmonary disease.
Establishing an accurate diagnosis is essential because treatment differs depending on the
underlying condition. Asthma, congestive heart failure, chronic obstructive pulmonary disease,
pneumonia, cardiac ischemia, interstitial lung disease, and psychogenic causes account for 85
percent of patients with this principal symptom. The history and physical examination should
guide selection of initial diagnostic tests such as electrocardiogram, chest radiograph, pulse
oximetry, spirometry, complete blood count, and metabolic panel. If these are inconclusive,
additional testing is indicated. Formal pulmonary function testing may be needed to establish a
diagnosis of asthma, chronic obstructive pulmonary disease, or interstitial lung disease. Highresolution computed tomography is particularly useful for diagnosing interstitial lung disease,
idiopathic pulmonary fibrosis, bronchiectasis, or pulmonary embolism. Echocardiography and
brain natriuretic peptide levels help establish a diagnosis of congestive heart failure. If the
diagnosis remains unclear, additional tests may be required. These include ventilation perfusion
scans, Holter monitoring, cardiac catheterization, esophageal pH monitoring, lung biopsy, and
cardiopulmonary exercise testing. (Karnani NG, 2005)
Wasserman, Karlman. "Dyspnea on exertion: Is it the heart or the lungs?."JaMa 248.16
(1982): 2039-2043.
WAHLS, S. A. (2012 Jul 15). Causes and Evaluation of Chronic Dyspnea. Am Fam
Physician, 86(2):173-180.
Lighezan et al. Acute dyspnea: from pathophysiology, evaluation to diagnosis. TMJ 2006;
56(2-3)
Karnani NG, Reisfield GM, Wilson GR. Evaluation of chronic dyspnea. Am Fam
Physician. 2005;71(8):1529-37