Breathlessness history
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I now have comprehensive material to structure a thorough answer on taking a history of breathlessness. Let me compile this.
History of Breathlessness (Dyspnoea)
Dyspnoea is defined as a subjective sensation of difficulty breathing, commonly reported as "shortness of breath," "chest tightness," or "can't get enough air." It is extremely common — up to 50% of inpatients and 25% of ambulatory patients experience it, accounting for 3–4 million ED visits per year.
1. Definition and Key Terms
| Term | Definition |
|---|---|
| Dyspnoea on exertion (DOE) | Breathlessness provoked by physical effort; quantified as stairs climbed or distance walked before symptom onset |
| Orthopnoea | Dyspnoea in the recumbent position, relieved by sitting/standing; quantified in number of pillows used |
| Paroxysmal nocturnal dyspnoea (PND) | Sudden onset of breathlessness at night, rousing the patient from sleep, relieved by sitting upright |
| Platypnoea | Dyspnoea induced by the upright position, relieved by recumbency (opposite of orthopnoea) |
| Trepopnea | Dyspnoea when lying on one side (typically the affected side in asymmetric lung disease) |
| Tachypnoea | Respiratory rate >18 breaths/min in adults |
| Hyperventilation | Minute ventilation exceeding metabolic demand |
2. Structured History — Key Questions
Onset & Duration
- Sudden onset (seconds to minutes): pulmonary embolism, spontaneous pneumothorax, acute LVF/pulmonary oedema, anaphylaxis, foreign body, arrhythmia
- Sub-acute (hours to days): pneumonia, asthma exacerbation, pleural effusion, acute coronary syndrome
- Chronic/progressive (weeks to months): COPD, heart failure, interstitial lung disease, pulmonary hypertension, anaemia, malignancy
Character / Quality
- "Chest tightness" — fairly specific to bronchoconstriction (asthma, COPD); stimulation of airway receptors
- "Can't get a deep breath / air hunger" — pulmonary parenchymal disease, ILD, heart failure
- "Increased effort to breathe" — obstructive airways disease, neuromuscular weakness, chest wall disease
- Inability to get deep breath — interstitial lung disease, chest wall restriction
Severity / Functional Impairment
Use the MRC Dyspnoea Scale (integrated into GOLD COPD guidelines):
| Grade | Description |
|---|---|
| 0 | Not troubled except with strenuous exercise |
| 1 | Short of breath on level ground or slight hill |
| 2 | Walks slower than peers, or must stop to rest on level ground at own pace |
| 3 | Stops after 100 m or a few minutes on level ground |
| 4 | Too breathless to leave the house, or breathless with activities of daily living (dressing) |
Timing & Pattern
- Constant vs. episodic
- Time of day (nocturnal → PND, cardiac asthma; early morning/late evening → asthma)
- Seasonal variation → allergic/occupational asthma
- Worse at rest vs. on exertion
Positional Variation
- Orthopnoea → left heart failure, bilateral diaphragm paralysis
- Platypnoea → hepatopulmonary syndrome, AVM at lung bases (worse upright due to gravity increasing right-to-left shunt)
- Trepopnea → asymmetric lung disease (worse on the affected side down)
- Worse lying flat in chronic lung disease / asthma → greater difficulty of bellows movement in recumbency
Aggravating & Relieving Factors
- Exercise, cold air, smoke, allergens, occupational exposures
- Rest, bronchodilators, diuretics, supplemental oxygen, specific posture
- Medications (aspirin, NSAIDs, beta-blockers can worsen asthma; ACE inhibitors → cough)
Associated Symptoms
| Symptom | Suggests |
|---|---|
| Wheeze | Asthma, COPD, cardiac asthma (left heart failure) |
| Cough (dry end-inspiratory) | ILD |
| Cough with frothy/pink sputum | Acute pulmonary oedema |
| Productive cough | COPD, pneumonia, bronchiectasis |
| Haemoptysis | PE, malignancy, TB, bronchiectasis |
| Chest pain (pleuritic) | PE, pneumothorax, pleuritis |
| Chest pain (central) | ACS, aortic dissection |
| Ankle swelling / orthopnoea | Heart failure |
| Palpitations | Arrhythmia |
| Fever / rigors | Infection |
| Weight loss / anorexia | Malignancy, TB, ILD |
| Dizziness / syncope | Low cardiac output |
3. Past Medical History
- Known cardiac disease (IHD, heart failure, valve disease, cardiomyopathy)
- Known respiratory disease (asthma, COPD, ILD, sarcoidosis, TB)
- Anaemia or haematological conditions
- Malignancy
- Thyroid disease (thyrotoxicosis → increased ventilation)
- Metabolic conditions (diabetes → DKA)
- Renal failure
- Neuromuscular disease (myasthenia gravis, Guillain-Barré, motor neurone disease)
- Prior VTE (DVT/PE)
- Previous thoracic surgery or trauma
4. Drug History
- Causative or worsening agents: aspirin, NSAIDs (bronchoconstriction), beta-blockers, ACE inhibitors (cough/angioedema), amiodarone (pulmonary toxicity), methotrexate (pneumonitis), nitrofurantoin
- Beneficial agents currently used: inhalers (type, technique, compliance), diuretics, anticoagulants
- Oxygen: home O₂ therapy → suggests severe chronic disease
5. Social History
- Smoking: pack-year history (COPD, malignancy, IHD)
- Occupational exposure: asbestos (mesothelioma, asbestosis), coal/silica dust, isocyanates, bird droppings (hypersensitivity pneumonitis), farmer's lung
- Pets: birds, cats (allergens, hypersensitivity pneumonitis)
- Travel: TB-endemic areas, endemic fungi (histoplasmosis, coccidioidomycosis)
- Exercise capacity baseline: what was normal before? How has it changed?
- Activities of daily living: impact on quality of life
6. Family History
- Asthma, atopy, COPD, emphysema (α1-antitrypsin deficiency), pulmonary fibrosis, cardiac disease, DVT/PE (thrombophilia)
7. Systems Review Highlights
- Psychiatric/anxiety: sudden onset breathlessness, tingling (hyperventilation syndrome), no hypoxia, situational triggers, history of depression/anxiety; breathlessness in depression is typically sudden onset vs. insidious in pulmonary disease
- "Happy hypoxic" phenomenon (COVID-19): profound hypoxia without perceived distress — patient's perception correlates poorly with physiological severity
8. Differential Diagnosis Framework
Acute Dyspnoea — Critical Diagnoses to Exclude First
| Category | Critical | Emergent | Non-urgent |
|---|---|---|---|
| Pulmonary | Airway obstruction, PE, ARDS, anaphylaxis, ventilatory failure | Pneumothorax, asthma, aspiration | Effusion, COPD, pneumonia (mild) |
| Cardiac | Pulmonary oedema (LVF), MI, cardiac tamponade | Pericarditis | Valvular disease, cardiomyopathy |
| Metabolic | Toxic ingestion, DKA | Renal failure, metabolic acidosis | Fever, thyroid disease |
| Psychogenic | — | — | Panic attack, hyperventilation, somatisation |
Chronic Dyspnoea — By Mechanism
| Mechanism | Example Diseases |
|---|---|
| Airways obstruction | Asthma, COPD, upper airway obstruction |
| Parenchymal disease | ILD, pneumonia, emphysema |
| Chest wall/neuromuscular | Kyphoscoliosis, myasthenia, diaphragm paralysis |
| Pulmonary vasculature | Pulmonary hypertension, chronic PE |
| Left heart failure | IHD, cardiomyopathy, valvular disease |
| Reduced O₂ carrying capacity | Anaemia |
| Increased CO₂ production / metabolic | DKA, thyrotoxicosis, pregnancy, sepsis |
| Miscellaneous | Musculoskeletal, obesity, ascites |
9. SOCRATES Applied to Breathlessness
| Component | Breathlessness-specific question |
|---|---|
| Site | Chest? Upper airway? Throat tightness? |
| Onset | Sudden / gradual / chronic |
| Character | Tightness, air hunger, effortful |
| Radiation | Associated chest/shoulder pain |
| Associated symptoms | Wheeze, cough, haemoptysis, oedema, palpitations |
| Timing | Constant, episodic, nocturnal, exertional |
| Exacerbating/relieving | Posture, exercise, cold, allergens, medications |
| Severity | MRC grade; comparison with baseline |
Sources
- Harrison's Principles of Internal Medicine, 22nd Ed., Ch. 39 — Dyspnoea (differential diagnosis table, MRC scale, CPET)
- Fishman's Pulmonary Diseases and Disorders — Dyspnoea, Orthopnoea, PND, positional breathlessness, cardiac asthma, anaemia, metabolic causes
- Rosen's Emergency Medicine — Acute dyspnoea differential, pivotal history findings, critical diagnoses
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