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Causes of Dyspnoea/Breathlessness

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In difficult cases It is reasonable to treat more than one - suspected pathology e.g. PE, pneumonia and pulmonary oedema at one time while you await test and radiology results.

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Work your way through the list in the context of the patient.
Could this be a second pathology e.g. PE in COPD or a small PTX

Physiology

The normal adult respiratory rate is 14-20 breaths/min.
Tachypnoea > 30 breaths/min at rest indicates that increased ventilation is needed because of hypoxaemia associated with disease affecting the airway, breathing or circulation.
Another cause is hyperventilation due to a metabolic acidosis associated with a non-respiratory problem.
Respiratory rate < 10 breaths/min is an indication of respiratory fatigue or loss of central respiratory drive, both potentially requiring ventilatory support

Differentials of Breathlessness

Cause	Clinical Presentation	Diagnostic Tests	Treatment
Heart Failure	Exertional dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea, fatigue, edema, elevated jugular venous pressure.	Echocardiogram, BNP levels, chest X-ray (cardiomegaly, pulmonary edema), ECG, blood tests (renal function, electrolytes).	Diuretics, ACE inhibitors or ARBs, beta-blockers, lifestyle changes (e.g., sodium restriction), possible advanced therapies (e.g., ICD, heart transplant).
Chronic Obstructive Pulmonary Disease (COPD)	Chronic dyspnoea, productive cough, wheezing, history of smoking or exposure to lung irritants.	Spirometry (reduced FEV1/FVC ratio), chest X-ray (hyperinflation), CT scan, arterial blood gases in advanced cases.	Smoking cessation, bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy in advanced cases.
Asthma	Intermittent dyspnoea, wheezing, chest tightness, cough, often worse at night or early morning, triggers include allergens, exercise, cold air.	Spirometry (reversible airway obstruction), peak flow measurement, allergy testing, bronchoprovocation testing.	Inhaled corticosteroids, bronchodilators (short-acting beta agonists for relief, long-acting for maintenance), avoidance of triggers.
Pulmonary Embolism (PE)	Sudden onset dyspnoea, pleuritic chest pain, tachypnea, tachycardia, haemoptysis, signs of deep vein thrombosis (DVT).	CT pulmonary angiography (CTPA), D-dimer test, ventilation-perfusion (V/Q) scan, lower limb ultrasound for DVT, ECG (may show S1Q3T3 pattern).	Anticoagulation (e.g., heparin, warfarin, DOACs), thrombolysis in massive PE, supportive care (oxygen, fluids), possible surgical intervention (embolectomy).
Pneumonia	Acute dyspnoea, productive or non-productive cough, fever, chills, pleuritic chest pain, tachypnea.	Chest X-ray (consolidation or infiltrates), sputum culture, blood cultures if sepsis suspected, pulse oximetry, blood tests (white blood cell count).	Antibiotics (empirical therapy based on likely pathogens), supportive care (hydration, antipyretics), hospitalization if severe.
Interstitial Lung Disease (ILD)	Progressive dyspnoea, dry cough, fatigue, fine crackles on auscultation, clubbing of fingers, history of exposure to lung irritants.	High-resolution CT scan, pulmonary function tests (reduced lung volumes), lung biopsy if needed for diagnosis.	Management of underlying cause, corticosteroids or immunosuppressants, oxygen therapy, lung transplantation in severe cases.
Anaemia	Exertional dyspnoea, fatigue, pallor, tachycardia, dizziness, potential history of bleeding, dietary insufficiency, or chronic disease.	Complete blood count (CBC), reticulocyte count, iron studies, vitamin B12 and folate levels, peripheral blood smear.	Iron supplementation for iron deficiency, vitamin B12 or folate supplementation for deficiencies, transfusion if severe anaemia, treatment of underlying cause.
Pneumothorax	Sudden onset dyspnoea, pleuritic chest pain, reduced breath sounds on affected side, hyperresonance to percussion.	Chest X-ray (collapsed lung), CT scan for detailed imaging, arterial blood gases in severe cases.	Observation for small, asymptomatic pneumothorax; needle aspiration or chest tube insertion for larger or symptomatic pneumothorax; surgery for recurrent cases.
Heart Attack (Myocardial Infarction)	Dyspnoea, chest pain (pressure, squeezing), radiating pain (to arm, neck, or jaw), diaphoresis, nausea, palpitations.	ECG (ST elevation or depression), cardiac enzymes (troponins), echocardiogram, coronary angiography.	Immediate reperfusion therapy (PCI or thrombolysis), antiplatelet agents (aspirin, clopidogrel), beta-blockers, ACE inhibitors, statins, lifestyle modifications.
Congestive Heart Failure (CHF)	Dyspnoea on exertion, orthopnea, paroxysmal nocturnal dyspnoea, fatigue, peripheral edema, jugular venous distension.	Echocardiogram (left ventricular function), chest X-ray (pulmonary edema, cardiomegaly), BNP levels, ECG.	Diuretics, ACE inhibitors or ARBs, beta-blockers, aldosterone antagonists, lifestyle changes (sodium restriction, fluid management), advanced therapies (ICD, heart transplant) in severe cases.

Definition

Dyspnoea is defined as difficulty in breathing. Usually respiratory or cardiovascular disease
Orthopnoea is defined as breathlessness lying flat and is usually a sign of cardiac failure.
Paroxysmal nocturnal dyspnoea: waking from sleep suddenly breathless. Awake breathless and anxious, they often describe having to sit up and may hang their legs over the side of the bed or go to the window to relieve the dyspnoea.

Investigations

FBC, U&E, Dimer, Glucose, Troponin, CRP
CXR: pulmonary oedema, consolidation, PTX
If needed ABG if sats < 92%
If needed CTA to exclude PE and can also identify other lung pathology

Management

ABC, Give Oxygen, Get IV access and send bloods
ABG if sats < 92% or ongoing breathlessness
Get ECG, CXR and seek senior help

Individualised: sometimes you may combine if waiting for tests e.g. CTPA

Chest infection: Antibiotics, Oxygen, Chest physio, Hydration
Pulmonary oedema: IV Furosemide, S/L GTN, Identify cause
Pneumothorax: Oxygen, Aspiration and/or drain
Asthma: Salbutamol [US Albuterol], Hydrocortisone - See acute severe asthma
COPD: Salbutamol [US Albuterol], Oral Steroids, NIV may be needed
Pulmonary embolism: Start treatment dose LMWH. Thrombolysis if in extremis
Metabolic acidosis due to DKA and Kussmaul's breathing. High Glucose, Low pH. Needs IV fluids, K and Insulin

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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