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Dyspnea (/dspni/ disp-NEE-; also dyspnoea; Latin: dyspnoea; Greek: , dspnoia), shortness of

breath (SOB), or air hunger,[1] is the subjective symptom of breathlessness.[2][3]


The clinical definition of dyspnea is an uncomfortable awareness of one's breathing effort. It is a normal
symptom of heavy exertion but becomes pathological if it occurs in unexpected situations. [2] In 85% of cases it
is due to either asthma, pneumonia, cardiac ischemia, interstitial lung disease, congestive heart failure, chronic
obstructive pulmonary disease, or psychogenic causes.[4] Treatment typically depends on the underlying cause.[5]

2 Differential diagnosis
o 2.1 Acute coronary syndrome
o 2.2 Congestive heart failure
o 2.3 Chronic obstructive pulmonary disease
o 2.4 Asthma
o 2.5 Pneumothorax
o 2.6 Pneumonia
o 2.7 Pulmonary embolism
o 2.8 Anaemia
o 2.9 Other

DD dyspnea
The most common cardiovascular causes are acute myocardial infarction and congestive heart failure while
common pulmonary causes include chronic obstructive pulmonary disease, asthma, pneumothorax, pulmonary
edema and pneumonia.[2] On a pathophysiological basis the causes can be divided into: (1) an increased
awareness of normal breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3)
an abnormality in the ventilatory system.[10]

Congestive heart failure


Congestive heart failure frequently presents with shortness of breath with exertion, orthopnea, and paroxysmal
nocturnal dyspnea.[2] It affects between 1-2% of the general United States population and occurs in 10% of
those over 65 years old.[2][12] Risk factors for acute decompensation include high dietary salt intake, medication
noncompliance, cardiac ischemia, dysrhythmias, renal failure, pulmonary emboli, hypertension, and infections.
[12]
Treatment efforts are directed towards decreasing lung congestion.[2]

Acute coronary syndrome


Acute coronary syndrome frequently presents with retrosternal chest discomfort and difficulty catching the
breath.[2] It however may atypically present with shortness of breath alone. [12] Risk factors include old age,
smoking, hypertension, hyperlipidemia, and diabetes.[12] An electrocardiogram and cardiac enzymes are
important both for diagnosis and directing treatment. [12] Treatment involves measures to decrease the oxygen
requirement of the heart and efforts to increase blood flow.[2]

Chronic obstructive pulmonary disease

People with chronic obstructive pulmonary disease (COPD), most commonly emphysema or chronic bronchitis,
frequently have chronic shortness of breath and a chronic productive cough. [2] An acute exacerbation presents
with increased shortness of breath and sputum production.[2] COPD is a risk factor for pneumothorax; thus this
condition should be ruled out.[2] In an acute exacerbation treatment is with a combination of anticholinergics,
beta2-adrenoceptor agonists, steroids and possibly positive pressure ventilation.[2]

Asthma
Asthma is the most common reason for presenting to the emergency with shortness of breath. [2] It is the most
common lung disease in both developing and developed countries affecting about 5% of the population.[2] Other
symptoms include wheezing, tightness in the chest, and a non productive cough. [2] Inhaled corticosteroids are
the preferred treatment for children, however these drugs can reduce the growth rate. [13] Acute symptoms are
treated with short-acting bronchodilators.

Pneumothorax
Pneumothorax presents typically with pleuritic chest pain of acute onset and shortness of breath not improved
with oxygen.[2] Physical findings may include absent breath sounds on one side of the chest, jugular venous
distension, and tracheal deviation.[2]

Pneumonia
The symptoms of pneumonia are fever, productive cough, shortness of breath, and pleuritic chest pain.[2]
Inspiratory crackles may be heard on exam.[2] A chest x-ray can be useful to differential pneumonia from
congestive heart failure.[2] As the cause is usually a bacterial infections antibiotics are typically used for
treatment.[2]
Important to remember: Severity and prognosis of Pneumonia can be estimated from CURB65, where
C=Confusion, U= Uremia (>7), R=Respiratory rate >30, B= BP<90, 65= Age>65.

Pulmonary embolism
Pulmonary embolism classically presents with an acute onset of shortness of breath. [2] Other presenting
symptoms include pleuritic chest pain, cough, hemoptysis, and fever.[2] Risk factors include deep vein
thrombosis, recent surgery, cancer, and previous thromboembolism.[2] It must always be considered in those
with acute onset of shortness of breath owing to its high risk of mortality.[2] Diagnosis however may be difficult.
[2]
Treatment is typically with anticoagulants.[2]

Anaemia
Anaemia caused by low hemoglobin levels is often a cause of dyspnea. Menstruation, particularly if excessive,
can contribute to anaemia and to consequential dyspnea in women. Headaches are also a symptom of dyspnea
in patients suffering from anaemia, some patients report a numb sensation in their head, and others have
reported blurred vision caused by hypotension behind the eye due to a lack of oxygen and pressure, these
patients have also reported severe head pain many of which lead to permanent brain damage, symptoms of this
can be loss of concentration, focus, fatigue, language faculty impairment and memory loss.[citation needed]

Other
Other important or common causes of shortness of breath include cardiac tamponade, anaphylaxis, interstitial
lung disease, panic attacks,[4][5][14] and pulmonary hypertension. Cardiac tamponade presents with dyspnea,
tachycardia, elevated jugular venous pressure, and pulsus paradoxus.[14] The gold standard for diagnosis is
ultrasound.[14] Anemia, that develops gradually, usually presents with exertional dyspnea, fatigue, weakness,
and tachycardia.[14] It may lead to heart failure.[14] Anaphylaxis typically begins over a few minutes in a person
with a previous history of the same.[5] Other symptoms include urticaria, throat swelling, and gastrointestinal

upset.[5] The primary treatment is epinephrine.[5] Interstitial lung disease presents with gradual onset of shortness
of breath typically with a history of a predisposing environmental exposure. [4] Shortness of breath is often the
only symptom in those with tachydysrhythmias.[12] Panic attacks typically present with hyperventilation,
sweating, and numbness.[5] They are however a diagnosis of exclusion.[4] Around 2/3 of women experience
shortness of breath as a part of a normal pregnancy.[8] Neurological conditions such as spinal cord injury,
phrenic nerve injuries, Guillain-Barre syndrome, amyotrophic lateral sclerosis, multiple sclerosis and muscular
dystrophy can all cause an individual to experience shortness of breath.[10] A relatively unknown condition
involving shortness of breath is empty nose syndrome.

Pathophysiology Dyspnea
Different physiological pathways may lead to shortness of breath including via chemoreceptors,
mechanoreceptors, and lung receptors.[12]
It is thought that three main components contribute to dyspnea: afferent signals, efferent signals, and central
information processing. It is believed the central processing in the brain compares the afferent and efferent
signals; and dyspnea results when a "mismatch" occurs between the two: such as when the need for ventilation
(afferent signaling) is not being met by physical breathing (efferent signaling).[15]
Afferent signals are sensory neuronal signals that ascend to the brain. Afferent neurons significant in dyspnea
arise from a large number of sources including the carotid bodies, medulla, lungs, and chest wall.
Chemoreceptors in the carotid bodies and medulla supply information regarding the blood gas levels of O 2, CO2
and H+. In the lungs, juxtacapillary (J) receptors are sensitive to pulmonary interstitial edema, while stretch
receptors signal bronchoconstriction. Muscle spindles in the chest wall signal the stretch and tension of the
respiratory muscles. Thus, poor ventilation leading to hypercapnia, left heart failure leading to interstitial edema
(impairing gas exchange), asthma causing bronchoconstriction (limiting airflow) and muscle fatigue leading to
ineffective respiratory muscle action could all contribute to a feeling of dyspnea.[15]
Efferent signals are the motor neuronal signals descending to the respiratory muscles. The most important
respiratory muscle is the diaphragm. Other respiratory muscles include the external and internal intercostal
muscles, the abdominal muscles and the accessory breathing muscles.
As the brain receives its plentiful supply of afferent information relating to ventilation, it is able to compare it to
the current level of respiration as determined by the efferent signals. If the level of respiration is inappropriate
for the body's status then dyspnea might occur. There is also a psychological component to dyspnea, as some
people may become aware of their breathing in such circumstances but not experience the distress typical of
dyspnea.[15]

Treatment dyspnea
In those who are not palliative the primary treatment of shortness of breath is directed at its underlying cause. [5]
Extra oxygen is effective in those with hypoxia; however, this has no effect in those with normal blood oxygen
saturations, even in those who are palliative.[3][18]

Physiotherapy
Individuals can benefit from a variety of physical therapy interventions.[19] Persons with
neurological/neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal,
abdominal and/or other muscles needed for ventilation.[20] Some physical therapy interventions for this
population include active assisted cough techniques,[21] volume augmentation such as breath stacking, [22]
education about body position and ventilation patterns[23] and movement strategies to facilitate breathing.[22]

Palliative

Along with the measure above, systemic immediate release opioids are beneficial in reducing the symptom of
shortness of breath due to both cancer and non cancer causes. [3][24] There is a lack of evidence to recommend
midazolam, nebulised opioids, the use of gas mixtures, or cognitive-behavioral therapy.[25]