Shortness of breath: Looking beyond the usual suspects

,

Applied Evidence

Shortness of breath: Looking beyond the usual suspects

J Fam Pract. 2016 August;65(8):526-533

By

Christopher Taggart, MD

COPD and pneumonia come to mind when a patient is short of breath. But the signs and symptoms detailed here should lead you to suspect an uncommon cause.

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References

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PRACTICE RECOMMENDATIONS

› Consider diagnoses other than asthma, COPD, heart failure, and pneumonia in patients with persistent or progressive dyspnea. C
› Avoid steroids in patients with acute pericarditis because research shows that they increase the risk of recurrence. B
› Consider anticoagulation with warfarin in patients with pulmonary arterial hypertension and cor pulmonale. Evidence shows that it improves survival and quality of life. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Joan C is a 68-year-old woman who presents to the office complaining of an enlarging left chest wall mass that appeared within the past month. She was treated for small-cell lung cancer 11 years ago. She has a 45 pack-year smoking history (she quit when she received the diagnosis) and has heart failure, which is controlled. Your examination reveals a large (5 cm) firm mass on her left chest wall. There is no erythema or tenderness. She has no other complaints. You recommend surgical biopsy and refer her to surgery.

Ms. C returns to your office several days later complaining of new and worsening shortness of breath with exertion that began the previous day. The presentation is similar to prior asthma exacerbation episodes. She denies any cough, fever, chest pain, symptoms at rest, or hemoptysis. On exam she appears comfortable and not in any acute distress. You refill her albuterol.

The next day you learn that she is being admitted to the hospital with respiratory distress. An x-ray of her chest shows a concerning mass in her right upper lung.

Dyspnea is an uncomfortable awareness of breathing that occurs when complex neurochemical pathways used to maintain oxygenation and ventilation are disrupted. (See "The variable, and subjective, process of dyspnea"^1-5). Sometimes described as air hunger, increased work of breathing, chest tightness, or chest constriction, the symptom is usually disproportionate to the patient’s level of exertion.