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Breathlessness - Management
How should I investigate people with chronic breathlessness?

  • If the person does not have an indication for emergency admission, arrange investigations to identify or confirm the underlying cause of breathlessness.
  • Where the diagnosis cannot confidently be established by clinical features alone:
    • Initial investigations should include:
      • Chest radiography — to look for signs of heart failure and pulmonary pathology (including pleural effusion).
      • Electrocardiography (ECG) — to look for signs of heart failure, arrhythmia, and pulmonary embolism.
      • Spirometry — to look for signs of obstructive airway disease or a restrictive pattern associated with interstitial lung disease (such as idiopathic pulmonary fibrosis, sarcoidosis, pneumoconiosis, or extrinsic allergic alveolitis).
      • Full blood count — to check for anaemia.
      • Urea and electrolytes, and random blood glucose level — to test for renal failure and diabetes as causes of metabolic acidosis and breathlessness.
      • Thyroid function tests — to detect thyroid disease as a cause of breathlessness.
    • If initial investigations do not identify the cause of breathlessness:
      • Arrange echocardiography and test for B-type natriuretic peptide (BNP), depending on local guidelines, to assess for heart failure.
      • Reassess for risk factors and clinical features of pulmonary embolism. If this is suspected, arrange urgent referral for further investigations.
  • Suspected asthma or COPD
    • Assess airways obstruction by spirometry. Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) less than 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio less than 70%.
    • Distinguish asthma from COPD, based on:
      • Smoking history — almost always present in people with COPD.
      • Age — usually older than 35 years of age for COPD.
      • Chronic productive cough — common with COPD, uncommon with asthma.
      • Breathlessness — progressive with COPD, variable with asthma.
      • Variability of symptoms — common with asthma, uncommon with COPD.
    • If asthma and COPD can not be distinguished based on clinical features:
      • Arrange measurements of peak expiratory flow rate (PEFR) — morning and night-time measurements, and during symptoms (to assess variability).
      • If doubt still remains, a large response (more than 400 mL) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma; but not COPD.
      • If doubt still remains, refer the person for a specialist's opinion.
    • For people with COPD, arrange chest radiography (to exclude other serious lung pathology, such as lung cancer) and full blood count (to identify polycythaemia/erythrocytosis secondary to chronic hypoxia).
  • Suspected bronchiectasis. Arrange chest radiography to exclude other causes for the symptoms, and refer the person to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
  • Suspected pleural effusion. Arrange chest radiography to confirm the diagnosis.
  • Suspected abdominal splinting secondary to ascites. Arrange an abdominal ultrasound scan to confirm the presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer. Arrange other investigations guided by clinical findings (for example liver function tests or erythrocyte sedimentation rate; for signs of cancer).

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