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Dyspnea

Last updated: September 15, 2020

Summary

Dyspnea, or shortness of breath, is a commonly reported symptom in acute care and outpatient settings. Causes of dyspnea include pulmonary (e.g., pneumonia, asthma exacerbation), cardiac (e.g., acute coronary syndrome, congestive heart failure), toxic-metabolic (e.g., metabolic acidosis, medications), and upper airway (e.g., epiglottitis, foreign body) pathologies. On initial presentation, it is important to immediately evaluate the patient for any urgent or life-threatening causes of dyspnea with patient history, physical examination, and diagnostic testing. Once immediately life-threatening causes are ruled out, a more detailed patient history should be obtained and further testing should be done to narrow the differential diagnoses.

Approach

Approach to management

ABCDE survey

Establish IV access, cardiac and pulse oximetry monitoring.

Start supplemental oxygen as needed.

Assess the need for ventilation support and airway management.

Stabilize cardiovascular function (e.g., IV fluid resuscitation).

Perform focused history, examination, and diagnostics to rule out life-threatening reversible causes (see “Diagnostics” below).

Once life-threatening causes have been ruled out:
- Conduct a detailed patient history and clinical examination (see overview of pulmonary examination findings).
- Consider further diagnostic testing (e.g., peak flow, PFTs).

Treat the underlying cause.

Red flags for dyspnea

Dyspnea at rest
Signs of increased work of breathing
Chest pain
Diaphoresis
Decreased level of consciousness or agitation
Stridor
Distant heart sounds
New cardiac murmur
Pulsus paradoxus
Cyanosis
Focal neurologic deficits
Hypotension
Respiratory acidosis

Immediately life-threatening causes

Diagnostics

Dyspnea approach

The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in patients with acute dyspnea.

Initial workup ^[1]

Laboratory studies

Imaging

ECG
Chest x-ray
CT chest with IV contrast (PE protocol)
TTE
FAST

Further diagnostics to consider

Respiratory viral panel
Blood and sputum cultures
Negative inspiratory flow
Peak flow and PFTs
X-ray of ribs
CT brain without IV contrast
Lumbar puncture
Serum salicylate level
TSH and free T4
CT neck with IV contrast

Pulmonary causes

	Clinical features	Diagnostic findings	Acute management
Pneumonia ^[2]	Fever, chills Cough, dyspnea Hypoxemia Crackles, egophony	Labs: leukocytosis, ↑ ESR/CRP, ↑ procalcitonin Positive sputum culture CXR: consolidation, pleural effusion CT chest with IV contrast: hyperdense consolidation	See the acute management checklist for pneumonia.
COPD exacerbation (AECOPD) ^[3]^[4]	Dyspnea, cough, purulent sputum Tachypnea, hypoxemia Diffuse wheezing, decreased breath sounds Increased work of breathing Signs of imminent respiratory arrest: confusion, absent breath sounds, bradycardia	ABG: ↓ pH, ↑ P_aCO₂, ↓ P_aO₂ (respiratory acidosis) CXR: hyperinflated lungs; signs of pneumonia, pneumothorax, and/or pleural effusion may be present	See the acute management checklist for AECOPD.
Asthma exacerbation ^[5]	Dyspnea, cough Tachycardia Tachypnea, hypoxemia Diffuse wheezing, decreased or absent breath sounds Signs of increased work of breathing	ABG: ↓ pH, ↑ P_aCO₂, ↓ P_aO₂ (respiratory acidosis) Peak expiratory flow: decreased from predicted or personal best	See the acute management checklist for asthma exacerbation.
Tension pneumothorax ^[6]^[7]	Severe, sharp chest pain Dyspnea, hypoxemia History of trauma Hyperresonance, decreased breath sounds, tracheal deviation Tachycardia, hypotension	Clinical diagnosis CXR: absent lung markings, tracheal deviation, pneumomediastinum	See the acute management checklist for tension pneumothorax.
Spontaneous pneumothorax ^[6]^[8]^[9]	Sudden, sharp unilateral chest pain Acute dyspnea Hypoxemia Hyperresonance, decreased breath sounds on affected side Crepitus History of lung disease or trauma	CXR (in inspiration): increased lucency, displaced lung markings, subcutaneous emphysema Ultrasound: absent lung sliding	See the acute management checklist for spontaneous pneumothorax.
Pulmonary embolism ^[10]	Pleuritic chest pain Acute onset dyspnea, hypoxemia Cough, hemoptysis Unilateral leg swelling or history of DVT Hypotension, shock (if massive PE)	Elevated D-dimer ↑ Troponin, BNP ECG: normal sinus rhythm (most common), sinus tachycardia, signs of right ventricular strain CTA chest: pulmonary artery filling defect V/Q scan: perfusion-ventilation mismatch TTE: right ventricle hypokinesis with normal apical movement Wells criteria for pulmonary embolism	See the acute management checklist for pulmonary embolism.
Acute chest syndrome ^[11]^[12]	Chest pain Fever Cough, shortness of breath, wheezing Signs of vaso-occlusive crisis Rib or sternal pain	Clinical diagnosis (see diagnostic criteria for acute chest syndrome) ↓ Hgb, leukocytosis CXR: new pulmonary infiltrate	See the acute management checklist for acute chest syndrome.
ARDS ^[13]^[14]	Acute hypoxemic respiratory failure (within 1 week of inciting event ) Diffuse, bilateral crackles	ABG: ↓ PaO₂, ↑ A-a gradient, P/F ratio < 300 mm Hg CXR: bilateral patchy diffuse or homogeneous lung infiltrates TTE: normal systolic function	See the acute management checklist for ARDS.

Lobar pneumonia

Cardiac causes

	Clinical features	Diagnostic findings	Acute management
Acute coronary syndrome ^[15]^[16]	Heavy, dull, pressure/squeezing sensation Substernal pain with radiation to left shoulder Nausea, vomiting Diaphoresis, anxiety Dizziness, lightheadedness, syncope Pain may improve with nitroglycerin.	ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions, Q waves Increased or normal troponin TTE: hypokinesis, regional wall motion abnormalities	See the acute management checklist for STEMI and the acute management checklist for NSTEMI/UA.
Cardiac tamponade ^[17]	Tachypnea, dyspnea Tachycardia Pulsus paradoxus Cardiogenic shock Beck triad	ECG: low voltage, electrical alternans CXR: enlarged cardiac silhouette TTE: circumferential fluid layer, collapsible chambers , high EF, dilated IVC Inspiration: Both ventricular and atrial septa move sharply to the left. Expiration: Both ventricular and atrial septa move sharply to the right.	See the acute management checklist for cardiac tamponade.
Heart failure exacerbation ^[18]^[19]^[20]^[21]	Chest pressure Cough, dyspnea Hypoxemia Crackles, JVD, peripheral edema Chronic exertional dyspnea and paroxysmal nocturnal dyspnea	Clinical diagnosis Labs: ↑ BNP, ↑ troponin, hyponatremia CXR: diffuse opacities, Kerley B lines TTE: global or focal wall abnormalities, systolic and/or diastolic dysfunction, decreased LVEF	See the acute management checklist for heart failure exacerbation.
Atrial fibrillation with RVR ^[22]^[23]	Dyspnea Palpitations Dizziness Hypotension, syncope	ECG: irregularly irregular rhythm, absent P waves CXR: pulmonary edema, left atrial enlargement	See the acute management checklist for atrial fibrillation with RVR
Acute mitral regurgitation ^[24]	Tachycardia, hypotension, cardiogenic shock Tachypnea, dyspnea Weakness, dizziness, altered mental state Faint systolic decrescendo murmur	ECG: tachycardia, nonspecific ST-wave and T-wave changes; in some cases, signs of ischemia CXR: pulmonary edema TTE: mitral regurgitation, normal left ventricular size , ejection fraction intact, signs of the underlying pathology (e.g., chordal rupture)	See the acute management checklist for acute mitral regurgitation

Upper airway causes

	Clinical features	Diagnostic findings	Acute management
Angioedema ^[25]^[26]	Swelling of the face, upper airway, body Urticaria, hypotension, and/or bronchospasm	Clinical diagnosis ↑ Serum tryptase (in histamine-mediated forms) ↓ C4 (during hereditary angioedema attacks)	See the acute management checklist for angioedema.
Foreign body aspiration ^[27]	Choking, coughing Respiratory distress, cyanosis, altered mental state Wheezing, stridor, absent breath sounds In chronic cases : cough, recurrent pulmonary infections	X-ray chest: radio-opacity in the trachea or bronchi, atelectasis CT chest : direct identification of the foreign body Rigid or flexible bronchoscopy: visualization of the foreign body	See the acute management checklist for foreign body aspiration.
Epiglottitis ^[28]^[29]	Odynophagia, pain over larynx on palpation Respiratory distress, hypoxia, toxic appearance Dysphagia, stridor, drooling, muffled voice Absence of hoarseness, cough	↑ WBC, ↑ CRP X-ray of lateral neck soft tissue: thumb sign (i.e., a swollen epiglottis), vallecula sign Endoscopy : edematous, inflamed epiglottis	See the acute management checklist for epiglottitis.
Deep neck infection ^[30]	Fever, fatigue Dysphagia, dysphonia, otalgia Unilateral erythema and neck swelling/lymphadenopathy Trismus, drooling, dyspnea, stridor Ludwig angina: bilateral neck swelling, lingual swelling, woody/brawny cellulitis	↑ WBC, ↑ CRP Ultrasound: abscess, lymphadenitis, jugular thrombophlebitis X-ray of the lateral neck: widening of retropharyngeal tissues CT neck with contrast: decreased definition of anatomic spaces, abscess, lymphadenitis, gas collections	See the acute management checklist for deep neck infection.

Toxic-metabolic and other causes

	Clinical features	Diagnostic findings	Acute management
Salicylate toxicity ^[31]^[32]	Tachypnea, nausea/vomiting, tinnitus Lethargy, dizziness, restlessness, diaphoresis Severe toxicity: coma, seizures, AKI, pulmonary edema	↑ BUN and creatinine, elevated anion gap ^[32] ABG Early/mild toxicity: respiratory alkalosis Moderate/severe toxicity: mixed primary respiratory alkalosis with primary high anion gap metabolic acidosis ↑ Serum salicylate levels (> 40 mg/dL)	See the acute management checklist for salicylate toxicity.
DKA ^[33]^[34]	Polyuria, polydipsia Nausea and vomiting Signs of volume depletion Altered mental status, coma	Hyperglycemia, high anion gap metabolic acidosis, ketonuria/ketonemia	See the acute management checklist for hyperglycemic crises
CO toxicity ^[35]^[36]	Headache, dizziness, confusion, loss of consciousness Nausea, vomiting Shortness of breath, tachypnea Chest pain, tachycardia, hypotension “Cherry red” skin Hypoxia	Clinical diagnosis: history of exposure, typical symptoms, and ↑ COHb CXR: usually normal ABG: ↓ PaO₂, ↑ Serum COHb (nonsmokers > 3–4%, smokers > 10%)	See the acute management checklist for carbon monoxide toxicity.
Anemia ^[37]^[38]	Postural hypotension, dizziness, tachycardia Altered mental status Cool and/or clammy skin Pallor, signs of bleeding (e.g., melena) Tachypnea	Normal or ↓ Hb	See the acute management checklist for anemia.

Anything that can cause metabolic acidosis (e.g., DKA, lactic acidosis, salicylate toxicity) can also cause acute dyspnea.

Differential diagnoses

System	Differential Diagnoses ^[39]^[40]^[41]^[42]
Cardiac	Coronary artery disease Acute coronary syndrome Congestive heart failure (right, left, or biventricular) Arrhythmias Myocarditis Pericarditis Valvular dysfunction Aortic stenosis Mitral valve regurgitation Papillary muscle dysfunction or rupture Cardiac tamponade Hypertrophic cardiomyopathy
Pulmonary	Pneumonia COPD exacerbation Asthma exacerbation Pneumothorax Tension pneumothorax Hemothorax Pleural effusion Pleuritis Pulmonary embolism Restrictive lung disease Aspiration Foreign body aspiration Pulmonary alveolar hemorrhage Pulmonary contusion Acute bronchitis Acute respiratory distress syndrome Lung cancer Pulmonary hypertension Pneumomediastinum
Gastrointestinal	Ascites Large hiatal hernia Abdominal obesity GERD/gastritis Hepatopulmonary syndrome Chronic aspiration
Musculoskeletal	Rib fractures Flail chest Diaphragmatic paralysis Deconditioning Severe kyphosis Muscular dystrophy
Neurologic	Neuromuscular disorders Myasthenia gravis Guillain-Barre syndrome Multiple sclerosis Amyotrophic lateral sclerosis Pain Ischemic stroke Intracranial hemorrhage Spinal cord injury
Endocrine	Metabolic acidosis Salicylate poisoning Carbon monoxide poisoning Diabetic ketoacidosis Thyrotoxicosis Organophosphate poisoning Toxic ingestions
Psychogenic	Panic attack Anxiety
Hematologic	Anemia Acute chest syndrome (sickle cell disease)
Upper airway	Anaphylaxis Angioedema Deep neck infections Epiglottitis Foreign body aspiration Croup Epstein-Barr virus infection
Reproductive	Pregnancy
Renal	Acute renal failure Chronic renal disease

The differential diagnoses listed here are not exhaustive.

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