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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 12
Shortness ofBreath
KiyoshiKinjo
Introduction
Dyspnea of acute onset may suggest serious and potentially
life-threatening illness. When the vital signs are abnormal and
the patient looks acutely ill, the diagnosis and treatment need
to be provided expeditiously; in many instances, the best
approach would be to transfer the patient to the emergency
room [1].
Chronic dyspnea should be approached systematically.
Pulmonary and cardiac abnormalities, anemia, and obesity/
deconditioning are the most common etiologies [2].
Decision-Making/Differential Diagnosis
andKey History andPhysical Exam
The onset and duration of dyspnea can be divided into four
categories: sudden-onset, acute, episodic, and chronic dyspnea (Fig.12.1).
K. Kinjo (*)
Department of Internal Medicine, Okinawa Chubu Hospital,
Uruma City, Okinawa, Japan
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_12
251
252
cC
K. Kinjo
Dyspnea
Sudden onset
• Pnuemothorax
• PE
• Airway obstruction
Acute Episodi
• CHF
• Asthma
• Pneumonia
• Other
• Asthma
• Panic attack
• Flash pulmonary edema
• Recurrent aspiration
hronic
• Cardiac
CHF
CAD
• Pulmonary
COPD
ILD
Pulmonary vascular
disease
• Other
Anemia
Deconditioning
Neuromuscular
disease
Tense ascites
Kyphosis/scoliosis
F . Differential diagnosis of dyspnea. PE pulmonary
embolism, CHF congestive heart failure, CAD coronary artery disease, COPD chronic obstructive pulmonary disease, ILD interstitial
lung disease
Sudden-Onset Dyspnea
When the patient can tell what he/she was exactly doing at
the onset of dyspnea, the likely differential diagnoses are
pneumothorax, pulmonary embolism, and acute airway
obstruction (foreign body or anaphylaxis).
Spontaneous pneumothorax is often seen in young slender
men who smoke. Secondary pneumothorax is mostly seen in
patients with known chronic lung diseases such as COPD
(chronic obstructive pulmonary disease). Patients can sometimes recall straining during exercise or reaching out an arm
when he/she develops sudden dyspnea, often accompanied by
pleuritic chest pain.
Pulmonary embolism (PE) can present with sudden-onset
dyspnea, pleuritic chest pain, syncope, or hemoptysis. When
considering PE, the risk factors should be reviewed, and validated clinical prediction rule (such as Wells score; see
Table 12.1) should be used [3]. When the patient with sus-
Chapter 12. Shortness ofBreath
T . Wells prediction rule (simplied score)
Clinical characteristic Score
Previous PE or DVT (deep vein
thrombosis)
Heart rate >100 beats/min 1
Surgery or immobilization within the past
4weeks
Clinical signs of DVT 1
Alternative diagnosis less likely than PE 1
Hemoptysis 1
Active cancer 1
Modified from Gibson NS, Sohne M, Kruip MJHA et al. Further
validation and simplification of the Wells clinical decision rule in
pulmonary embolism Thrombosis and Haemostasis 2008;99:229–34
Pretest probability
≤1: PE unlikely (low)
>1: PE likely (high)
1
1
253
pected acute PE is hemodynamically unstable, he/she needs
to be transferred to the emergency room. In massive PE,
thrombolytic therapy might be beneficial.
If the pretest clinical probability is low, one can order
D-dimer; if D-dimer is negative (<500 ng/mL), PE can be
safely ruled out. When D-dimer is positive, additional imaging is necessary. When the pretest probability is high, the
patient needs evaluation in the emergency room (CT pulmonary angiography or VQ scan). If the transfer and imaging
studies take time, one should consider starting empirical
anticoagulation therapy in the absence of contraindication,
pending definitive diagnostic workup.
Diagnosis of acute airway obstruction is usually obvious
based on the history of aspiration or signs of anaphylaxis (lip
and tongue swelling, urticaria, tachycardia, and hypotension)
and stridor.
254
K. Kinjo
Acute-Onset Dyspnea
The most common causes in this category are congestive
heart failure (new onset or exacerbation), asthma attack, and
pneumonia. With history (by paying attention to risk factors
and associated symptoms), physical examination, and simple
tests including chest X-ray, electrocardiogram, and BNP
(brain natriuretic peptide), it is usually easy to reach the correct diagnosis [4].
Congestive heart failure (CHF) is characterized by dyspnea, which is worsened by lying flat (orthopnea), nocturia,
weight gain, and bilateral lower extremity edema. Many
patients have cardiovascular risk factors: when those risks are
absent, acute valvular heart disease (including infective endocarditis (IE)) or acute myocarditis should be considered.
On physical examination, one should look for jugular
venous distension, lower extremity edema, bilateral lower
lung crackles and heart gallop, laterally displaced PMI (point
of maximal impulse), and possibly cardiac murmurs (implying underlying valvular heart disease). Occasionally, wheezing can be heard, and the patient may even respond to a
beta-agonist bronchodilator.
Asthma exacerbation typically presents with acute-onset
dyspnea, cough (mostly dry), and chest tightness, which is worse
late at night or early in the morning, often triggered by upper
respiratory infections. In many cases, wheezing can be easily
audible, but in a severe asthma attack with impending respiratory failure, wheezing may diminish or become absent. History
of allergy (atopic dermatitis, allergic rhinitis, or conjunctivitis) as
well as family history of asthma and allergy is helpful.
Pneumonia is not difficult to diagnose when a patient presents with typical symptoms such as fever and cough with
purulent sputum, but the presentation can be quite variable
[5]. Many elderly may have no fever, but present with appetite loss, impaired mental status, or acute decline from baseline ADLs (activities of daily living) [6]. Atypical pneumonia
can present with GI symptoms or headache. Tachycardia or
tachypnea may be the only clue to the correct diagnosis.
Chapter 12. Shortness ofBreath
Other etiologies of acute dyspnea can be identified by history, physical examination, chest X-rays, and electrocardiogram in most cases.
255
Episodic Dyspnea
When a patient presents with recurrent episodes of dyspnea,
the common diagnoses to consider are (1) asthma, (2) panic
attack, (3) flash pulmonary edema, and (4) recurrent
aspiration.
Panic attack is characterized by episodes of intense fear
accompanied by somatic complaints including dyspnea.
Although it is important to exclude other medical illnesses,
patients with typical features of panic disorders would benefit
from early psychiatric evaluation and treatment including
cognitive behavioral therapy.
Flash pulmonary edema presents with an acute episode of
pulmonary edema, presenting like acute CHF, but can be
caused by a noncardiac infirmity such as bilateral renal artery
stenosis [7].
Elderly with advanced dementia or patients with underlying neuromuscular disorders may develop intermittent aspiration with desaturation. Rhonchi and wheezing are often
detected when the patient becomes dyspneic.
Chronic Dyspnea
Etiology of chronic dyspnea can be divided into three categories: (1) cardiac, (2) pulmonary, and (3) others. One should
always consider and thoroughly evaluate each category since
more than one cause may coexist, especially in the elderly
(e.g., COPD and coronary artery disease). When dyspnea
seems out of proportion to the severity of one disease,
another overlapping condition may be present.
The most common etiologies are (1) CHF, (2) COPD, (3)
interstitial lung disease, (4) asthma, (5) anemia, and (6) obesity/deconditioning (Table12.2).
K. Kinjo
256
T . Common causes of chronic dyspnea
Physical
Diagnosis History
CHF History of
coronary
artery disease,
hypertension,
valvular
disease,
orthopnea,
edema, weight
gain
COPD >50years
old with
significant
smoking
history, chronic
cough, sputum
Interstitial lung
disease
Asthma Episodic
Anemia Dyspnea on
Obesity/
deconditioning
Chronic dry
cough, h/o
occupational
exposure,
rheumatic
disease
wheezy
dyspnea,
triggered by
URI, seasonal
changes
exertion
Dyspnea
on exertion,
sedentary
lifestyle,
obesity
exam Diagnostic test
Jugular
venous
distension,
lower
extremity
edema,
bibasilar
crackles,
gallop
sound, AFib
Distant
lung sounds,
barrel chest,
wheezes
Bibasilar
fine crackles,
clubbing
Wheezes PFT with
Pale
conjunctiva
Normal or
obese
Electrocardiogram
Chest X-ray
Echocardiography
BNP
Chest X-ray
PFT
Chest X-ray and
chest CT
PFT
bronchodilator
response
Hemoglobin
Workup
underlying cause
of anemia
Exclude other
etiologies
Chapter 12. Shortness ofBreath
Although many interstitial lung diseases are chronic, acute
interstitial pneumonia, acute eosinophilic pneumonia, pneumocystis pneumonia, and dermatomyositis-associated lung
disease may present acutely or subacutely.
Other less common diagnoses to consider may include
lung cancer, pleural effusion, pulmonary hypertension, tense
ascites, neuromuscular diseases, and chest wall deformity.
When the diagnosis remains elusive after routine evaluation, pulmonary or cardiology consultation should be considered. In difficult cases, cardiopulmonary exercise testing may
be helpful [8].
257
Treatment
Once the etiology is identified, the specific treatment can be
provided.
The stepwise asthma treatment is shown in Table12.3 [9]. In
most cases, symptoms of asthma can be managed with low- dose
inhaled corticosteroids (ICS). A recent guideline recommends
the use of ICS-formoterol (LABA) as both controller and
reliever; even patients with infrequent asthma symptoms are at
risk for severe exacerbation. Patients often use only short-acting
beta agonist inhaler without ICS.Overuse of beta agonist is a
risk factor for fatal asthma. Patients who cannot use the steroid
inhaler despite repeated instructions (e.g., cognitive impairment
or hand deformity) may use a leukotriene receptor antagonist,
although it is less effective. Patients with more frequent, more
severe symptoms should be treated with a low-dose steroid and
a long-acting beta-agonist (ICS- LABA) inhaler. If asthma is
poorly controlled, one needs to review the diagnosis of asthma,
medication adherence (especially inhaler technique), triggering
factors (e.g., smoking, use of NSAIDs or beta blockers), and
comorbid conditions (e.g., rhinosinusitis or GERD) and then
consider stepping up the treatment regimen. If symptoms are
well controlled for 3months, consider stepping down, but it is
strongly recommended to continue the steroid inhaler.
COPD management is summarized in Table 12.4 [10].
FEV1 value is important to establish the diagnosis of COPD
258
K. Kinjo
Add LAMA
Refer to
asthma
specialist
Medium dose
maintenance ICS-
formoterol
maintenance ICS-
formoterol
Add LAMA
Refer to
asthma
specialist
Medium−/high-
dose maintenance
ICS-LABA
Low-dose
maintenance ICS-
LABA
Low-dose ICS
maintenance
As needed low dose ICS-formoterol Low-dose
T . Stepwise asthma management
Reliever Step 1 Step 2 Step 3 Step 4 Step 5
Preferred
controller
Reliver As needed low-dose ICS-formoterol
Take low-dose
Alternate
ICS whenever
controller
SABA taken
choice
Reliever As needed SABA
Modified from Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2022
ICS inhaled corticosteroid, LABA long-acting beta2-agonist, SABA short-acting beta2-agonist, LAMA long acting
muscarinic antagonist
Chapter 12. Shortness ofBreath
T . COPD management
mMRC 0–1
CAT <10
Exacerbation
≥two/year
or ≥ one
hospitalization
0–1
exacerbation/
year and no
hospitalization
Global Initiative for Chronic Obstructive Lung Disease Global
Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease (2022 Report)
mMRC modified MRC dyspnea scale (Fletcher CM.BMJ 1960; 2:
1662), CAT COPD assessment test (Jones etal. ERJ 2009; 34: 648–54
http://www.catestonline.org), LABA long-acting beta-agonist, SABA
short-acting beta-agonist, LAMA long-acting muscarinic antagonist,
SAMA short-acting antimuscarinics, ICS inhaled corticosteroid
1. Smoking cessation
2. Assess the symptom severity and exacerbation history and select
bronchodilator treatment (see table)
3. Treat comorbid conditions: Common comorbid conditions include
cardiovascular disease, skeletal muscle dysfunction, metabolic
syndrome, osteoporosis, depression, anxiety, and lung cancer. One
should actively screen and treat them appropriately in order to
maximize the patient’s quality of life
4. Vaccination: Vaccinate against influenza, COVID-19 and
pneumococcus
Start LAMA
• If further
exacerbation,
LAMA +
LABA or
LABA + ICS
Choose one
from SABA,
LABA, SAMA,
or LAMA
• If effective,
continue
• If ineffective,
stop and
change to
another
mMRC ≥2
CAT ≥10
Start LAMA
• If further exacerbation,
LAMA + LABA or
ICS+LABA
• If still further exacerbation,
refer to pulmonologist
Start LABA or LAMA
• If symptoms persist,
LABA+LAMA.Consider
other cause of respiratory
symptoms
259
260
K. Kinjo
(post bronchodilator FEV1/FVC <70%), but the medication
choice is strongly influenced by the degree of symptoms and
the history of exacerbation. LAMA (long-acting muscarnic
antagonist) is the preferred choice in many patients; it is
shown to improve symptoms and quality of life and reduce
exacerbation and hospitalizations and has little systemic side
effects. As opposed to asthma, inhaled steroid should be used
selectively in patients with COPD.ICS increases the risk of
pneumonia, and the effect is limited in patients whose blood
eosinophil count is low (<100/μg). None of the pharmacologic
therapies are shown to slow the decline of the lung functions;
smoking cessation is the only definitive treatment of COPD;
patients should be strongly counseled to quit smoking. A
detailed discussion of COPD therapy is beyond the scope of
this chapter. Comanagement with a pulmonary specialist may
be indicated in patients with advanced COPD. Pulmonary
rehabilitation and oxygen therapy may be appropriate in
some patients. Comorbid conditions such as cardiovascular
disease, depression, and osteoporosis are very common in
patients with COPD; screening and treatment of comorbidity
is important.
Management of heart failure is summarized in Fig. 12.2.
While cardiologists may provide many aspects of specialized
care, the primary care providers should work in conjunction
with cardiologists and manage comorbid conditions such as
obesity, smoking, hypertension, and diabetes.
In patients with chronic heart or lung disease, the symptom of dyspnea can be challenging to manage; physical therapy may be beneficial in some cases. Oxygen therapy can be
considered in select hypoxic patients. Those with advanced
end-stage illness may suffer from refractory dyspnea; opiates
should be considered in these situations [11].