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Breathlessness - Management
What are the clinical features of the common pulmonary causes of breathlessness?
- Asthma
- Risk factors — personal history of rhinitis or eczema, or family history of atopy.
- Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
- Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
- Peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is:
- Life-threatening — when PEFR is less than 33% of predicted, and is associated with tachycardia, hypotension, a silent chest, or impaired level of consciousness.
- Severe — when PEFR is 33–50% of predicted, and is associated with a respiratory rate of more than 25 breaths per minute and an inability to complete full sentences.
- Moderate — when PEFR is more than 50% of predicted, with a respiratory rate of less than 25 breaths per minute.
- Chronic obstructive pulmonary disease
- History — typically, the person is older than 35 years of age, is a smoker (or past smoker), and reports slowly progressive breathlessness.
- Symptoms — persistent progressive breathlessness that is often associated with wheezing or chest tightness, and a cough (producing purulent sputum). Acute exacerbations of symptoms are common, and are frequently caused by respiratory tract infection.
- Signs — wheeze, hyperinflated chest (in emphysema), crackles (when infection is present). There may be signs of right-side heart failure in people with severe disease, including swollen ankles and increased jugular venous pressure. The person's peripheries (the hands and feet) are often warm to the touch and a dusky colour (cyanosed), with distended veins.
- Pneumonia
- Symptoms — cough associated with at least one other symptom of breathlessness, sputum production, wheeze, or pleuritic pain.
- Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus/resonance) plus at least one systemic feature (such as fever/sweating, myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.
- Pulmonary embolism (PE)
- Risk factors — immobilization, surgery, cancer, symptoms or signs of deep vein thrombosis (DVT).
- Symptoms — acute-onset breathlessness (in 73% of people with PE), pleuritic pain (66%), cough (37%), haemoptysis (13%). Recurrent acute episodes may lead to chronic breathlessness.
- Signs — tachypnoea of more than 20 breaths per minute (in 70% of people with PE), crackles (51%), tachycardia (30%), signs of DVT (11%).
- Pneumothorax/tension pneumothorax
- Risk factors — smoking, age and body type (adults who are young, tall, and slim), previous pneumothorax, chronic respiratory disease (such as chronic obstructive pulmonary disease or asthma), trauma to chest wall (including therapeutic procedures such as injections and aspirations).
- Symptoms — collapse, sudden-onset pleuritic pain, breathlessness.
- Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in a rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
- Pleural effusion
- Causes — include: heart, liver, or renal failure; pneumonia; pulmonary embolism; cancer (including mesothelioma); tuberculosis; pleural infection (empyema); and autoimmune disease.
- Symptoms — progressive breathlessness.
- Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.
- Lung/lobar collapse
- Causes — airway compression (for example by enlarged lymph nodes infiltrated with cancer) or blockage (secondary to pneumonia or an inhaled foreign body).
- Symptoms — breathlessness, cough.
- Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
- Bronchiectasis
- History — suspect in people with a history of recurrent or chronic productive cough, especially if they do not smoke.
- Symptoms — cough with daily sputum production (present in 75–100% of adults), progressive breathlessness (72–83%), haemoptysis (51–45%), non-pleuritic chest pain between exacerbations (31%).
- Signs — coarse crackles during early inspiration that are heard in the affected areas, usually in the lower lung fields (70% of adults). Others include wheeze (34%) and large airway rhonci (44%). Finger clubbing occurs infrequently.
- Interstitial lung disease (ILD)
- Causes — include idiopathic pulmonary fibrosis, sarcoidosis, pneumoconioses, ILD associated with drug therapy, ILD associated with connective tissue disease, and hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens; for example from birds, hay, or mushrooms).
- Symptoms — cough and slowly progressive breathlessness. When it is caused by extrinsic allergic alveolitis there may be a history of recurrent episodes of flu-like illness following exposure to the responsible allergen. There may be symptoms of the underlying cause (for example joint pains when the ILD is associated with connective tissue disease).
- Signs — there may be none in sarcoidosis. When present, there may be fine end-inspiratory crepitations (indicative of fibrosis), finger clubbing, cyanosis, and signs of right heart failure.
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