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Dyspnoea

INTRODUCTION

Dyspnoea is the subjective sensation of breathlessness that is excessive for any given level of physical activity.

Important causes of dyspnoea

  • Asthma (image 47)

  • COPD (image 135)

  • Heart failure (image 291)

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Table D10 Comparison of distinguishing features between dyspnoea due to heart disease and to lung disease

Lung disease

Heart disease

History of respiratory disease

History of hypertension, cardiac ischaemia or valvular heart disease

Slow development

Rapid development

Present at rest

Mainly on exertion

Productive cough common

Cough uncommon, and then ‘dry’

Aggravated by respiratory infection

Usually unaffected by respiratory infection

Table D11Dyspnoea: diagnostic strategy model
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Table D11 Dyspnoea: diagnostic strategy model

Probability diagnosis

Bronchial asthma

Bronchiolitis (children)

Left heart failure

COPD

Lack of fitness/ageing

Obesity

Functional hyperventilation

Serious disorders not to be missed

Cardiovascular

  • acute heart failure (e.g. AMI)

  • arrhythmias

  • pulmonary embolism

  • fat embolism

Neoplasia

  • bronchial carcinoma

Severe infections

  • pneumonia/influenza

  • coronavirus (e.g. COVID-19)

  • acute epiglottitis (children)

Respiratory disorders

  • inhaled foreign body

  • pneumothorax

  • atelectasis

  • pleural effusion

  • tuberculosis

  • acute respiratory disease syndrome (ARDS)

Neuromuscular disease

  • infective polyneuritis

  • poliomyelitis

Pitfalls (often missed)

Idiopathic pulmonary fibrosis

Hypersensitivity pneumonitis

Chemical pneumonitis

Silicosis

Metabolic acidosis

Radiotherapy

Renal failure (uraemia)

Multiple small pulmonary emboli

Drug-induced interstitial lung disease (e.g. cytotoxics, sulfasalazine, amiodarone)

Sarcoidosis

Masquerades

Drugs

Anaemia

Thyrotoxicosis

KEY INVESTIGATIONS FOR DYSPNOEA

  • Pulmonary function tests including pulse oximetry

  • CXR

  • FBE/ESR/CRP

  • Arterial blood gases

  • Cardiac, e.g. ECG, echocardiography

PULMONARY FUNCTION TESTS

Figure D12

Spirograms showing normal, obstructive and restrictive patterns

A graph represents the pulmonary function tests. The horizontal axis representing time in seconds ranges from 0 to 5, in increments of 1. The vertical axis representing volume in litres ranges from 0 to 5, in increments of 1. The graph shows five curves. The first curve representing restrictive passes through (0, 0), (1, 2), (2, 2.3), (3, 2.5), (4, 2.5), and (5, 2.5). The second curve representing severe obstructive passes through (0, 0), (1, 1.5), (3, 3), and (5, 3.9). The third curve representing moderate obstructive passes through (0, 0), (1, 2.5), (3, 4), and (5, 4.8). The fourth curve representing mild obstructive passes through (0, 0), (1, 3.2), (3, 4.5), and (5, 4.8). The fifth curve representing normal passes through (0, 0), (1, 4), (2, 4.8), (3, 5), (4, 5), and (5, 5). A vertical line labelled F E V subscript 1 drawn at 1 second touches the normal curve at the point (1, 4). A vertical line drawn beyond 5 seconds is labelled F V C and it touches the curves representing moderate obstructive, mild obstructive, and normal at (beyond 5 seconds, 5).
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Figure D13

Maximum expiratory and inspiration flow volume curves with examples of relative changes of patterns with respiratory disease

Five graphs represent the relative changes of patterns with respiratory disease. In each graph, the horizontal axis represents volume and the vertical axis represents flow. The first graph represents the normal subject. The flow is high initially and it decreases linearly as the volume increases. The second graph represents obstructive airway disease (example: asthma). The flow is somewhat high and it decreases exponentially as the volume increases. The third graph represents severe obstructive disease (example: emphysema). The flow is minimal and as a little volume adds up, the flow decreases drastically. The fourth graph represents restrictive lung disease (example: pulmonary fibrosis). The flow is high for the lower volume and as the volume gets increased, the flow decreases steeply. The fifth graph represents fixed major airway obstruction (example: carcinoma of the trachea). The flow almost remains the same throughout for varying volumes and it is minimum.
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INTERSTITIAL LUNG DISEASES

Interstitial lung diseases comprise a group of disorders that have the common features of inflammation and fibrosis of the interalveolar septum, representing a non-specific reaction of the lung to injury of various causes. Causes of pulmonary infiltration include:

  • sarcoidosis

  • idiopathic pulmonary fibrosis

  • hypersensitivity pneumonitis (extrinsic allergic alveolitis)

  • lymphangitis carcinomatosis

  • drug induced (e.g. nitrofurantoin, cytotoxics)

Common clinical features:

  • dyspnoea and dry cough (insidious onset)

  • slowly progressive dyspnoea over months to years

  • fine inspiratory crackles at lung base

  • finger clubbing

  • PFTs:

    • – restrictive ventilatory deficit

    • – decrease in gas transfer factor

  • characteristic X-ray changes

Sarcoidosis

Clinical features:

  • may be asymptomatic (one-third)

  • onset usually 3rd or 4th decade (but any age)

  • bilateral hilar lymphadenopathy (on CXR)

  • cough

  • fever, malaise, arthralgia

  • erythema nodosum

  • ocular lesions (e.g. anterior uveitis)

  • other multiple organ lesions (uncommon)

  • overall mortality 2–5%

Diagnosis

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