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238 DYSPHAGIA
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ipsilateral otalgia, chronic cough, and cachexia.
Palpation reveals enlarged cervical nodes.
◆ Laryngeal nerve damage. Commonly the
result of radical neck surgery, superior laryngeal
nerve damage may produce painless phase 2
dysphagia.
◆ Lower esophageal ring. Narrowing of the
lower esophagus can cause an attack of phase 3
dysphagia that may recur several weeks or
months later. During the attack, the patient
complains of a foreign body sensation in the
lower esophagus, which may be relieved by
drinking water or vomiting. Esophageal rupture
produces severe lower chest pain followed by a
feeling of something giving way.
◆ Mediastinitis. Varying with the extent of
esophageal perforation, mediastinitis can cause
insidious or rapid onset of phase 3 dysphagia.
The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be
aggravated by breathing, coughing, or sneezing.
Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and
falling blood pressure.
◆ Myasthenia gravis. Fatigue and progressive
muscle weakness characterize this disorder and
account for painless phase 1 dysphagia and
possibly choking. Typically, dysphagia follows
ptosis and diplopia. Other features include
masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory
muscle weakness. Signs and symptoms worsen
during menses and with exposure to stress,
cold, or infection.
◆ Oral cavity tumor. Painful phase 1 dyspha-
gia is accompanied by hoarseness and ulcerating lesions in patients with this type of tumor.
◆ Parkinson’s disease. Usually a late symp-
tom, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and
symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled
voice, increased salivation and lacrimation,
constipation, stooped posture, a propulsive gait,
incontinence, and sexual dysfunction.
◆ Pharyngitis (chronic). This condition caus-
es painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry,
sore throat; a cough; and thick mucus in the
throat.
◆ Plummer-Vinson syndrome. This syndrome
causes phase 3 dysphagia for solids in some
women with severe iron deficiency anemia.
Related features include upper esophageal pain;
atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue;
dry mouth; chills; inflamed lips; spoon-shaped
nails; pallor; and splenomegaly.
◆ Rabies. Severe phase 2 dysphagia for liquids
results from painful pharyngeal muscle spasms
occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated
and possibly apneic. Dysphagia also causes
drooling and, in 50% of patients, hydrophobia.
Eventually, rabies causes progressive flaccid
paralysis that leads to peripheral vascular
collapse, coma, and death.
◆ Scleroderma (progressive systemic scle-
rosis). Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with this disorder. The dysphagia may be mild at first and
described as a feeling of food sticking behind
the breastbone. The patient also complains of
heartburn after meals that’s aggravated by lying
down. As the disease progresses, dysphagia
worsens until only liquids can be swallowed. It
may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other
characteristic late features include joint pain
and stiffness, masklike facies, and thick, taut,
shiny skin.
◆ Syphilis. Rarely, tertiary-stage syphilis caus-
es ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation
after meals and heartburn that’s aggravated by
lying down or bending over.
◆ Systemic lupus erythematosus. This disor-
der may cause progressive phase 2 dysphagia.
However, its primary signs and symptoms include nondeforming arthritis, a characteristic
butterfly rash, and photosensitivity.
◆ Tetanus. Phase 1 dysphagia usually
develops about 1 week after the patient
receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever.
Painful, involuntary muscle spasms account for
lockjaw (trismus), risus sardonicus,
opisthotonos, boardlike abdominal rigidity, and
intermittent tonic seizures.
O
THER CAUSES
◆ Lead poisoning. Painless, progressive dys-
phagia may result from lead poisoning. Related
findings include a lead line on the gums,
DYSPNEA 239
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metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe
mental impairment and seizures.
◆ Procedures. A recent tracheostomy or re-
peated or prolonged intubation may cause temporary dysphagia.
◆ Radiation therapy. When usd to treat oral
cancer, radiation therapy may cause scant salivation and temporary dysphagia.
S
PECIAL CONSIDERATIONS
Stimulate salivation by talking with the patient
about food, adding a lemon slice or dill pickle to
his tray, and providing mouth care before and
after meals. Moisten his food with a little liquid
if he has decreased salivation. Administer an
anticholinergic or antiemetic to control excess
salivation. If he has a weak or absent cough reflex, begin tube feedings or esophageal drips of
special formulas.
Consult with the dietitian to select foods
with distinct temperatures and textures. The
patient should avoid sticky foods, such as bananas and peanut butter. If the patient produces mucus, avoid uncooked milk products.
Arrange for a therapist to assess the patient for
his aspiration risk and to teach him swallowing
exercises that may help decrease his risk. At
mealtimes, take measures to minimize the patient’s risk of choking and aspiration. Place the
patient in an upright position, and have him
flex his neck forward slightly and keep his chin
at midline. Instruct the patient to swallow multiple times before taking the next bite or sip.
Separate solids from liquids; it depends on the
individual whether solids or liquids are harder
to swallow.
Prepare the patient for diagnostic tests, including endoscopy, esophageal manometry,
esophagography, and the esophageal acidity
test, to pinpoint the cause of dysphagia.
P
EDIATRIC POINTERS
child, pay close attention to his sucking and
swallowing ability. Coughing, choking, or regurgitation during feeding suggests dysphagia.
Corrosive esophagitis and esophageal obstruction by a foreign body are more common
causes of dysphagia in children than in adults.
However, dysphagia may also result from congenital anomalies, such as annular stenosis,
dysphagia lusoria, and esophageal atresia.
G
ERIATRIC POINTERS
Dysphagia is commonly the presenting complaint of patients older than age 50 with head or
neck cancer. The incidence of these cancers increases markedly in this age-group.
P
ATIENT COUNSELING
Advise the patient to prepare foods that are
easy to swallow.
Dyspnea
Typically a symptom of cardiopulmonary dysfunction, dyspnea is the sensation of difficult or
uncomfortable breathing. It’s usually described
as shortness of breath. Its severity varies greatly
and is usually unrelated to the severity of the
underlying cause. Dyspnea may arise suddenly
or slowly and may subside rapidly or persist for
years.
Most people normally experience dyspnea
when they exert themselves, and its severity depends on their physical condition. In a healthy
person, dyspnea is quickly relieved by rest.
Pathologic causes of dyspnea include pulmonary, cardiac, neuromuscular, and allergic
disorders. It may also be caused by anxiety. (See
Dyspnea: Causes and associated findings, pages
240 to 243.).
EMERGENCY INTERVENTIONS If a pa-
tient complains of shortness of breath,
quickly look for signs of respiratory distress, such
as tachypnea, cyanosis, restlessness, and accessory
muscle use. Prepare to administer oxygen by nasal
cannula, mask, or endotracheal tube. Ensure
patent I.V. access, and begin cardiac monitoring
and oxygen saturation monitoring to detect arrhythmias and low oxygen saturation, respectively.
Expect to insert a chest tube for severe pneumothorax and to administer continuous positive airway
pressure.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient can answer questions without
increasing his distress, take a complete history.
(See Differential diagnosis: Dyspnea, pages 244
and 245.) Ask if the shortness of breath began
suddenly or gradually. Is it constant or intermittent? Does it occur during activity or while
at rest? If the patient has had dyspneic attacks
before, ask if they’re increasing in severity.
Can he identify what aggravates or alleviates
these attacks? Does he have a productive or
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SIGNS & SYMPTOMS
Dyspnea: Causes and associated findings
Major associated signs and symptoms
Common
causes
Acute respiratory
distress syndrome
Amyotrophic lateral
sclerosis
Anemia
Anthrax (inhalation)
Aspiration of a
foreign body
Asthma
Avian influenza
Blast lung injury
Cardiac arrhythmia
Cor pulmonale
Emphysema
Flail chest
Guillain-Barré
syndrome
Accessory
muscle use
Blood pressure,
decreased
••
•
•
•
•
•
•
•
Breath sounds,
decreased
Chest pain
•
•
•
•
•
••
Cough,
nonproductive
Cough, productive
•
•
•
•
•
Crackles
Cyanosis
••
•
•
•
•
•
Diaphoresis
Edema
•
•
•
•
Fasciculations
Fever
•
•
•
•
Heart failure
Inhalation injury
Interstitial fibrosis
Lung cancer
Monkeypox
Myasthenia gravis
••
•
•
••
•
•
•
•
•
•
•
Muscle weakness
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Nausea
Jugular vein
•
•
•
•••
•
distention
Orthopnea
•
Stridor
•
•
Tachycardia
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
(continued)
Tachypnea
Weight loss
•
•
•
DYSPNEA 241
nonproductive cough or chest pain? Ask about
recent trauma, and note a history of upper
respiratory tract infection, deep vein phlebitis,
or other disorders. Ask the patient if he
smokes or is exposed to toxic fumes or irritants on the job. Find out if he also has orthopnea, paroxysmal nocturnal dyspnea, or
progressive fatigue.
CULTURAL CUE Because dyspnea is sub-
jective and is exacerbated by anxiety, patients from cultures that are highly emotional
may complain of shortness of breath sooner
than those who are more stoic about symptoms
of illness.
During the physical examination, look for
signs of chronic dyspnea such as accessory
muscle hypertrophy (especially in the shoulders
and neck). Also look for pursed-lip exhalation,
clubbing, peripheral edema, barrel chest, diaphoresis, and jugular vein distention.
Check blood pressure and auscultate the
lungs for crackles, abnormal heart sounds or
rhythms, egophony, bronchophony, and whispered pectoriloquy. Finally, palpate the abdomen for hepatomegaly, and assess the patient
for edema.
M
EDICAL CAUSES
◆ Acute respiratory distress syndrome
(ARDS). This life-threatening form of noncardiogenic pulmonary edema usually produces
acute dyspnea as the first complaint. As respiratory distress progresses, the patient develops
restlessness, anxiety, decreased mental acuity,
tachycardia, and crackles and rhonchi in both
lung fields. Other findings include cyanosis,
tachypnea, motor dysfunction, and intercostal
and suprasternal retractions. Severe ARDS can
produce signs of shock, such as hypotension
and cool, clammy skin.
◆ Amyotrophic lateral sclerosis. Also known
as Lou Gehrig’s disease, this disorder causes
slow onset of dyspnea that worsens with time.
Other features include dysphagia, dysarthria,
muscle weakness and atrophy, fasciculations,
shallow respirations, tachypnea, and emotional
lability.
◆ Anemia. Dyspnea usually develops gradually
in anemia, which commonly causes fatigue,
weakness, and syncope; severe anemia may
also cause tachycardia, tachypnea, restlessness,
anxiety, and thirst.
◆ Anthrax, inhalation. Anthrax is an acute in-
fectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis.
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Dyspnea: Causes and associated findings (continued)
Major associated signs and symptoms
Common
causes
Myocardial
infarction
Plague
Pleural effusion
Pneumonia
Pneumothorax
Poliomyelitis
(bulbar)
Popcorn lung disease
Pulmonary edema
Pulmonary
embolism
Sepsis
Severe acute respiratory syndrome
Shock
Tuberculosis
Tularemia
Accessory
muscle use
Blood pressure
•
•
,decreased
•
•
•
•
•
Breath sounds,
decreased
Chest pain
•
•
•
•
•
•
•
•
•
•
•
Cough,
nonproductive
Cough, productive
•
•
•
•
•
•
•
•
•
•
•
Crackles
•
•
•
•
Cyanosis
•
•
•
•
Diaphoresis
Edema
•
•
•
•••
Fasciculations
Fever
•
•
•
•
•
•
•
•
•
•
Although the disease most commonly occurs in
wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the
soil for many years. The disease can occur in
humans exposed to infected animals, tissue
from infected animals, or biological agents.
Most natural cases occur in agricultural regions
worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.
Inhalation anthrax is caused by inhalation of
aerosolized spores. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. Dyspnea is a
symptom of the second stage of this disorder
along with fever, stridor and hypotension; the
patient usually dies within 24 hours. Initial signs
and symptoms are flulike and include fever,
chills, weakness, cough, and chest pain.
Muscle weakness
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Nausea
Jugular vein
distention
Orthopnea
Stridor
Tachycardia
Tachypnea
Weight loss
•
•
•
•
•
•
•
•
•
•
••
•
•
•
•
•
•
•
•
•
◆ Aspiration of a foreign body. Acute
dyspnea marks this life-threatening condition,
along with paroxysmal intercostal, suprasternal, and substernal retractions. The patient
may also display accessory muscle use, inspiratory stridor, tachypnea, decreased or absent
breath sounds, asymmetrical chest expansion,
anxiety, cyanosis, diaphoresis, and hypotension.
DYSPNEA 243
◆ Asthma. Acute dyspneic attacks occur in this
chronic disorder along with audible wheezing, a
dry cough, accessory muscle use, nasal flaring,
intercostal and supraclavicular retractions,
tachypnea, tachycardia, diaphoresis, prolonged
expiration, flushing or cyanosis, and apprehension. Medications that block beta receptors can
exacerbate asthma attacks.
◆ Avian influenza. These potentially life-
threatening viruses are spread to humans
through contact with infected poultry or surfaces contaminated with infected bird excretions. Within 1 to 5 days of exposure to avian
influenza, the patient typically develops flulike
symptoms, such as fever, sore throat, cough,
and muscle aches. Those with severe forms of
the virus may develop dyspnea caused by acute
respiratory distress or pneumonia. To date, the
most virulent strain of this virus has not yet
surfaced in humans in the United States, but a
recent outbreak in Asian countries has had a
mortality rate of about 50% among infected
humans.
◆ Blast lung injury. The result of a forceful
percussive wave following an explosive detonation, blast lung injury is commonly characterized by dyspnea and hypoxia. Worldwide terrorist activity has recently increased the incidence
of this condition, which may also cause
cyanosis, chest pain, wheezing, and hemopytsis. Chest X-ray, the primary diagnostic tool, reveals a characteristic “butterfly” pattern. Many
of these patients suffer concomitant injuries and
require complex management, usually in an intensive care setting.
◆ Cardiac arrhythmias. Acute or gradual dys-
pnea can result from decreased cardiac output
in a patient with arrhythmias. The pulse rate
may be rapid, slow, or irregular, with frequent
premature or escape beats. Alternating pulse
may be present. Other symptoms include
palpitations, chest pain, diaphoresis, lightheadedness, weakness, and vertigo.
◆ Cor pulmonale. Chronic dyspnea begins
gradually with exertion and progressively worsens until it occurs even at rest. Most patients
with cor pulmonale have an underlying cardiac
or pulmonary disease. Other findings may include a chronic productive cough, wheezing,
tachypnea, jugular vein distention, dependent
edema, hepatomegaly, increasing fatigue, weakness, and light-headedness.
◆ Emphysema. This chronic disorder gradually
causes progressive exertional dyspnea as well
(Text continues on page 246.)
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Differential diagnosis: Dyspnea
History of present illness
Focused physical examination: Abdomen; respiratory, cardiovascular,
and neurologic systems
Asthma, acute
Signs and symptoms
◆ Acute dyspneic attacks
◆ Audible or auscultated wheezing
◆ Dry cough
◆ Hyperpnea
◆ Chest tightness
◆ Accessory muscle use
◆ Nasal flaring
◆ Intercostal and supraclavicular retractions
◆ Tachypnea
◆ Tachycardia
◆ Diaphoresis
◆ Prolonged expiration
◆ Flushing or cyanosis
◆ Apprehension
Diagnosis: Laboratory tests (complete blood
count [CBC], arterial blood gas [ABG]
analysis, allergy skin testing), pulmonary
function tests, chest X-ray
reatment: Avoidance of allergens and
T
tobacco, medication (beta-adrenergic
blockers, inhaled beta
corticosteroid [cromolyn if age younger than
12], leukotriene receptor agonist, systemic
corticosteroids during infections and
exacerbations, mast cell stabilizer), peak
expiratory flow monitoring
Follow-up: For acute exacerbation, return
visit within 24 hours, then every 3 to 5 days,
then every 1 to 3 months; referral to
pulmonologist, if the treatment is ineffective
, peak flow meter
-agonists, inhaled
2
Pulmonary embolism
Signs and symptoms
◆ Acute dyspnea
◆ Sudden pleuritic chest pain
◆ Tachycardia
◆ Low-grade fever
◆ Tachypnea
◆ Nonproductive or productive cough with
blood-tinged sputum
◆ Pleural friction rub
◆ Crackles
◆ Possible hemoptysis
◆ Diffuse wheezing
◆ Dullness on percussion
◆ Decreased breath sounds
◆ Diaphoresis
◆ Restlessness
◆ Acute anxiety
◆ Signs of shock (possibly)
Diagnosis: Imaging studies (chest X-ray
pulmonary V·/Q·scan or pulmonary
angiography
tomography scan), electrocardiography
(ECG)
Treatment: Oxygen therapy, medication
(anticoagulants, thrombolytic therapy)
Follow-up: Reevaluation within the first
week after hospitalization
, spiral chest computed
,
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Common signs and symptoms
◆ Gradually developing dyspnea
◆ Chronic paroxysmal nocturnal dyspnea
◆ Ortopnea
◆ Tachypnea
◆ Tachycardia
◆ Palpitations
◆ S
3
◆ Fatigue
◆ Dependent peripheral edema
◆ Hepatomegaly
◆ Dry cough
◆ Anorexia
◆ Weight gain
◆ Loss of mental acuity
◆ Hemoptysis
Heart failure Acute onset
heart failure
Additional signs
and symptoms
◆ Jugular vein
distention (JVD)
◆ Bibasilar
crackles
◆ Oliguria
◆ Hypotension
Diagnosis: Physical examination, laboratory
tests (CBC, cardiac enzymes), imaging
studies (chest X-ray, echocardiogram), ECG
Treatment: Medication (angiotensinconverting enzyme inhibitor, diuretics,
carvedilol [possibly], digoxin [possibly]),
inotropic agents
Follow-up: Return visit within 1 week after
discharge, at 4 weeks, and then every 3
months; referral to cardiologist if chronic
Common signs and symptoms
◆ Acute dyspnea
◆ Sudden, stabbing chest pain that may radiate to
the arms, face
◆ Anxiety
◆ Restlessness
◆ Dry cough
◆ Cyanosis
◆ Decreased vocal fremitus
achypnea
◆ T
◆ Tympany
◆ Decreased or absent breath sounds on the
affected side
◆ Asymmetrical chest expansion
◆ Splinting
◆ Accessory muscle use
Pneumothorax
Diagnosis: ABG,
chest X-ray
Treatment: Chest
tube insertion,
oxygen therapy
Follow-up: Return
visit in 1 to 2 weeks
after hospitalization
, back, or abdomen
Tension
pneumothorax
Additional signs
and symptoms
◆ Tracheal deviation
◆ Decreased blood
pressure
◆ Tachycardia
◆ JVD
Diagnosis: ABG,
chest X-ray
T
reatment:
Immediate needle
decompression
followed by chest
tube insertion,
oxygen therapy
Follow-up: Return
visit in 1 to 2 weeks
after hospitalization
Additional differential diagnoses: acute respiratory distress syndrome ◆ anemia ◆ aspiration of
a foreign body ◆ cardiac arrhythmias ◆ chronic obstructive pulmonary disease ◆ cor pulmonale ◆
emphysema ◆ flail chest ◆ inhalation injury ◆ interstitial fibrosis ◆ lung cancer ◆ myocardial
infarction ◆ pleural effusion ◆ pneumonia ◆ pulmonary edema
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as barrel chest, accessory muscle hypertrophy,
diminished breath sounds, anorexia, weight
loss, malaise, peripheral cyanosis, tachypnea,
pursed-lip breathing, prolonged expiration
and, possibly, a chronic productive cough.
Clubbing is a late sign. The patient may have
a history of smoking, an alpha
deficiency, or exposure to an occupational
irritant.
-antitrypsin
1
◆ Flail chest. In this condition, dyspnea results
suddenly from multiple rib fractures and is accompanied by paradoxical chest movement, severe chest pain, hypotension, tachypnea, tachycardia, and cyanosis. Bruising and decreased or
absent breath sounds occur over the affected
side.
◆ Guillain-Barré syndrome. This syndrome,
which usually follows a fever and upper respiratory tract infection, causes slowly worsening
dyspnea along with fatigue, ascending muscle
weakness and, eventually, paralysis.
◆ Heart failure. Dyspnea usually develops
gradually in patients with heart failure. Chronic
paroxysmal nocturnal dyspnea, orthopnea,
tachypnea, tachycardia, palpitations, ventricular
gallop, fatigue, dependent peripheral edema,
hepatomegaly, dry cough, weight gain, and loss
of mental acuity may occur. With acute onset,
heart failure may produce jugular vein distention, bibasilar crackles, oliguria, and hypotension.
◆ Interstitial fibrosis. Besides dyspnea, this
disorder causes chest pain, a dry cough, crackles, weight loss and, possibly, cyanosis and
pleural friction rub.
◆ Lung cancer. Dyspnea develops slowly and
worsens progressively in late-stage lung cancer.
Other findings include fever, hemoptysis, a productive cough, wheezing, clubbing, chest pain,
and pleural friction rub.
◆ Monkeypox. Dyspnea is one of the less com-
mon symptoms of this rare viral disease. Infected individuals may also experience fever, muscle
aches, sore throat, chills, and lymphadenopathy.
A papular rash appears 1 to 3 days after the
fever begins. The virus is similar to smallpox;
however, the symptoms are milder and the
disease is rarely fatal in developed countries.
◆ Myasthenia gravis. This neuromuscular dis-
order causes bouts of dyspnea as the respiratory
muscles weaken. In myasthenic crisis, acute
respiratory distress may occur, with shallow
respirations and tachypnea.
◆ Myocardial infarction. Sudden dyspnea oc-
curs with crushing substernal chest pain that
may radiate to the back, neck, jaw, and arms.
Other signs and symptoms include nausea,
vomiting, diaphoresis, vertigo, hypertension or
hypotension, tachycardia, anxiety, and pale,
cool, clammy skin.
◆ Plague. Caused by Yersinia pestis, plague is
one of the most virulent and, if untreated, most
lethal bacterial infections known. Clinical forms
include bubonic (the most common), septicemic,
and pneumonic plagues. The pneumonic form
can be contracted by inhaling respiratory
droplets from an infected person or inhaling the
organism that has been dispersed in the air
through biological warfare. Among the symptoms of the pneumonic form are dyspnea, a
productive cough, chest pain, tachypnea, hemoptysis, increasing respiratory distress, and
cardiopulmonary insufficiency.
◆ Pleural effusion. Dyspnea develops slowly
and worsens progressively in this disorder. Initial findings include a pleural friction rub accompanied by pleuritic pain that worsens with
coughing or deep breathing. Other findings include a dry cough; dullness on percussion;
egophony, bronchophony, and whispered pectoriloquy; tachycardia; tachypnea; weight loss;
and decreased breath sounds, chest motion,
and tactile fremitus. Fever may occur if infection
is present.
◆ Pneumonia. Dyspnea occurs suddenly in
pneumonia and is usually accompanied by
fever, shaking chills, pleuritic chest pain that
worsens with deep inspiration, and a productive
cough. Fatigue, headache, myalgia, anorexia,
abdominal pain, crackles, rhonchi, tachycardia,
tachypnea, cyanosis, decreased breath sounds,
and diaphoresis may also occur.
◆ Pneumothorax. This life-threatening disor-
der causes acute dyspnea unrelated to the
severity of pain. Sudden, stabbing chest pain
may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, dry cough, cyanosis, decreased vocal fremitus, tachypnea, tympany,
decreased or absent breath sounds on the affected side, asymmetrical chest expansion,
splinting, and accessory muscle use. In patients
with tension pneumothorax, tracheal deviation
occurs in addition to these typical findings. Decreased blood pressure and tachycardia may
also occur.
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◆ Poliomyelitis (bulbar). Dyspnea develops
gradually in this disorder and worsens progressively. Additional signs and symptoms include fever, facial weakness, dysphasia, hypoactive deep tendon reflexes, decreased
mental acuity, dysphagia, nasal regurgitation,
and hypopnea.
◆ Popcorn lung disease. Popcorn lung dis-
ease occurs in factory workers who experience
respiratory symptoms after inhaling butter flavoring chemicals such as diacetyl, used in the
manufacture of microwave popcorn. The patient typically complains of gradual onset of a
nonproductive cough that worsens over time,
progressive shortness of breath, and unusual fatigue. Clinical findings include wheezing, chest
pain, fever, night sweats, and weight loss. Bronchiolitis fibrosa obliterans, an irreversible fixed
airway obstructive lung disorder, is the most severe condition reported.
◆ Pulmonary edema. Commonly preceded by
signs of heart failure, such as jugular vein distention and orthopnea, this life-threatening
disorder causes acute dyspnea. Other features
include tachycardia, tachypnea, crackles in
both lung fields, a ventricular gallop (third
heart sound [S
potension, diaphoresis, cyanosis, and marked
anxiety. The patient’s cough may be dry or may
produce copious amounts of pink, frothy
sputum.
]), oliguria, thready pulse, hy-
3
◆ Pulmonary embolism. This life-threatening
disorder is characterized by acute dyspnea
that’s usually accompanied by sudden pleuritic
chest pain. Related findings include tachycardia,
low-grade fever, tachypnea, a nonproductive
cough or a productive cough with blood-tinged
sputum, pleural friction rub, crackles, diffuse
wheezing, dullness on percussion, decreased
breath sounds, diaphoresis, restlessness, and
acute anxiety. A massive embolism may cause
signs of shock, such as hypotension and cool,
clammy skin.
◆ Sepsis. This potentially fatal disorder gradu-
ally causes dyspnea along with chills and sudden fever. As dyspnea worsens, it may be accompanied by tachycardia, tachypnea,
restlessness, anxiety, decreased mental acuity,
and warm, flushed, dry skin. Late findings include hypotension; oliguria; cool, clammy skin;
and rapid, thready pulse.
◆ Severe acute respiratory syndrome
(SARS). SARS is an acute infectious disease of
unknown etiology; however, a novel coronavirus has been implicated as a possible cause.
Although most cases have been reported in Asia
(China, Vietnam, Singapore, Thailand), cases
have cropped up in Europe and North America.
After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually
greater than 100.4° F [38° C]). Other symptoms
include headache, malaise, a nonproductive
cough, and dyspnea. The severity of the illness
is highly variable, ranging from mild illness to
pneumonia and, in some cases, progressing to
respiratory failure and death.
◆ Shock. Dyspnea arises suddenly and wors-
ens progressively in this life-threatening disorder. Related findings include severe hypotension, tachypnea, tachycardia, decreased
peripheral pulses, decreased mental acuity, restlessness, anxiety, and cool, clammy skin.
◆ Tuberculosis. Dyspnea commonly occurs
with chest pain, crackles, and a productive
cough. Other findings are night sweats, fever,
anorexia and weight loss, vague dyspepsia,
palpitations on mild exertion, and dullness on
percussion.
◆ Tularemia. Also known as “rabbit fever,”
this infectious disease causes dyspnea along
with fever, chills, headache, generalized myalgia, a nonproductive cough, pleuritic chest pain,
and empyema.
O
THER CAUSES
◆ Inhalation injury. Dyspnea may develop
suddenly or over several hours after inhalation of chemicals or hot gases. Increasing
hoarseness, a persistent cough, sooty or
bloody sputum, and oropharyngeal edema
may also be present. The patient may also
exhibit thermal burns, singed nasal hairs,
and orofacial burns as well as crackles,
rhonchi, wheezing, and signs of respiratory
distress.
S
PECIAL CONSIDERATIONS
Monitor the dyspneic patient closely. Be as calm
and reassuring as possible to reduce his anxiety,
and help him into a comfortable position—usually high Fowler’s or a forward-leaning position.
Support him with pillows, loosen his clothing,
and administer oxygen if appropriate.
Prepare the patient for diagnostic studies,
such as arterial blood gas analysis, chest
X-rays, and pulmonary function tests. Administer
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