Chronic Dyspnea

Aka: Chronic Dyspnea, Chronic Shortness of Breath

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II. Definitions

  1. Chronic Dyspnea
    1. Subjective difficult or distressed breathing lasting >1 month

III. Epidemiology

  1. Reported by a third of patients over age 60-70 years old
    1. Confers an increased mortality risk (esp. COPD)

IV. Causes

  1. See Dyspnea Causes

V. History

  1. See Dyspnea History
  2. See COPD Population Screener Questionnaire
  3. See Lung Function Questionnaire

VI. Exam

  1. See Dyspnea
  2. Pulse Oximetry (at rest and while walking)
  3. Six-Minute Walk Test

VII. Labs

  1. Complete Blood Count (CBC)
  2. Chemistry panel (e.g. chem8)
  3. Thyroid Stimulating Hormone (TSH)
  4. Arterial Blood Gas (ABG)
  5. Brain Natriuretic Peptide (BNP)
  6. D-Dimer
  7. Troponin

VIII. Diagnostics

  1. See Dyspnea
  2. Spirometry or Peak Flow
  3. Complete Pulmonary Function Testing (PFT)
    1. See Obstructive Lung Disease
    2. See Restrictive Lung Disease
  4. Electrocardiogram (EKG)
    1. Coronary Artery Disease
    2. Atrial Fibrillation is a common cause of exertional Dyspnea
    3. Left Ventricular Hypertrophy
  5. Echocardiogram
  6. Holter Monitor
  7. Exercise Stress Test

IX. Imaging

  1. Chest XRay
    1. Congestive Heart Failure
    2. Pleural Effusion
    3. Interstititial Lung Disease
    4. COPD
  2. Chest CT (high resolution)
  3. Bedside Ultrasound
    1. See Lichtenstein Dyspnea Evaluation by Ultrasound Protocol (Blue Protocol)
    2. See Volpicelli Dyspnea Evaluation with Ultrasound Protocol

X. Management

  1. Empiric Therapy to consider
    1. Bronchodilator trial for episodic Dyspnea
    2. Proton Pump Inhibitor if GERD suspected
  2. Eliminate provocative measures
    1. Medication Causes of Dyspnea
    2. Tobacco Cessation
  3. Optimize management of chronic conditions
    1. COPD Management
    2. Asthma Management
    3. Systolic Heart Failure
    4. Diastolic Heart Failure
    5. Coronary Artery Disease
    6. Dyspnea in Paliative Care

XI. Management: Refractory Dyspnea of unclear cause

  1. Consider cardiology evaluation for angiography
  2. Consider pulmonology for bronchoscopy and biopsy
  3. Consider esophageal pH and manometry testing

XII. References

  1. Fangman in Noble (2001) Primary Care, p. 175-8
  2. Budhwar (2020) Am Fam Physician 101(9):542-8 [PubMed]
  3. Karnani (2005) Am Fam Physician 71(8):1529-37 [PubMed]
  4. Wahls (2012) Am Fam Physician 86(2): 173-80 [PubMed]

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