Breathlessness history
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History of Breathlessness (Dyspnoea)
Breathlessness (dyspnoea) is an uncomfortable awareness of breathing that is abnormal for the level of activity. Patients describe it variously as "tightness," "choking," "unable to take a deep breath," "suffocating," "can't get enough air," or "feeling tired." A systematic history nearly always reveals the underlying cause.
1. Onset & Time Course
| Feature | Significance |
|---|---|
| Acute (minutes–hours) | Myocardial ischaemia, acute heart failure, pulmonary embolism, pneumothorax, upper airway obstruction, anaphylaxis, severe asthma, pneumonia, drug overdose (e.g. salicylates) |
| Subacute (days–weeks) | Pleural effusion, pericardial effusion, worsening COPD/asthma, anaemia |
| Chronic (months–years) | COPD, heart failure, ILD, pulmonary hypertension, deconditioning, neuromuscular disease |
Key question: Has it been getting progressively worse? — patients with COPD often slow their activity so gradually they attribute it to aging.
2. Severity / Functional Impairment
Accurately quantify the activity needed to provoke dyspnoea:
- Breathless at rest?
- On getting dressed, eating, or speaking on the phone?
- On climbing stairs — how many flights?
- On level walking at own pace — how far before stopping?
Validated scales include the MRC Dyspnoea Scale and the Borg Scale.
3. Quality / Character of the Sensation
Different descriptors point to different mechanisms:
| Description | Likely mechanism |
|---|---|
| "Hunger for air / urge to breathe" | Heart failure, pulmonary oedema |
| "Increased effort / hard work to breathe" | Airway obstruction (COPD, asthma), neuromuscular disease |
| "Chest tightness / constriction" | Bronchoconstriction (asthma, COPD), pulmonary oedema |
| "Heavy breathing / rapid breathing" | Deconditioning, anaemia, metabolic acidosis |
4. Positional Variation
- Orthopnoea — worsens lying flat; caused by increased venous return to the pulmonary vasculature or diaphragmatic splinting. Seen in left heart failure and chronic lung disease. Quantify by number of pillows needed.
- Paroxysmal nocturnal dyspnoea (PND) — wakes patient from sleep, relieved by sitting/standing; classic for left ventricular failure; also seen in COPD (pooling secretions), nocturnal aspiration.
- Platypnoea — worsens in the upright position; suggests intracardiac shunting or hepatopulmonary syndrome.
- Trepopnoea — dyspnoea in one lateral position; seen with unilateral pleural effusion or lung disease.
- Instant orthopnoea (cannot assume supine position at all) — bilateral diaphragm paralysis.
5. Precipitating & Aggravating Factors
- Exercise (universal — quantify threshold)
- Allergens, dust, mould, cigarette smoke, perfumes → airway disease / occupational asthma
- Cold air, emotional stress → asthma
- Lying flat → heart failure, GORD-related
- Specific lateral position → unilateral lung/pleural pathology
6. Relieving Factors
- Albuterol (salbutamol) → asthma/COPD
- Sitting upright / GTN → cardiac
- Staying indoors → allergic/occupational cause
- Diuresis → heart failure (though relief not always proportional to diuresis)
7. Associated Symptoms
| Symptom | Suggests |
|---|---|
| Wheeze | Asthma, COPD, cardiac asthma |
| Productive cough / fever | Pneumonia, bronchitis |
| Lower limb oedema, PND, orthopnoea | Heart failure |
| Haemoptysis | PE, lung cancer, TB, bronchiectasis |
| Chest pain | ACS, PE, pleurisy, pneumothorax |
| Palpitations / syncope | Arrhythmia, cardiac cause |
| Weight loss, night sweats | Malignancy, TB |
| Fatigue, pallor | Anaemia |
8. Past Medical History
- Known cardiac disease (IHD, valve disease, cardiomyopathy)
- Known respiratory disease (asthma, COPD, TB, ILD)
- Anaemia, renal failure, thyroid disease
- Previous DVT/PE
9. Drug History
- Beta-blockers → bronchospasm
- ACE inhibitors → cough (may mimic breathlessness)
- NSAIDs → aspirin-sensitive asthma
- Amiodarone → pulmonary fibrosis
- Methotrexate, bleomycin, nitrofurantoin → ILD
10. Social & Occupational History
- Smoking (pack-years) → COPD, lung cancer
- Occupational exposures (asbestos, silica, organic dusts, fumes) → pneumoconiosis, occupational asthma
- Travel → TB, endemic fungi, altitude
11. Family History
- Asthma, atopy
- Alpha-1 antitrypsin deficiency
- Familial cardiomyopathy or pulmonary hypertension
Summary Mnemonic — SOCRATES + Position
| Letter | Domain |
|---|---|
| Site | — (dyspnoea is central) |
| Onset | Acute / subacute / chronic |
| Character | Effort, tightness, hunger for air |
| Radiation | — |
| Associations | Wheeze, cough, oedema, chest pain |
| Time course | Constant / episodic / progressive |
| Exacerbating/relieving | Exercise, position, triggers, medications |
| Severity | MRC grade, functional limitation |
| +Position | Orthopnoea, PND, platypnoea, trepopnoea |
Sources: Goldman-Cecil Medicine, 2 Volume Set; Murray & Nadel's Textbook of Respiratory Medicine
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