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ULY CLINIC

9 Septemba 2025, 04:36:54

Dyspnea

Dyspnea is the subjective sensation of difficult or uncomfortable breathing, commonly reported as shortness of breath. It is typically a symptom of cardiopulmonary dysfunction but may also arise from neuromuscular, allergic, metabolic, or psychological conditions. Its severity often does not correlate with the severity of the underlying cause.

Dyspnea can:

Develop suddenly or gradually.
Subside rapidly or persist for years.
Be physiologic (e.g., exertional dyspnea in healthy individuals, relieved by rest) or pathologic (due to underlying disorders).

Pathophysiology

Dyspnea results from an imbalance between the respiratory system’s demand and the body’s ability to meet it. Causes may involve:

Pulmonary dysfunction (e.g., obstruction, restrictive disease, gas exchange impairment)
Cardiac dysfunction (e.g., left or right heart failure, ischemia)
Neuromuscular weakness (e.g., ALS, myasthenia gravis)
Allergic reactions or inflammatory processes
Psychogenic factors such as anxiety

Signs and Symptoms

Shortness of breath, either acute or chronic
Tachypnea
Cyanosis
Use of accessory respiratory muscles
Restlessness or anxiety
Orthopnea or paroxysmal nocturnal dyspnea in chronic cases
Associated symptoms depending on underlying etiology (e.g., chest pain, cough, fever)

Emergency interventions

If a patient presents with acute shortness of breath, rapidly assess and intervene:

Look for respiratory distress: tachypnea, cyanosis, restlessness, accessory muscle use.
Administer oxygen (nasal cannula, mask, or endotracheal tube).
Ensure IV access for fluids/medications.
Initiate cardiac monitoring and pulse oximetry.
Prepare for advanced interventions:
- Chest tube insertion for pneumothorax.
- CPAP for pulmonary edema.
- Rotating tourniquets for severe pulmonary edema (rare, historical).

History taking

If the patient can answer without worsening distress, ask:

Onset: sudden vs. gradual.
Course: constant, intermittent, or progressive.
Triggers: exertion, rest, irritants, position.
Associated symptoms: cough (productive/nonproductive), chest pain, wheezing, trauma, orthopnea, paroxysmal nocturnal dyspnea, fatigue.
Risk factors: smoking, occupational exposures, history of DVT, infections, or chronic illness.

Physical Examination

Look for both acute and chronic signs:

General: tachypnea, diaphoresis, anxiety, cyanosis, clubbing.
Respiratory: accessory muscle hypertrophy, pursed-lip breathing, barrel chest, chest retractions, paradoxical chest movement.
Cardiac: abnormal heart sounds, S3 gallop, arrhythmias, jugular venous distention, edema.
Others: hepatomegaly, cachexia, signs of chronic hypoxia.

Cultural Cue

Because dyspnea is subjective and worsened by anxiety, carefully listen to the patient’s own description. Be aware that cultural and linguistic differences may influence how symptoms are expressed.

Medical causes of dyspnea and distinguishing features

Cause	Onset/Pattern	Distinguishing Features
Acute Respiratory Distress Syndrome (ARDS)	Acute	Severe noncardiogenic pulmonary edema, tachypnea, cyanosis, crackles/rhonchi, hypotension, shock-like signs.
Amyotrophic Lateral Sclerosis (ALS)	Gradual, progressive	Dyspnea with dysphagia, dysarthria, muscle weakness, fasciculations, shallow breathing.
Inhalation Anthrax	Biphasic; flu-like → sudden	Initial flu-like symptoms; later dyspnea, stridor, chest pain, shock; high fatality within 24 hrs.
Aspiration of Foreign Body	Sudden, acute	Inspiratory stridor, retractions, asymmetric chest expansion, decreased breath sounds, cyanosis.
Asthma	Recurrent, paroxysmal	Audible wheeze, dry cough, tachypnea, nasal flaring, prolonged expiration, diaphoresis, cyanosis.
Atelectasis	Acute/subacute	Dyspnea, tachycardia, cyanosis, dry cough; decreased breath sounds, dull percussion, inspiratory lag.
Blast Lung Injury	Sudden, post-explosion	Severe chest pain, hemoptysis, hypoxia, wheezing, contusions, hemodynamic instability.
Cor Pulmonale	Gradual, chronic	Dyspnea with exertion → rest; chronic cough, JVD, edema, hepatomegaly, fatigue.
Emphysema	Chronic, progressive	Barrel chest, pursed-lip breathing, diminished breath sounds, clubbing (late), weight loss.
Flail Chest	Sudden, traumatic	Dyspnea with paradoxical chest movement, severe pain, cyanosis, hypotension.
Heart Failure	Gradual/chronic; acute possible	Orthopnea, PND, edema, S3 gallop, JVD, crackles, weight gain, oliguria.
Inhalation Injury (smoke/chemicals)	Acute → progressive	Hoarseness, cough with sooty sputum, facial burns, stridor, wheezing, edema.
Myasthenia Gravis	Intermittent → crisis	Muscle weakness, shallow respirations, tachypnea, acute crisis = respiratory failure.
Myocardial Infarction	Sudden	Crushing chest pain radiating to arm/jaw, diaphoresis, nausea, arrhythmias, hypotension.
Plague (Pneumonic)	Sudden, severe	Dyspnea, productive cough with hemoptysis, fever, cardiopulmonary failure if untreated.
Pleural Effusion	Gradual, progressive	Dyspnea, pleuritic pain, decreased breath sounds, dull percussion, friction rub.
Pneumonia	Sudden, acute	Fever, chills, pleuritic pain, productive cough, crackles, rhonchi, diaphoresis.
Pneumothorax	Sudden, acute	Unilateral absent breath sounds, hyperresonance, tracheal deviation (tension), hypotension.
Poliomyelitis (Bulbar)	Gradual	Facial weakness, dysphagia, nasal regurgitation, hypopnea.
Pulmonary Edema	Sudden, severe	Pink frothy sputum, crackles, JVD, orthopnea, S3 gallop, diaphoresis, anxiety.
Pulmonary Embolism	Sudden	Dyspnea + pleuritic pain, hemoptysis, tachycardia, crackles, signs of shock if massive.
SARS (Coronavirus)	Acute, variable	Fever, dry cough, myalgia, dyspnea; can progress to pneumonia/respiratory failure.
Shock (any type)	Sudden, progressive	Severe hypotension, tachypnea, tachycardia, restlessness, cold clammy skin.
Tuberculosis	Gradual, chronic	Night sweats, productive cough, fever, weight loss, hemoptysis, chest crackles.
Tularemia	Acute, infectious	Fever, chills, pleuritic pain, nonproductive cough, empyema.

Special considerations

General Care: Position patient upright (High Fowler’s), loosen clothing, provide calm reassurance.
Investigations: ABG, chest X-ray, CT scan, PFTs, ECG, echocardiography, Doppler for DVT.
Medications: Bronchodilators, diuretics, antiarrhythmics, analgesics as indicated.

Patient counseling

Teach pursed-lip and diaphragmatic breathing.
Educate on avoiding triggers (pollutants, allergens, infections).
Emphasize adherence to treatment of underlying chronic conditions.

Pediatric pointers

Infants normally breathe abdominally; costal breathing = abnormal.
Severe dyspnea in children: think epiglottitis or croup (emergencies).
Use mist tent, oxygen hood as appropriate.

Geriatric pointers

Older patients may under-report dyspnea due to adaptation to chronic illness.
High suspicion needed for subtle worsening of baseline breathing.

References

Ditre JW, Gonzalez BD, Simmons VN, Faul LA, Brandon TH, Jacobson PB. Associations between pain and current smoking status among cancer patients. Pain. 2011;152:60–65.
Gaguski ME, Brandsema M, Gernalin L, Martinez E. Assessing dyspnea in patients with non-small cell lung cancer in the acute care setting. Clin J Oncol Nurs. 2010;14:509–513.