Breathlessness u/e
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breathlessness examination clinical assessment causes
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dyspnea differential diagnosis investigations management
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Here is a structured clinical overview of breathlessness under examination (u/e):
Breathlessness — Clinical Overview
Definition
Dyspnea is the subjective sensation of breathing discomfort. It is multidimensional, involving sensory, affective, and cognitive components.
Differential Diagnosis
Per Harrison's Principles of Internal Medicine (p. 1108), chronic dyspnea (>1 month) is most commonly attributable to pulmonary or cardiac causes (~85% of cases). Up to one-third of patients have multifactorial aetiology.
Common Causes by System
| System | Causes |
|---|---|
| Cardiac | Heart failure (LVF/RVF), ACS, arrhythmias, pericardial effusion, valvular disease |
| Respiratory | Asthma, COPD, pneumonia, pleural effusion, pneumothorax, pulmonary embolism, ILD, malignancy |
| Haematological | Anaemia, methaemoglobinaemia |
| Neuromuscular | Diaphragm weakness, MND, Guillain-Barré |
| Metabolic | Acidosis (DKA, renal failure), thyrotoxicosis |
| Psychogenic | Anxiety, hyperventilation syndrome, panic disorder |
| Upper airway | Foreign body, epiglottitis, anaphylaxis |
History (Key Features)
- Onset: Acute (PE, pneumothorax, pulmonary oedema) vs. gradual (HF, COPD, anaemia)
- Duration & progression
- Exertional vs. rest: Orthopnoea, PND (LVF); platypnoea (hepatopulmonary syndrome)
- Associated symptoms: Chest pain, palpitations, cough, wheeze, haemoptysis, fever, leg swelling
- Triggers: Allergens (asthma), exertion (HF, PE), posture
- Severity: MRC dyspnoea scale, NYHA class
- PMH: Cardiac disease, COPD, DVT/PE, malignancy, autoimmune disease
- Drug history: Beta-blockers (bronchospasm), amiodarone (ILD), ACE inhibitors (cough)
- Social: Smoking, occupational exposure, travel (PE)
Examination
General
- Cyanosis (central vs. peripheral), pallor (anaemia), cachexia
- Accessory muscle use, intercostal recession
- Respiratory rate, posture (tripod = severe respiratory distress)
- Able to speak in full sentences?
Hands/Arms
- Clubbing (ILD, bronchiectasis, malignancy, cyanotic heart disease)
- Peripheral cyanosis
- Asterixis (CO₂ retention)
- Fine tremor (salbutamol, thyrotoxicosis)
- Pulse: rate, rhythm, character
Face/Neck
- JVP elevation (RHF, cardiac tamponade, SVC obstruction)
- Tracheal position (deviated away from pneumothorax/large effusion; towards collapse)
- Cervical lymphadenopathy
Chest
| Step | Findings & Significance |
|---|---|
| Inspection | Chest shape (barrel = COPD), scars, asymmetry, movement |
| Palpation | Expansion (reduced bilateral = COPD/fibrosis; unilateral = effusion, pneumothorax, collapse), TVF |
| Percussion | Dull = consolidation/effusion/collapse; Hyper-resonant = pneumothorax/COPD |
| Auscultation | Wheeze (asthma/COPD), crackles (pulmonary oedema/fibrosis/pneumonia), absent breath sounds (effusion/pneumothorax), bronchial breathing (consolidation), pleural rub |
Cardiovascular
- Apex beat: displaced (dilated cardiomyopathy), heaving (LVH), tapping (MS)
- Heart sounds: S3 (HF), loud P2 (pulmonary hypertension), murmurs
- Peripheral oedema (RHF, hypoalbuminaemia)
Abdomen
- Hepatomegaly, ascites (RHF, malignancy), splenomegaly
- Hepatojugular reflux
Investigations
Bedside
- Obs: RR, SpO₂, HR, BP, temperature, PEFR
- ECG: AF, ST changes (ACS), right heart strain (PE — S1Q3T3), P-pulmonale, LVH
- ABG: Type 1 vs. Type 2 respiratory failure, metabolic acidosis, PaO₂/FiO₂ ratio
Bloods
- FBC (anaemia, polycythaemia, infection)
- U&E, LFTs
- BNP/NT-proBNP (heart failure — high sensitivity)
- CRP, ESR
- TFTs
- Troponin (ACS)
- D-dimer (if low-intermediate PE probability)
Imaging
- CXR: Cardiomegaly, pulmonary oedema (bat-wing opacification, Kerley B lines, upper lobe diversion), consolidation, effusion, pneumothorax, hyperinflation
- CT chest: PE (CTPA), ILD, malignancy, HRCT
- Echo: LV/RV function, valvular disease, pericardial effusion, pulmonary pressures
Special
- Spirometry/PFTs: Obstructive (FEV₁/FVC <0.7 — asthma, COPD) vs. restrictive pattern (ILD, neuromuscular)
- V/Q scan: Alternative to CTPA for PE (renal impairment, contrast allergy)
- Exercise testing: Unexplained exertional dyspnea
- Bronchoscopy: Endobronchial lesions, haemoptysis
Severity Grading
MRC Dyspnoea Scale:
| Grade | Description |
|---|---|
| 1 | Only with strenuous exercise |
| 2 | Hurrying on level/walking uphill |
| 3 | Slower than peers on level; stops after ~15 min |
| 4 | Stops after ~100 m or a few minutes on level |
| 5 | Too breathless to leave house / breathless when dressing |
Red Flags (Urgent Assessment)
- SpO₂ <92%, RR >25, inability to speak in sentences
- Haemoptysis
- Acute onset with pleuritic chest pain (PE, pneumothorax)
- Signs of anaphylaxis
- Stridor (upper airway obstruction)
- New bilateral crackles + elevated JVP (acute pulmonary oedema)
Sources: Harrison's Principles of Internal Medicine, 21st ed. (p. 1108); Management of Dyspnea in Advanced Cancer (p. 8)
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