OfficialreprintfromUpToDate

www.uptodate.com2017UpToDate

Approachtothepatientwithdyspnea

Author: RichardMSchwartzstein,MD
SectionEditor: TalmadgeEKing,Jr,MD
DeputyEditor: HelenHollingsworth,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2017.|Thistopiclastupdated:Feb16,2017.

INTRODUCTIONDyspnea,orbreathingdiscomfort,isacommonsymptomthatafflictsmillionsofpatients
withpulmonarydiseaseandmaybetheprimarymanifestationoflungdisease,myocardialischemiaor
dysfunction,anemia,obesity,ordeconditioning.Examinationofthelanguageofdyspneasuggeststhatthis
symptomrepresentsanumberofqualitativelydistinctsensations,andthatthewordsutilizedbypatientsto
describetheirbreathingdiscomfortmayprovideinsightintotheunderlyingpathophysiologyofthedisease.

Thekeyelementsintheevaluationofthepatientwithdyspneawillbereviewedhere.Thebasicphysiologyof
dyspnea,theevaluationofacutedyspnea,anddyspneainpregnancyarediscussedseparately.(See
"Physiologyofdyspnea"and"Evaluationoftheadultwithdyspneaintheemergencydepartment"and
"Dyspneaduringpregnancy".)

DEFINITIONOFDYSPNEAAconsensusstatementoftheAmericanThoracicSocietydefinesdyspneain
thefollowingway[1]:

"Dyspneaisatermusedtocharacterizeasubjectiveexperienceofbreathingdiscomfortthatiscomprisedof
qualitativelydistinctsensationsthatvaryinintensity.Theexperiencederivesfrominteractionsamongmultiple
physiological,psychological,social,andenvironmentalfactors,andmayinducesecondaryphysiologicaland
behavioralresponses."

Dyspneaisconsideredacutewhenitdevelopsoverhourstodaysandchronicwhenithasbeenformorethan
fourtoeightweeks.Somepatientspresentwithacuteworseningofchronicbreathlessnessthatmaybe
causedbyanewproblemoraworseningoftheunderlyingdisease(eg,asthma,chronicobstructive
pulmonarydisease,heartfailure).

TheAmericanThoracicSociety(ATS)statementonthemechanisms,assessment,andmanagementof
dyspnea,aswellasotherATSguidelines,canbeaccessedthroughtheATSwebsiteat
www.thoracic.org/statements.

PATHOPHYSIOLOGYMostpatientswithbreathingdiscomfortcanbecategorizedintooneoftwogroups:
respiratorysystemdyspneaorcardiovascularsystemdyspnea.Respiratorysystemdyspneaincludes
discomfortrelatedtodisordersofthecentralcontroller,theventilatorypump,andthegasexchanger,while
cardiovascularsystemdyspneaincludescardiacdiseases(eg,acuteischemia,systolicdysfunction,valvular
disorders,pericardialdiseases),anemia,anddeconditioning(figure1).Morethanoneprocessmaybeactive
inagivenpatient,andthebasicphysiologyofdyspneadoesnotalwaysadheretothisstructureforexample,
stimulationofpulmonaryreceptorscanresultfrominterstitialinflammation(respiratorysystem)orinterstitial
edema(cardiovascularsystem).Nevertheless,thisconstructoffersanorganizedapproachtothepatientwith
dyspneaofunclearetiology.(See"Physiologyofdyspnea".)

RespiratoryTherespiratorysystemisdesignedtomoveairbybulktransportfromtheatmospheretothe
alveoli,whereoxygenisexchangedforcarbondioxidebydiffusionacrossthealveolarcapillarymembrane.
Carbondioxideisthenremovedfromthelungsbybulktransporttotheatmosphere.Severalcomponents
mustbefunctioningsmoothlyforthisprocesstooccurderangementsinanyoftheseelementscanleadto
dyspnea.

ControllerThe"respiratorycontroller"determinestherateanddepthofbreathingviaefferentsignals
senttotheventilatorymuscles.Factorsthatstimulatetherespiratorycentersinthebrainstemleadto
increasedventilationandbreathingdiscomfortinavarietyofsettingstheseoftenaresecondaryto
derangementsinotherpartsofthesystem,suchashypoxiaorhypercapniaduetoventilation/perfusion
mismatchinginthegasexchanger,orstimulationofpulmonaryreceptorsasoccurswithinterstitial
inflammationoredema.Inaddition,drugssuchasaspirin(atatoxicdose)orprogesteroneand
conditionssuchaspregnancyordiabeticketoacidosiscanproducedyspneathroughcentraleffects
independentofproblemsintheventilatorypumporgasexchanger.Typically,dyspneaassociatedwith
stimulationoftherespiratorycontrollerisdescribedasasensationof"airhunger"oran"urgeorneedto
breathe"[24].(See"Controlofventilation"and"Physiologyofdyspnea".)

Tosomedegree,thebreathingpatternmayalsoreflectwhatarepresumedtobeattemptsbythe
controllertoreducebreathingdiscomfort.Thus,patientswithsevereairflowobstructiongenerallyadapta
slow,deepbreathingpatterntominimizethepleuralpressuresneededtoovercomeairwaysresistance.
Alternatively,patientswithinterstitialfibrosisorkyphoscoliosisandreducedlungorchestwallcompliance
haveacharacteristicrapid,shallowbreathingpatternwhichminimizestheworkneededtoexpandthe
thorax.

Whentherespiratorycontrollerisstimulated(eg,byexercise),airflowobstructionmayheightenthe
sensationofairhunger.Theincreaseinrespiratoryrateduringexerciseinthesettingofexpiratoryflow
limitationcanleadtoexerciseinducedairtrapping,aprocessknownasdynamichyperinflation.Dynamic
hyperinflationisassociatedwithareducedinspiratoryreserveandincreaseddyspnea.Forthoseinwhom
hyperinflationissubstantial,suchthatinspiratorycapacityatrestorduringexerciseislimitedbytotallung
capacity,dyspneaisfurtherexacerbated.(See"DynamichyperinflationinpatientswithCOPD".)

Forpatientswithrestrictivelungdisease,theadoptionofbreathingpatternswitheitheranincreaseor
decreaseintidalvolumefromtheiraveragerestingtidalvolumeresultsinincreaseddyspnea[5].
Breathingwitharapid,shallowpattern,thepatientexperiencesanincreaseintheratioofdeadspaceto
tidalvolume(sinceanatomicdeadspaceisrelativelyfixed),whichleadstoaneedforgreatertotal
ventilation(hence,theincreaseinrespiratoryrate)thisaddstorespiratoryworkloadandmaycontribute
tothedevelopmentofhypercapnia.Incontrast,anincreaseintidalvolumerequiresasignificantincrease
inrespiratoryworkduetothestiffnessofthelung.Sincemostpatientswithrestrictivelungdiseasetend
tousearapid,shallowbreathingpattern,weconcludethatthispatternultimatelymustproduceless
dyspnea.

VentilatorypumpThe"ventilatorypump"comprisestheventilatorymuscles,theperipheralnerves
whichtransmitsignalstothemfromthecontroller,thebonesofthechestwalltowhichtherespiratory
musclesareconnected,thepleurawhichtransformsmovementofthechestwalltonegativepressure
insidethethorax,andtheairwaysthatserveasaconduitfortheflowofgasfromtheatmospheretothe
alveoliandbackagain.Themostcommonderangementsoftheventilatorypumpresultinasenseof
increased"workofbreathing"[610].

Neuromuscularweakness(eg,myastheniagravis,GuillainBarrsyndrome)leadstoaconditioninwhich
thepatientmustexertnearmaximalinspiratoryefforttoproduceanormalnegativepleuralpressure[11].
Patientswithreducedcomplianceofthechestwall(eg,kyphoscoliosis)orlungs(eg,interstitialfibrosis)
mustperformmoreworkthannormaltomoveairintothelungs.Obstructivelungdiseaseisassociated
withincreasedresistancetoflowand,inpatientswithsignificanthyperinflation,reducedcomplianceas
breathingoccursonthestiffportionofthepressurevolumecurveoftherespiratorysystem.When
hyperinflationresultsinanendinspiratoryvolumethatapproximatestotallungcapacity,patientsoften
complainofaninabilitytogetadeepersatisfyingbreath[9].Asensationofchesttightnessmayalsobe
presentinpatientsinwhomacutebronchoconstrictionisthecauseofairflowobstruction[6,7,12,13].
 GasexchangerThe"gasexchanger"consistsofthealveoliandthepulmonarycapillariesacrosswhich
oxygenandcarbondioxidediffuse.Mostofthecommoncardiopulmonarydisordersleadingtodyspnea
areassociatedwithsomederangementofthegasexchangerdueeithertodestructionofthediffusing
membrane(eg,emphysema,pulmonaryfibrosis)ortheimpositionoffluidorinflammatorymaterial
betweenthecapillariesandthegasinthealveoli.Diseasesaffectingthegasexchangeraretypically
characterizedbyhypoxemia,eitheratrestorwithexercise,andbychronichypercapniainmoresevere
cases.Thesegasexchangeabnormalitiesstimulatetherespiratorycentersinthebrainstemandleadtoa
sensationof"airhunger"oranincreasedurgetobreathe.

CardiovascularThecardiovascularsystemisdesignedtomoveoxygenatedbloodfromthelungsto
metabolicallyactivetissues,andthentransportcarbondioxidefromthetissuesbacktothelungs.Forthis
systemtoworkoptimallyandavertbreathingdiscomfort,onemusthaveapumpthatfunctionswithout
generatinghighpulmonarycapillarypressures.Theremustalsobesufficienthemoglobintocarryoxygenand
appropriateenzymestoutilizeoxygeninthetissues.

HeartfailureHeartfailureisaclinicalsyndromethatcanresultfromanystructuralorfunctionalcardiac
disorderthatimpairstheabilityoftheventricle(s)tofillwithorejectblood.Symptomsofheartfailurefall
intotwomajorclasses:thoseduetoareductionincardiacoutput(fatigue,weakness)andthosedueto
increasedpulmonaryorsystemicvenouspressureandfluidaccumulation(dyspnea,edema,hepatic
congestion,andascites).Whenheartfailurecausesanincreaseinpulmonaryvenouspressure,itcan
leadtodyspneaeitherbyproducinghypoxemiaorbystimulatingpulmonaryvascularand/orinterstitial
receptors(eg,unmyelinatedJreceptors,alsocalledCfibers).Causesofheartfailureincludeventricular
systolicdysfunction,ventriculardiastolicdysfunction,andvalvulardisease.Cardiactamponademayalso
leadtodyspneabyincreasingpulmonaryvascularpressures.(See"Physiologyofdyspnea"and
"Evaluationofthepatientwithsuspectedheartfailure"and"Cardiactamponade".)

AnemiaAnemiacanseverelyimpairoxygendeliverybecausethebulkofoxygencarriedinthebloodis
hemoglobinbound(see"Structureandfunctionofnormalhemoglobins").Nevertheless,theexact
mechanismbywhichanemiaproducesdyspneaisnotknown.TotheextentthatthelocalpHof
metabolicallyactivecellsdecreasesduetotheinabilitytosustainaerobicmetabolism,theremaybe
stimulationof"ergoreceptors,"whicharebelievedtobelocatedinthemusclesandwhichrespondtosuch
changesinthemicroenvironmentofthecell[14,15].Anemiaalsoleadstoincreasedcardiacoutput,
whichmaynecessitateelevatedleftventricularvolumeandpulmonaryvascularpressures.However,the
qualityofdyspneaisusuallyquitedifferentinthesetwoclinicalsituations.

DeconditioningIndividualsusuallycomplainofrespiratorydiscomfortwhentheyengageinvigorous
physicalactivity,eveninthepresenceofanormalcardiovascularandrespiratorysystemandnormal
hematocrit.Morefitindividualsexperiencelessdiscomfortforanygivenworkloadcardiovascularfitness
isdeterminedbytheabilityofthehearttoincreasemaximalcardiacoutputandbytheabilityofthe
peripheralmusclestoutilizeoxygenefficientlyforaerobicmetabolism.

Incontrast,asedentaryexistencereducesfitnessandleadstodyspnea,oftenwithseeminglytrivial
tasks.Itiscommonforpatientswithchroniccardiopulmonarydiseasetoassumeasedentarylifestylein
anefforttoavoidbreathingdiscomfort.However,theendresultoveraspanofmonthstoyearsisthatthe
individualbecomesprogressivelydeconditionedandultimatelymaybelimitedmorebypoor
cardiovascularfitnessthanbytheunderlyingdisease[16].Dyspneaduetodeconditioningistypically
describedas"heavybreathing"orasenseof"breathingmore"[8],andwithcarefulquestioning,onecan
determinethatthepatientisactuallylimitedbyfatigueratherthanbreathingdiscomfort.

CLINICALASSESSMENTWhileclinicalhistoryisofteninsufficienttomakeasecurediagnosis,itprovides
guidanceinnarrowingthediagnosticpossibilitiesandselectingdiagnostictests.Inonestudyof85patients
presentingtoapulmonaryunitwithacomplaintofchronicdyspnea,theinitialimpressionoftheetiologyof
dyspneabaseduponthepatienthistoryalonewascorrectinonly66percentofcases[17].Thus,asystematic
diagnosticapproachtothesepatientsisnecessary.
TemporalpatternandtriggersThetemporalpatternofbreathlessnessandassociationwithcertain
triggerscanprovideimportantclues.Breathingdiscomfortarisingoverthecourseofminutestohoursisdue
toarelativelylimitednumberofconditions(table1).Theseentitiestypicallyhaveassociatedsymptomsand
signsthatprovidecluestotheappropriatediagnosis,eg,substernalchestpainwithcardiacischemiafever,
cough,andsputumwithrespiratoryinfectionsurticariawithanaphylaxisandwheezingwithacute
bronchospasm.However,dyspneamaybethesolecomplaint.Inthesecases,attentiontohistorical
informationandareviewofthislimiteddifferentialdiagnosisareimportant.Theapproachtoacutedyspneais
describedseparately.(See"Evaluationoftheadultwithdyspneaintheemergencydepartment".)

ExertionalandnocturnaldyspneaChronicexertionaldyspneaandparoxysmalnocturnaldyspnea
(PND)arebothassociatedwithheartfailure,althoughnocturnaldyspneaismorespecifictoheartfailure.
Asthmaisalsoassociatedwithexertionalandnocturnaldyspnea,butunlikePNDdoesnotusually
improvewithsittingorstanding.

Dyspneathatisnotexacerbatedbyexertionismoreoftenduetoafunctionalorperceptualproblem,than
cardiopulmonarydisease.

IntermittentdyspneaIntermittentdyspneaassociatedwithcoldairoranimaldanderexposure
suggestsasthmaworkrelateddyspneamaysuggestoccupationalasthmaanddyspneafollowingupper
respiratoryinfectionsmaybeduetoasthmaorchronicobstructivepulmonarydisease(COPD).

Inadditiontoasthma,intermittentsymptomsthatresolvecompletelybetweenepisodescanbeseenwith
recurrentaspirationrecurrentpulmonaryemboliandheartfailurecanalsowaxandwane,butgenerally
leaveabaselinelevelofdysfunction.Thepresenceofspecific,reproducibleincitingeventssuchas
exerciseorcoldairexposureiscommonwithairwayshyperreactivity.

RapidityofsymptomonsetandprogressionTherapiditywithwhichsymptomsdevelopduring
exercisecanalsoprovideusefuldiagnosticinformation.Forexample,patientswhodevelopshortnessof
breathandwheezingafterwalking50to100feetoftenhaveacuteelevationsinpulmonarycapillary
wedgepressure(usuallyduetocardiacdiastolicdysfunction)orpulmonaryhypertension.Incontrast,
symptomsofexerciseinducedasthmausuallyareprecipitatedbymoreintenseactivity,beginningthree
minutesintoexercise,peakingwithin10to15minutes,andresolvingby60minutes.(See"Exercise
inducedbronchoconstriction".)

Respiratorymuscleweaknessgenerallyleadstograduallyprogressivedyspnea,sometimeswithanacute
worseningatatimeofillness,particularlyarespiratoryinfection.

SeverityofdyspneaForpatientswithchronicdyspnea,formalassessmentoftheseverityofdyspneacan
helpcreateabaselineforfuturecomparisons[18].Anumberofinstrumentsareavailabletohelpassessthe
severityofdyspnea,suchastheBaselineDyspneaIndexandtheModifiedMedicalResearchCouncil
(mMRC)dyspneascale(table2),andtheBorgscale(table3)[1923].

AssociatedsymptomsAssociatedsymptomssuchascough,sputumproduction,nasalcongestion,chest
pain,peripheraledema,Raynaudphenomenon,jointswelling,andmuscleweaknesscanhelpidentifyareas
forfurtherinvestigation.Asymmetriclowerextremityedemamightsuggestvenousthromboembolicdisease
Raynaudphenomenonisseeninanumberofrheumaticdiseasesthatareassociatedwithinterstitiallung
diseaseandsymmetricswellingofthemetacarpophalangealjointsmaybeacluetorheumatoidlungdisease.

DescriptorsofbreathingdiscomfortAttentiontothequalityordescriptorthatapatientassociateswith
thebreathingdiscomfortoftenprovidescluestotheunderlyingdiagnosis[24].Thisobservationcomesfrom
studiesinwhichdyspneaquestionnaires(table4)werepresentedtopatientswithbreathingdiscomfortfroma
varietyofcardiopulmonarydisorders[68,25].Subjectswereaskedtoselectthephrasesthatbestdescribed
theirbreathingdiscomfort,anddistinctclustersemerged.Whilesomeclustersofphraseswerecommontoa
numberofdiseasecategories(eg,increasedworkoreffortofbreathingwasfoundwithCOPD,asthma,and
neuromusculardisease),eachdiseasehadarelativelyuniquesetofclustersassociatedwithit.
Thecombineddatafromstudiesthatwereperformedinpatientswithknowncardiopulmonarydisordersorin
normalsubjectsmadebreathlessunderexperimentalconditionsindicatethefollowing(table5)[2,68,24,25]:

Thesensationof"airhunger"hasbeenassociatedwithacutehypercapniainasthmaandCOPD,heart
failure,pulmonaryembolism,andrestrictedthoracicmotion[3,4,26].

Acutebronchoconstrictionleadstoaseriesofsensationsasthedegreeofobstructionworsens,from
"chesttightness"toanincreased"efforttobreathe"toasensationof"airhunger"[69,12,13].The
sensationof"tightness"appearstobeindependentoftheworkofbreathing[27].Attentiontotheuseof
verbaldescriptorsofdyspneamayhelptheclinicianavoidunderestimationoftheseverityofairflow
limitationwhenobjectivemeasurementsoflungfunctionarenotpossible.

Reportof"increasedworkofbreathing"isassociatedwithCOPD,moderatetosevereasthma,myopathy,
andpulmonaryfibrosis.

PatientswithCOPDsometimescomplainofasensationof"unsatisfyingbreaths"orasensethatthey
"cannotgetadeepbreath"[9].

Asensationofrapid,shallowbreathingmaycorrespondtointerstitiallungdiseaseorreducedchestwall
compliance.

Heartfailureisalsoassociatedwithasensationof"suffocation"[6].

Asenseofheavybreathingistypicalofdeconditioning.

However,itisimportanttorememberthatanindividualslanguage,sex,ethnicity,andculturecaninfluence
thewordingusedtodescribedyspnea[2833].Furtherresearchinthisareaisunderway.(See'Perceptual
andpsychologicalfactors'below.)

CigarettesmokingandexposurestodustsandfumesTheabsenceofcigarettesmokingargues
stronglyagainstadiagnosisofCOPD,unlessthepatienthasahistoryoftuberculosisoruseofbiomass
cookingfuels.Inonestudy,ahistoryofsmokingcigaretteshadapositivepredictivevalueforCOPDof0.4
COPDisuncommonamongpatientswhohaveneversmokedorhavesmokedlessthan10packyears[34].
Theoccupationalhistorymayleadtodiagnosisofdiseasessuchasasbestosis,chronicberylliumdisease,
silicosis,oranotherpneumoconiosis.(See"Asbestosrelatedpleuropulmonarydisease"and"Chronic
berylliumdisease(berylliosis)"and"Silicosis".)

PhysicalexaminationAcompletephysicalexaminationisessential.Inparticular,attentionshouldbe
directedatthepresenceorabsenceofstridor,wheezing,crackles,tachycardia,arrhythmia,heartmurmurs,
gallop,peripheraledema,muscleweakness,dysphonia,andevidenceofrheumaticdisease.However,the
absenceofphysicalfindingstendstohaveagreaternegativepredictivevalue,thanthepositivepredictive
valueofanyidentifiedsigns[17].

Clubbingisassociatedwithanumberofcausesofdyspnea,includingbronchiectasis,idiopathic
pulmonaryfibrosis,lungcancer,andcyanoticheartdisease,butnotasthmaorCOPD.

Jugularvenousdistentionmaysuggestleftsidedheartfailureorcorpulmonale.

Decreasedordistantheartsoundsmaysuggestapericardialeffusion,butmayalsobeduetoobesityor
hyperinflationfromemphysema.

EVALUATIONOFACUTEDYSPNEABreathingdiscomfortarisingoverthecourseofminutestohoursis
generallyduetoalimitednumberofconditions(table1)andgenerallyinvolvesprocessesthatrequireprompt
evaluationandtreatment.Cluestotheneedforanurgentevaluationincludeheartrate>120beats/minute,
respiratoryrate>30breaths/minute,pulseoxygensaturation(SpO2)<90percent,useofaccessory
respiratorymuscles,difficultyspeakinginfullsentences,stridor,asymmetricbreathsoundsorpercussion,
diffusecrackles,diaphoresis,andcyanosis.Theevaluationofdyspneaintheemergencydepartmentis
describedseparately.(See"Evaluationoftheadultwithdyspneaintheemergencydepartment".)

INITIALTESTINGINCHRONICDYSPNEAWhenevaluatingchronicdyspnea,wefollowastepwise
diagnosticapproachofinitialtesting,followuptesting,andadvancedtesting,startingwiththeteststhatare
theleastinvasiveandmostlikelytoyieldadiagnosis.

MostcommoncausesThemajorityofpatientswithchronicdyspneaofunclearetiologyhaveoneoffive
diagnoses,althoughthespectrumofpotentialcausesisbroadandmorethanoneetiologymaybepresent
(table6)[17,34,35].Itisalsoimportanttorememberthatthepresenceofaknownchroniccardiopulmonary
diseasedoesnotguaranteethatthepatient'ssymptomsortheetiologyoftheirexerciselimitationaredueto
thatcondition,particularlyinpatientswithcoexistingconditions[16].

Thefivemostcommoncausesofchronicdyspneaarethefollowing:

Asthma(see'Cardiovascular'above)
Chronicobstructivepulmonarydisease(COPD)(see'Respiratory'above)
Interstitiallungdisease(see'Respiratory'above)
Myocardialdysfunction(see'Cardiovascular'above)
Obesity/deconditioning(see'Cardiovascular'above)

PaceoftestingForpatientswithchronicdyspnea,theseverityofdyspneaandrateofworseningare
importantdeterminantsofthepaceandlocationofdiagnostictesting[18].Theoptimalsequenceofdiagnostic
testingforchronicdyspneahasnotbeendetermined.Wetypicallyfollowanalgorithmthatutilizesthreetiers
oftesting:initialtesting(table7),followuptestingbasedonresultsofinitialtests(table8Aandtable8Band
table8C),andadvancedtestingifthediagnosisremainsuncertain(table9).Withineachtier,weselecttests
basedonthepatientsclinicalfeatures,resultsofpriortests,andlikelihoodofadiagnosticresult.Onestudy
foundthatthemostinformativetestsforadults(age45to84)withdyspneaandnoknowncardiopulmonary
diseaseweretheforcedexpiratoryvolumeinonesecond(FEV1)obtainedbyspirometry,theNterminalpro
brainnatriureticpeptide(NTproBNP),andpercentemphysemaonchestcomputedtomography[36].

SpecifictestsAfterreviewingtheclinicalfindingsforpatternsthatappearsuggestiveofoneortwoofthe
abovefivemostcommonprocesses,thenarroweddifferentialdiagnosisisusedtoselectteststhatfocuson
thesepossibilities.Asanexample,ifthepatientisage20to40andhasaclinicalpictureofallergicrhinitisand
intermittentdyspnea,theinitialtestingmightbelimitedtospirometrypreandpostbronchodilator.Similarly,a
70yearoldpatientwithknowncoronaryarterydisease,peripheraledema,andnosmokinghistorymightbe
evaluatedforheartfailurewithanelectrocardiogram,aserumNTproBNP,andechocardiogrambefore
consideringspirometry.

Iftheclinicalevaluationdoesntallownarrowingofthedifferentialweusuallyobtainthefollowing"initialtests"
(table7):

Completebloodcount(toexcludeanemia):Thedegreeofdyspneaassociatedwithanemiamaydepend
ontherapidityofbloodlossandthedegreeofexertionthatthepatientundertakes.(See'Cardiovascular'
above.)
Glucose,bloodureanitrogen,creatinine,electrolytes.
Thyroidstimulatinghormone(TSH).
SpirometrypreandpostinhaledbronchodilatorORfullpulmonaryfunctiontests(PFTs)iftheclinical
evaluationdoesnotsuggestasthmaorCOPD.
Pulseoximetryduringambulationatanormalpaceoverapproximately200metersand/oruptwotothree
flightsofstairs.
Chestradiograph.
Electrocardiogram.
PlasmaBNPorNTproBNP
Spirometrycanidentifythepresenceandseverityofairflowobstruction.Whenintrathoracicairflowlimitationis
notedorwhenadiagnosisofasthmaissuspected,postbronchodilatorspirometrydetermineswhetherthereis
reversibilityofairflowlimitation.Typicallyinasthma,airflowlimitationisreversible,althoughalargecomponent
ofairwaysedemaandinflammationmayneedacourseofinhaledororalglucocorticoidtherapytoachieve
completereversibility.Patientswithaclinicalsuspicionofasthmaandreversibleairflowlimitationon
spirometrywouldbemanagedwithatrialofspecifictherapyforasthma.Patientswithasmokinghistory
longerthan20yearsandirreversibleairflowlimitationonspirometryareusuallymanagedwithapresumptive
diagnosisofchronicobstructivepulmonarydisease(COPD).However,othercausesofirreversibleairflow
limitation(eg,bronchiectasis,bronchiolitis,centralairwayobstruction)shouldbeconsideredifthepatientdoes
notrespondtoempirictherapyforasthmaorCOPD.(See"Diagnosisofasthmainadolescentsandadults",
sectionon'Diagnosis'and"Chronicobstructivepulmonarydisease:Definition,clinicalmanifestations,
diagnosis,andstaging",sectionon'Diagnosis'and"Bronchiolitisinadults",sectionon'Diagnosis'.)

Thechestradiographmayidentifyapleuraleffusion,kyphoscoliosis,cardiomegaly,orpulmonaryvascular
redistribution,aspotentialcausesofdyspnea.Apleuraleffusionwillneedadirectedevaluationastothe
cause(eg,benignasbestoseffusion,malignancy,trappedlung,rheumatoideffusion,infection,heartfailure),
usuallyincludingthoracentesis.Kyphoscoliosisidentifiedonchestradiograph(andphysicalexamination)is
typicallyevaluatedwithfullpulmonaryfunctionteststodeterminethelikelihoodofhypercapnia.Heartfailure
suggestedbytheNTproBNPandchestradiographwillneedfurtherevaluationwithanechocardiogramto
determinethecause.Theevaluationoftheseprocessesisdiscussedseparately.(See"Diagnosticevaluation
ofapleuraleffusioninadults:Initialtesting"and"Diseasesofthechestwall",sectionon'Kyphoscoliosis'and
"Determiningtheetiologyandseverityofheartfailureorcardiomyopathy".)

FOLLOWUPTESTINGINCHRONICDYSPNEAThesecondphaseoftheevaluationofdyspneaisaimed
atclarifyingabnormalitiesthatwerenotedoninitialtesting,butwerenotdiagnostic(table8Aandtable8Cand
table8B).Inaddition,somepatientswillhavehadnormalresultsoninitialtesting,buthavepersistent
symptomsthatrequirefurtherevaluation.

PulmonaryfunctiontestsPatientswithfindingssuggestiveofinterstitiallungdisease(eg,crackles,
reducedforcedvitalcapacitywithoutairflowlimitation,desaturationwithexertionalpulseoximetry)andthose
withoutacleardiagnosiswillneedpulmonaryfunctiontesting(PFT)beyondspirometry,guidedbytheresults
oftheabovetests(table8A).Alternatively,thesetestsmaybeobtainedatthetimeofinitialspirometry.(See
'Initialtestinginchronicdyspnea'aboveand"Overviewofpulmonaryfunctiontestinginadults"and"Diffusing
capacityforcarbonmonoxide".)

Asdescribedabove,spirometrybeforeandafterinhaledbronchodilatorcansecureadiagnosisinthecaseof
asthmaandchronicobstructivepulmonarydisease(COPD).OtherPFTfindingsmayprovidecluesregarding
whichfollowuptestsarelikelytobehelpful(table8A).

Reducedforcedvitalcapacity(FVC)IfadecreaseintheFVCisnotedonspirometry,butwithout
airflowlimitation,thenextstepistodeterminethecauseofthedecreaseinFVC.Thepossibilityofan
underlying"restrictive"abnormalityisassessedwithmeasurementoflungvolumes,lookingforasimilar
decreaseintotallungcapacityandfunctionalresidualcapacity.Arestrictivepatternmaybecausedby
interstitiallungdisease,pleuraldisease(eg,trappedlung),chestwalldisease(eg,kyphoscoliosis),or
ventilatorymuscleweakness(eg,diffuseorduetodiaphragmaticparalysis).Respiratorymuscle
weaknesscanbeevaluatedfurtherwithmaximalinspiratoryandexpiratorypressuresatthemouth,
maximalvoluntaryventilationinoneminute,andsupinespirometrythatiscomparedwithsitting
spirometryresults.(See"Respiratorymuscleweaknessduetoneuromusculardisease:Clinical
manifestationsandevaluation",sectionon'Evaluation'and"Testsofrespiratorymusclestrength".)

Alternatively,iftotallungcapacityandresidualvolumearenormalorincreased,thedecreaseinvital
capacitymaybeanindicatorofreducedelasticrecoilorairtrappingandthepatientmayhave
emphysemaorbronchiolitiswithoutairflowlimitationthatismeasurableonspirometry.(See"Office
spirometry"and"Pulmonaryfunctiontestinginasthma".)
 SuspicionforasthmawithnormalbaselinespirometryBronchoprovocationtesting(eg,with
methacholine,histamine,ormannitol)istypicallyobtainedinpatientswithrecurrent,episodicdyspnea
suggestiveofasthmawhohavenormalornearnormalspirometry.Atrialoftherapyforasthmaisan
alternative,butbronchoprovocationispreferredtoenableaprecisedeterminationofasthma.Empiric
therapycanleadtogradualaccelerationoftreatment,includinguseofsystemicglucocorticoids,with
attendantsideeffectsifthepatientdoesnothaveasthma.(See"Bronchoprovocationtesting"and
"Diagnosisofasthmainadolescentsandadults",sectionon'Initialspirometryisnormal'.)

Ifaflowvolumeloopwasnotobtainedduringtheinitialspirometry,weusethattesttoevaluatetheupper
airwayforobstruction,particularlyvariableupperairwayobstructionthatmaynotbeapparenton
expiratoryspirometry.However,pulmonaryfunctiontestingisrelativelyinsensitiveforupperairway
obstruction,sodirectvisualizationoftheupperairwayfollowingbronchoprovocationorexercisechallenge
maybenecessary.(See"Evaluationofwheezingillnessesotherthanasthmainadults",sectionon
'Evaluationofstablepatientswithwheeze'.)

EvaluationofgastransferAdiffusingcapacityforcarbonmonoxide(DLCO)ishelpfulinthe
evaluationofdyspnea,particularlyintheidentificationofinterstitiallungdisease(suggestedbyrestricted
lungvolumes),emphysemaorbronchiolitis(suggestedbyanobstructivepattern),andpulmonary
vasculardisease.Pulmonaryvasculardisease(eg,pulmonaryhypertension,chronicthromboembolic
disease,pulmonaryvenoocclusivedisease)issuggestedbythecombinationofnormalspirometryand
lungvolumes,butabnormalgastransfermanifestbyadecreaseinDLCOandpulseoxygensaturation
onexertion(eg,5percent).(See"Diffusingcapacityforcarbonmonoxide".)

LowoxygensaturationAlowrestingoxygensaturation(eg,95percent)orasignificantdeclinein
oxygensaturationduringexercise(5percent)warrantsfurtherevaluation.Thedifferentialdiagnosis
includesCOPD,interstitiallungdisease,pulmonaryvasculardisease,bronchiolitisobliterans,
intrapulmonaryorintracardiacshunt,andheartfailure.Thus,suchpatientstypicallyneedhighresolution
computedtomography(HRCT)andatransthoracicechocardiogram,possiblywithabubblestudy.

ReducedlungvolumesandobesityObesityisassociatedwithreductionsinexpiratoryreserve
volumeandfunctionresidualcapacityand,insomepatients,adecreaseintotallungcapacity(restrictive
ventilatorydefect)[37].However,thechangesinlungvolumesdonotnecessarilycorrelatewithdyspnea
anditcanbedifficulttoknowwhetherthispatternofreducedlungvolumesisduetoobesityoranother
respiratorydisease.Inapopulationstudy(NHANESIII),subjectsinthehighestquintileofbodymass
index(BMI),hadthelowestriskforsignificantairflowobstruction,soobesitybyitselfislesscommonlya
causeofairflowobstruction[38].(See"Diseasesofthechestwall",sectionon'Obesity'.)

ChestcomputedtomographyChestcomputedtomography(CT)ishelpfulintheevaluationofdyspnea
inthefollowingsettings(table8B):

AbnormalitiesonthechestradiographthatneedfurthercharacterizationSuspectedinterstitial
lungdiseaseisevaluatedbyHRCT,andcentralmassesandsuspectedlargeairwayobstruction(eg,
tumor)arebestevaluatedbyCTwithcontrastanddirectvisualization.Ontheotherhand,vascular
redistributionandabnormalheartsizearebestevaluatedbymeasurementofaserumNterminalpro
brainnatriureticpeptide(NTproBNP)ortransthoracicechocardiography.

WhenHRCTishelpfuldespiteanormalchestradiographAsmallpercentageofpatientswith
interstitiallungdiseasemayhaveanormalchestradiographonpresentationHRCTscanclearlyismore
sensitivefordetectingsubtlegroundglassorreticularopacities[39,40].Thus,patientswithcrackleson
physicalexamination,reducedlungvolumesonpulmonaryfunctiontesting,oradecreasedDLCOshould
haveHRCTscansevenifthechestradiographisnormal.(See"Highresolutioncomputedtomographyof
thelungs".)

Aminorityofpatientswithahistoryofcigarettesmoking,normalspirometry,andnormalchest
radiographshaveextensiveemphysemaonhighresolutionCTscan[41].Thesepatientsgenerally
 demonstrateoxygendesaturationwithexerciseandhavealowdiffusingcapacity.

EvaluationforsuspectedthromboembolicdiseaseForpatientswithsuspectedthromboembolic
diseasebasedonriskfactors,lowerextremityedema,oralowDLCOwithnormallungvolumes,a
computedtomographicpulmonaryangiogram(CTPA)isusuallythenextstepunlessthepatienthasa
contraindicationtointravenouscontrast.Alternativeteststhatarehelpfulintheevaluationofpossible
thromboembolicdiseaseincludeaventilationperfusionlungscan,lowerextremityproximalvein
compressiveultrasound,andmagneticresonancepulmonaryangiography.(See"Clinicalpresentation,
evaluation,anddiagnosisofthenonpregnantadultwithsuspectedacutepulmonaryembolism"and
"Clinicalmanifestationsanddiagnosisofchronicthromboembolicpulmonaryhypertension".)

EchocardiographyEchocardiographyisgenerallyperformedwhenheartfailure(HF)orpulmonary
hypertensionaresuspectedonthebasisofclinicalfindings,brainnatriureticpeptide(BNP)orNTproBNP
levels,cardiomegalyonchestradiograph,oxygendesaturationwithexertion,orwhenthecauseofdyspnea
remainsunclearaftertheinitialevaluationdescribedabove(table8C).Transthoracicechocardiogramwith
colorflowDoppleristypicallyordered(toevaluateleftventricularsystolicanddiastolicfunction,occultvalvular
abnormalities,andalsopulmonaryarteryandrightsidedpressures).

SuspectedleftventriculardysfunctionEchocardiographymayconfirmHFduetoreducedleft
ventricular(LV)systolicfunction(HFREF).(See"Determiningtheetiologyandseverityofheartfailureor
cardiomyopathy".)

SuspecteddiastolicdysfunctionIfLVejectionfractionandenddiastolicvolumearenormal,
echocardiographycanidentifyfeaturesofdiastolicdysfunction(heartfailurewithpreservedejection
fraction[HFPEF]),suchasLVhypertrophy(LVH),concentricremodeling,andleftatrialenlargement.
AdditionalDopplerfeaturesofdiastolicdysfunctionincludeelevatedpulmonaryarterysystolicpressure,
andimpairedventricularrelaxation(eg,early/late[E/A]filling<1).HFPEFduetodiastolicdysfunction
canbeacauseofexertionaldyspneafurthersupportforthediagnosiscomesfromanelevatedBNPand
atrialoftherapy.(See"Echocardiographicevaluationofleftventriculardiastolicfunction"and"Clinical
manifestationsanddiagnosisofheartfailurewithpreservedejectionfraction",sectionon
'Echocardiography'and"Treatmentandprognosisofheartfailurewithpreservedejectionfraction",
sectionon'Treatment'.)

Amongolderadultswithunexplainedchronicdyspneaafteraninitialevaluation(eg,history,physical
examination,pulmonaryfunctiontests,andachestradiograph),nearlytwothirdshaveevidenceof
diastolicdysfunction[42],whichcanmanifestasdyspneawithrelativelyminimalexertion.

SuspectedpericardialdiseaseConstrictivepericarditiscanbedifficulttodiagnoseinpatientswho
presentwithchronicdyspnea,althoughpatientsgenerallyhaveperipheraledema.Findingson
echocardiographythatmaysuggestconstrictivepericarditisincludeincreasedpericardialthickness,
dilationoftheinferiorvenacavawithabsentordiminishedinspiratorycollapse,abnormalfillingofthe
ventriclesindiastole,andpronouncedrespiratoryvariationinventricularfilling.Whenoccultconstrictive
pericarditisissuspected,rightheartcatheterizationisperformedwithmeasurementofhemodynamics
beforeandafterinfusionofaliterofwarmsaline.(See"Constrictivepericarditis",sectionon'Two
dimensionalandMmode'and"Constrictivepericarditis",sectionon'Occultconstrictivepericarditis'.)

SuspectedpulmonaryhypertensionElevatedpulmonaryartery(PA)pressuresbyDoppler
echocardiographymayindicatepulmonaryhypertension,butneedconfirmationbypulmonaryartery
catheterizationtoconfirmtheelevatedPApressuresandexcludeleftventriculardysfunction.(See
'Advancedtestinginchronicdyspnea'below.)

ADVANCEDTESTINGINCHRONICDYSPNEAReferraltoaspecialistisusuallyneededforpatientswho
donotrespondtotreatmentforthediagnosisdeemedmostlikelybytheinitialevaluationandwhendiagnostic
proceduressuchasabronchoscopy,lungbiopsy,cardiopulmonaryexercisetest,orpulmonaryartery
catheterizationmaybeneeded.Theuseoftheseteststoevaluatedyspneaisdescribedinthetable(table9).
SuspectedinterstitiallungdiseaseTheevaluationofinterstitiallungdiseasethatissuspectedonthe
basisofpulmonaryfunctiontestingandhighresolutioncomputedtomography(HRCT)mayincludeadditional
laboratorytesting,bronchoscopywithbronchoalveolarlavage,andlungormediastinallymphnodebiopsy,as
describedseparately.(See"Approachtotheadultwithinterstitiallungdisease:Clinicalevaluation"and
"Approachtotheadultwithinterstitiallungdisease:Diagnostictesting"and"Interpretationoflungbiopsy
resultsininterstitiallungdisease".)

PulmonaryhypertensionsuggestedbyechocardiographyWhenelevatedpulmonaryartery
pressuresaresuggestedbyDopplerechocardiographyandaresupportedbyanelevatedbrainnatriuretic
peptide(BNP)andoxygendesaturationonexertion,thenextstepispulmonaryarterycatheterizationto
confirmelevatedpulmonaryarterysystolicpressure(pulmonaryarterialsystolicpressure[PASP]>25mmHg
atrest)andexcludediastolicdysfunction(unlikelywithpulmonaryarterywedgepressure[PAWP]<15
mmHg).(See"Clinicalfeaturesanddiagnosisofpulmonaryhypertensioninadults",sectionon'Diagnostic
criteria'and"Echocardiographicevaluationofthepulmonicvalveandpulmonaryartery",sectionon
'Pulmonaryhemodynamics'.)

Ifthediagnosisofpulmonaryhypertensionisconfirmed,thepatientwillneedfurtherevaluationfortreatable
causesofpulmonaryhypertension.Inpatientsinwhomchronicthromboembolicdiseaseisaconsideration,a
ventilationperfusionlungscanisobtained.(See"Clinicalmanifestationsanddiagnosisofchronic
thromboembolicpulmonaryhypertension",sectionon'Diagnosticevaluation'.)

Exerciseechocardiographyhasbeenproposedasamethodtoscreenpatientsforearlypulmonary
hypertension.However,exerciseinducedincreasesinDopplerestimatesofPASParemultifactorialandnot
specificforpulmonaryhypertension.(See"Overviewofstressechocardiography".)

UnclearcauseofdyspneaonexertionForpatientswhohavedyspneathatispersistentand
unexplainedbytheresultsoftheabovestudies,additionaltestingmaybewarranted.Atthispointitmaybe
reasonableforthepatienttoengageinaconditioningprogramfortwotothreemonthstoseewhether
dyspneaimprovesbeforeproceedingwithmoreinvasivetesting.Otherpatients,whodonotfeelthat
deconditioningiscontributory,maywishtoproceeddirectlytoadditionaltesting.

CardiopulmonaryexercisetestingAcardiopulmonaryexercisetest(CPET)canbehelpfulwhenthe
etiologyofapatient'sdyspnearemainsunclearaftertheevaluationdescribedaboveorwhendyspneaseems
outofproportiontotheseverityofthepatient'sknowncardiacorpulmonarydisease[1,43,44].ACPETcan
assesstheworkloadthatthepatientcanachieve,thedegreeofdyspneaexperienced(eg,Borgorother
visualscale),thepeakoxygenuptake,cardiacoutput(calculatedfromcarbondioxideproductionandoxygen
uptake),andrelationshipofminuteventilationtocarbondioxideproduction.(See"Functionalexercisetesting:
Ventilatorygasanalysis"and"Exercisephysiology".)

Inparticular,CPETmayhelpidentifypatientswithmitochondrialdisorders(eg,McArdlesmyophosphorylase
deficiency,isolatedmitochondrialmyopathy)bydemonstratingareductioninmaximumoxygenuptake(VO2
max),reducedperipheraloxygenextraction(increasedmixedvenousoxygen),andanincreaseinblood
lactateafterexercise.(See"Mitochondrialmyopathies:Clinicalfeaturesanddiagnosis",sectionon'Exercise
testing'.)

ACPETmaybehelpfulinprovidingsupportforthepresenceofdeconditioningorindetectingalowthreshold
forrespiratorydiscomfort.Patientswithalowthresholdforrespiratorydiscomforttypicallyterminatethetestat
mildworkloadsbecauseofdyspnea,buthavenoevidenceofcardiopulmonaryabnormality.Inpatientswith
bothpulmonaryandcardiacdisease,eitherofwhichcouldcausethepatienttohavedyspnealimitingtheir
exercisecapacity,CPETmayassistinthedeterminationoftheactualcauseofthelimitation.(See'Chronic
dyspneawithanormalevaluation'below.)

CardiopulmonaryexercisetestingwithpulmonaryarterycatheterizationCardiopulmonary
exercisetestingwithpulmonaryarterycatheterization,alsoknownasaninvasiveCPEToriCPET,is
performedatspecializedcenters[45].TheroleofiCPETintheevaluationofdyspneahasnotbeenclearly
defined.Typically,itisusedintheevaluationofexerciseinducedpulmonaryarterialhypertension,exercise
inducedheartfailurewithpreservedleftventricularejectionfraction(HFpEF),andpreloaddependent
limitationstocardiacoutput.

CHRONICDYSPNEAWITHANORMALEVALUATIONOccasionalpatientswithchronicdyspneawillgo
throughacompleteevaluationwithoutidentificationofacause.Othersmayhavenearnormaltesting,such
thataslightdecreaseinpeakoxygenuptake,anaerobicthreshold,andpeakheartratearethoughttobe
mostconsistentwithdeconditioningorobesity.Whileobesepatientsfrequentlyreportdyspnea[46],inagiven
individualitcanbedifficulttoknowhowmuchdyspneaisattributabletoobesity.Forpatientswhoreport
dyspneabuthavenormalornearnormaltesting,weexplainthereassuringnatureoftestingindetail,advisea
conditioningprogram,andaskthepatienttoreturnin6to12monthsforreevaluation.Thereevaluationis
importantduetotheinfrequentsituationinwhichatreatablecauseofdyspneaismissedinitially,butbecomes
apparentonsubsequenttesting.

Dyspneaduetoobesityperseiscommonlyassociatedwithasenseofincreasedefforttobreatheorworkof
breathing,likelyduetothereducedcomplianceofthechestwall[47,48].Hypoxemia,eitheratrestorwith
exertion,maybecausedbyventilation/perfusionmismatchingatthebasesofthelungs,aconsequenceof
narrowingofairwaysintheseregionsduetotheweightofthechestwall.

Otherchestsymptoms(eg,heartburn)andpsychologicalfactorscanleadtotheperceptionofdyspnea,as
describedbelow.UseofaBorgscaleduringcardiopulmonaryexercisetestingwillsometimesidentifydyspnea
associatedwithalowworkloadandnormalcardiorespiratoryfunction(table3).(See"Functionalexercise
testing:Ventilatorygasanalysis".)

PERCEPTUALANDPSYCHOLOGICALFACTORSTheglobalratingthatapatientgivesfordyspneamay
reflectbothsensoryandemotional(ie,affective)elements.Inastudyoflaboratoryinduceddyspnea,air
hungerwasassociatedwithgreaterunpleasantnessforagivenlevelofsensoryintensitythanwasthesense
ofrespiratoryworkoreffort[49].Thecontextinwhichasensationoccursmayaltertheaffectivecomponentof
theintensityandneedstobeconsideredwhenassessingthepatient.

Foragivenphysiologicderangementthatmaycausedyspnea,perceptualresponsesvarywidelyamong
individuals.Anxiety,anger,pain,anddepressionmaybeassociatedwithdyspneaintensityoutofproportionto
thephysiologicimpairment[5053].Increasedventilationassociatedwithanxiety,anger,orpainmaypushan
individualwithalimitedpulmonaryreserveatbaselineclosertohisorherventilatorylimitsandincreasethe
perceivedrespiratorydiscomfortforanygivenactivity.

Totheextentthatdyspneaoccursunexpectedlyorcannotbequicklyrelieved,itmaygiverisetoarangeof
emotionalreactions,whichcanthenleadtofurtherphysiologicalderangements(eg,tachypnea,
hyperinflation).Foranygivengasexchangeormechanicalproblemwiththecardiopulmonarysystem,the
emotionaloraffectiveresponsemaycontributetotheintensityordiscomfortofthesensation[49]
questionnairesarenowindevelopmentthatincorporatebothqualitativeandaffectivedescriptors[49,54,55].

Patientswithhyperventilationsyndrometypicallyexperienceasensationofairhungeroraninabilitytotakea
deepbreathintheabsenceofcardiopulmonarydisease.Theseindividualsmayhavepanicand/oranxiety
disorders,andonexaminationareoftenobservedtobreathewithverylargetidalvolumesdespitethe
complaintthattheycannottakeadeepenoughbreath.(See"Hyperventilationsyndrome".)

Sex,ethnicity,andculturalcontextappeartoinfluenceanindividual'sdescriptionofdyspnea,butfurther
researchisneededtounderstandtheexactdifferencesandtheireffectsontheexperienceanddescriptionof
dyspnea[6,8,28,5659].

SOCIETYGUIDELINELINKSLinkstosocietyandgovernmentsponsoredguidelinesfromselected
countriesandregionsaroundtheworldareprovidedseparately.(See"Societyguidelinelinks:Chronic
obstructivepulmonarydisease".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingon"patientinfo"andthekeyword(s)ofinterest.)

Basicstopics(see"Patienteducation:Shortnessofbreath(dyspnea)(TheBasics)")

BeyondtheBasicstopics(see"Patienteducation:Shortnessofbreath(dyspnea)(BeyondtheBasics)")

SUMMARYANDRECOMMENDATIONS

Dyspneaisatermusedtocharacterizeasubjectiveexperienceofbreathingdiscomfortthatcomprises
qualitativelydistinctsensationsthatvaryinintensity.Dyspneaisconsideredacutewhenitdevelopsover
hourstodaysandchronicwhenithasbeenpresentformorethanfourtoeightweeks.(See'Definitionof
dyspnea'above.)

Dyspneacanbethefirstmanifestationofavarietyofcardiopulmonarydisorders.Itisnotuncommonfora
patienttohavemorethanoneproblemcontributingtobreathingdiscomfort.(See'Pathophysiology'
above.)

Thehistoryandphysicalexaminationleadtoaccuratediagnosesinpatientswithdyspneain
approximatelytwothirdsofcases.Importantcomponentsofthehistoryincludethecharacteristicsof
dyspnea(ie,timing,severity,andtriggers),exposuresthatmaycontributetothelungdisease(eg,
allergens,coldair,occupationalagents,cigarettesmoke),andinterventionsormedicationsthatreduce
dyspnea.(See'Clinicalassessment'above.)

Thepatientsdescriptionofbreathingdiscomfortcanhelpnarrowdowndiagnosticpossibilities.In
addition,thepresenceofmorethanonetypeofbreathingdiscomfortcanleadtorecognitionthatmore
thanonediseaseprocessiscontributingtodyspnea.(See'Descriptorsofbreathingdiscomfort'above.)

Breathingdiscomfortarisingoverthecourseofminutestohours(acutedyspnea)generallyrequires
promptevaluationandtreatment.Theevaluationofacutedyspneaisdescribedseparately.(See
'Evaluationofacutedyspnea'aboveand"Evaluationoftheadultwithdyspneaintheemergency
department".)

Amongthemanycausesofchronicdyspnea(table6),themostcommonareasthma,chronicobstructive
pulmonarydisease(COPD),interstitiallungdisease,cardiomyopathy,andobesity/deconditioning.In
addition,deconditioningisoftenacontributingfactorinpatientswithchroniclungdisease.(See'Initial
testinginchronicdyspnea'above.)

Whenevaluatingchronicdyspnea,wefollowastepwisediagnosticapproachofinitialtesting(table7),
followuptesting(table8AC),andadvancedtesting(table9),startingwiththeteststhataretheleast
invasiveandmostlikelytoyieldadiagnosis.Withineachtier,theindividualtestsareselectedbasedon
thepatientsclinicalfeatures,resultsofpriortests,andresponsetotherapy.(See'Initialtestinginchronic
dyspnea'above.)

Theinitialtestsareselectedbasedonareviewoftheclinicalfindingsforpatternssuggestiveofoneor
twooftheabovefivemostcommoncausesofdyspnea(table7).WhenasthmaorCOPDissuspected,
theinitialtestingmightbelimitedtospirometrypreandpostbronchodilator,whileanolderpatientwith
 coronaryarterydiseaseandperipheraledemashouldbeevaluatedforheartfailurebeforeconsidering
spirometry.(See'Initialtestinginchronicdyspnea'above.)

Followuptestingintheevaluationofdyspneashouldclarifyabnormalitiesthatwerenotedoninitial
testing,butwerenotdiagnostic(table8Aandtable8Bandtable8C).Inaddition,somepatientswith
normalresultsoninitialtesting,butpersistentsymptoms,requirefurtherevaluation.Thoraciccomputed
tomography(CT)isgenerallyreservedforpatientsinwhomthereisasuspicionofinterstitiallung
disease,occultemphysema,orchronicthromboembolicdisease.Echocardiographyisusefulfor
evaluatingsuspectedleftventriculardysfunction,pulmonaryhypertension,anddiastolicdysfunction.(See
'Followuptestinginchronicdyspnea'above.)

Advancedtestingincludesproceduressuchasrightheartcatheterization,stressechocardiography,
cardiopulmonaryexercisetesting(CPET),andinvasiveCPET(table9).Cardiopulmonaryexercise
testingisausefulstudyinpatientsinwhomthecauseoftheirbreathingdiscomfortremainselusiveafter
standardtesting,inpatientsinwhomdeconditioningisaseriousconsideration,andinpatientswho
appeartohavebreathingdiscomfortoutofproportiontotheirphysiologicderangements.(See'Unclear
causeofdyspneaonexertion'above.)

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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withunexplaineddyspnea:apressurevolumeloopanalysis.JAmCollCardiol201055:1701.
43.ERSTaskForce,PalangeP,WardSA,etal.Recommendationsontheuseofexercisetestinginclinical
practice.EurRespirJ200729:185.
44.AmericanThoracicSociety,AmericanCollegeofChestPhysicians.ATS/ACCPStatementon
cardiopulmonaryexercisetesting.AmJRespirCritCareMed2003167:211.
45.MaronBA,CockrillBA,WaxmanAB,SystromDM.Theinvasivecardiopulmonaryexercisetest.
Circulation2013127:1157.
46.LaunoisC,BarbeC,BertinE,etal.ThemodifiedMedicalResearchCouncilscalefortheassessmentof
dyspneaindailylivinginobesity:apilotstudy.BMCPulmMed201212:61.
47.ScanoG,StendardiL,BruniGI.Therespiratorymusclesineucapnicobesity:theirroleindyspnea.
RespirMed2009103:1276.
48.LittletonSW.Impactofobesityonrespiratoryfunction.Respirology201217:43.
49.BanzettRB,PedersenSH,SchwartzsteinRM,LansingRW.Theaffectivedimensionoflaboratory
dyspnea:airhungerismoreunpleasantthanwork/effort.AmJRespirCritCareMed2008177:1384.
50.BurnsBH,HowellJB.Disproportionatelyseverebreathlessnessinchronicbronchitis.QJMed1969
38:277.
51.DalesRE,SpitzerWO,SchechterMT,SuissaS.Theinfluenceofpsychologicalstatusonrespiratory
symptomreporting.AmRevRespirDis1989139:1459.
52.NishinoT,ShimoyamaN,IdeT,IsonoS.Experimentalpainaugmentsexperimentaldyspnea,butnot
viceversainhumanvolunteers.Anesthesiology199991:1633.
53.LivermoreN,ButlerJE,SharpeL,etal.Panicattacksandperceptionofinspiratoryresistiveloadsin
chronicobstructivepulmonarydisease.AmJRespirCritCareMed2008178:7.
54.YorkeJ,MoosaviSH,ShuldhamC,JonesPW.Quantificationofdyspnoeausingdescriptors:
developmentandinitialtestingoftheDyspnoea12.Thorax201065:21.
55.BanzettRB,O'DonnellCR,GuilfoyleTE,etal.MultidimensionalDyspneaProfile:aninstrumentfor
clinicalandlaboratoryresearch.EurRespirJ201545:1681.
56.GuiP,EbiharaS,KanezakiM,etal.Genderdifferencesinperceptionsofurgetocoughanddyspnea
inducedbycitricacidinhealthyneversmokers.Chest2010138:1166.
57.HanJN,XiongCM,YaoW,etal.Multipledimensionsofcardiopulmonarydyspnea.ChinMedJ(Engl)
2011124:3220.
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Portuguese:applicationinobesepatientsandinpatientswithcardiorespiratorydiseases.JBras
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 59.WilliamsM,GarrardA,CafarellaP,etal.Qualityofrecalleddyspnoeaisdifferentfromexerciseinduced
dyspnoea:anexperimentalstudy.AustJPhysiother200955:177.

Topic1436Version16.0
GRAPHICS

Efferentandafferentsignalsthatcontributetothesensation
ofdyspnea

Thesymptomofdyspnealikelyarisesfromarangeofsensoryinputs,manyofwhich
leadtoqualitativelydistinctdescriptivephrasesusedbypatients.Thesensationof
respiratoryeffortarisesfromsignalstransmittedfromthemotorcortextothesensory
cortex(greenarrow)whenoutgoingmotorcommandsaresenttotheventilatory
muscles(bluearrow).Motoroutputfromthebrainstem(bluearrow)mayalsobe
accompaniedbysignalstransmittedtothesensorycortex,contributingtothesensation
ofeffort(dottedgreenarrow).
Thesensationofairhungerprobablyderivesfromacombinationofstimulithatincrease
thedrivetobreathesuchasinsufficientoxygenorexcesscarbondioxide(mediatedby
signalsfromchemoreceptorsinthecarotidbodyandaorticarch),acutehypercapniaor
acidemia(mediatedbysignalsfromtheperipheralandcentralchemoreceptors),airway
andinterstitialinflammation(mediatedbypulmonaryafferents),andvascularreceptors.
Theintensityofairhungerisincreasedwhenthereisaperceivedmismatchbetweenthe
outgoingefferentmessagestotheventilatorymusclesandincomingafferentsignals
fromthelungsandchestwall.
Chesttightness,commonlyassociatedwithbronchospasm,ismediatedbystimulationof
vagalirritantreceptors.Afferentsignals(redarrows)fromairway,lung,andchestwall
receptorsmostlikelypassthroughthebrainstembeforebeingtransmittedtosensory
cortex,althoughitisalsopossiblethatsomeafferentinformationbypassesthebrain
stemandgoesdirectlytosensorycortex(dottedarrow).

Redarrows:afferentsignalsBluearrows:efferentsignalsGreenarrows:signalswithinthe
centralnervoussystemDottedlines:hypotheticalpathwaysCircles:chemoreceptors
Squares:mechanoreceptors.

Graphic69322Version5.0
Causesofacutedyspnea

Cardiovascularsystem
Acutemyocardialischemia

Heartfailure

Cardiactamponade

Respiratorysystem
Bronchospasm

Pulmonaryembolism

Pneumothorax

Pulmonaryinfectionbronchitis,pneumonia

Upperairwayobstructionaspiration,anaphylaxis

Graphic82700Version1.0
ModifiedMedicalResearchCouncil(MMRC)dyspneascale

Grade Descriptionofbreathlessness

0 Ionlygetbreathlesswithstrenuousexercise

1 Igetshortofbreathwhenhurryingonlevelgroundorwalkingupaslighthill

2 Onlevelground,Iwalkslowerthanpeopleofthesameagebecauseofbreathlessness,orhavetostop
forbreathwhenwalkingatmyownpace

3 Istopforbreathafterwalkingabout100yardsorafterafewminutesonlevelground

4 IamtoobreathlesstoleavethehouseorIambreathlesswhendressing

Adaptedfrom:FletcherCM,ElmesPC,FairbairnMB,etal.Thesignificanceofrespiratorysymptomsandthediagnosisof
chronicbronchitisinaworkingpopulation.BritishMedicalJournal19592:257.

Graphic86426Version1.0
ThemodifiedBorgScaleforassessingtheintensityofdyspneaorfatigue

0 Nothingatall

0.5 Very,veryslight(justnoticeable)

1 Veryslight

2 Slight(light)

3 Moderate

4 Somewhatsevere

5 Severe(heavy)

7 Verysevere

10 Very,verysevere(maximal)

ThisBorgscaleshouldbeprintedonheavypaper(11incheshighandperhapslaminated)in20pointtypesize.At
thebeginningofthe6minuteexercise,showthescaletothepatientandaskthepatientthis:"Pleasegradeyour
levelofshortnessofbreathusingthisscale."Thenaskthis:"Pleasegradeyourleveloffatigueusingthisscale."At
theendoftheexercise,remindthepatientofthebreathingnumberthattheychosebeforetheexerciseandask
thepatienttogradetheirbreathinglevelagain.Thenaskthepatienttogradetheirleveloffatigue,after
remindingthemoftheirgradebeforetheexercise.

Sources:
1.Reproducedwithpermissionfrom:BorgGA.Psychophysicalbasesofperceivedexertion.MedSciSportsExerc
198214:377.Copyright1982LippincottWilliams&Wilkins.
2.Reproducedwithpermissionfrom:theAmericanThoracicSociety.ATSstatement:Guidelinesforthesixminute
walktest.AmJRespirCritCareMed2002166:111.

Graphic63981Version3.0
Dyspneaquestionnaire

Pleaseselectuptothreephrasesthatbestdescribeyourbreathingdiscomfort.Ifyouchoosemorethanone
phrase,pleasealsonotethephrasethatmostcloselydescribesthesensationyoufeel.Ifnoneofthesephrases
applies,pleasewriteinyourowndescriptionofyourbreathingdiscomfort.

Mybreathingisshallow.

Ifeelanurgetobreathemore.

Mychestisconstricted.

Mybreathingrequireseffort.

Ifeelahungerformoreair.

Ifeeloutofbreath.

Icannotgetenoughair.

Mybreathdoesnotgoinalltheway.

Mychestfeelstight.

Mybreathingrequireswork.

IfeelthatIamsmothering/suffocating.

IfeelthatIcannotgetadeepbreath.

IfeelthatIambreathingmore.

Mybreathdoesnotgooutalltheway.

Mybreathingisheavy.

Otherdescriptions:

Graphic76579Version1.0
Qualitiesofdyspneaandassociateddiseasestates

Descriptor Pathophysiologicmechanism Diseasestate

Chesttightnessor Bronchochonstriction,interstitialedema Asthma

constriction
Myocardialischemia

Increasedworkor Airwaysobstruction,neuromusculardisease, COPD,moderatetosevereasthma,

effortofbreathing reducedchestwallorpulmonarycompliance myopathy,pulmonaryfibrosis

Airhunger,needto Increaseddrivetobreathe HF,pulmonaryembolism,moderate

breathe,urgeto tosevereasthmaorCOPD
breathe

Rapid,shallow Reducedchestwallorpulmonarycompliance Interstitialfibrosis

breathing

Suffocating,smothering Alveolaredema Pulmonaryedema

Heavybreathing, Inadequateoxygendeliverytothemuscles Deconditioning

breathingmore

Graphic69244Version1.0
Conditionsassociatedwithchronicdyspnea

Upperairway
Laryngealmass

Vocalfoldparalysis

Paradoxicalvocalfolddysfunction

Goiter

Neckmasscompressingairway

Chest/abdominalwall
Diaphragmaticparalysis

Kyphoscoliosis

Latepregnancy

Massiveobesity

Ventralhernia

Ascites

Intraabdominalprocess

Pulmonary
Asthma

Bronchiectasis

Bronchiolitis

COPD/emphysema

Chronicthromboembolicdisease

Interstitiallungdisease

Lungmasscompressingoroccludingairway

Pleuraleffusion

Pulmonaryrighttoleftshunt

Pulmonaryhypertension

Trappedlung

Cardiac
Arrhythmia

Constrictivepericarditis,pericardialeffusion

Coronaryheartdisease

Deconditioning

Heartfailure(systolicordiastolicdysfunction)

Intracardiacshunt

Restrictivecardiomyopathy

Valvulardysfunction

Neuromusculardisease
Amyotrophiclateralsclerosis

Brachialplexopathy

Glycolyticenzymedefects(eg,McArdle)

Mitochondrialdiseases

Polymyositis/dermatomyositis

Toxic/metabolic/systemic
 Anemia

Metabolicacidosis(eg,poorlycontrolleddiabetesmellitus,renaltubularacidosis,treatmentwithacetazolamide)

Renalfailure

Thyroiddisease

Miscellaneous
Anxiety

Earlypregnancy(effectofprogesterone)

COPD:chronicobstructivepulmonarydisease.

Graphic104817Version2.0
Evaluationofdyspnea:Initialtesting

Testsareselectedbasedonclinicallikelihood.Asexamples,apatientunderage40withsuspected
asthmamightjustneedspirometrypre/postbronchodilatorayoungpatientwithoutsuspicionfor
heartfailureorpulmonaryhypertensionmightnotneedanECGorplasmaBNPandapatientwith
suspectedheartfailuremightnotneedspirometry.However,somepatientswillneedalltestsinthis
section.

Test Rationale/indications

Hemoglobin/hematocrit Anemiacanpresentasdyspneaorreducedexercisetolerance.

Glucose,bloodureanitrogen, Foradultswithothercomorbiditiesoroverage40,screenformetaboliccauses
creatinine,electrolytes, ofdyspnea.
phosphate,calcium

Thyroidstimulatinghormone Hyperandhypothyroidismcanpresentasdyspneaorreducedexercise
(TSH) tolerance.

Spirometrypre/post
bronchodilatorwithorwithout
lungvolumesandDLCO
DependingonthelikelihoodofasthmaorCOPDanddifficultiesoftraveland
scheduling,spirometrypre/postbronchodilatormaybeorderedinitiallywithout
fullPFTs.Alternatively,fulltesting(spirometrypreandpostbronchodilator,
lungvolumes,DLCO,ambulatoryoximetry)maybemoreexpeditious.
RefertoUpToDatetableonfollowuptestingbasedoninitialresults.

AssessSpO 2 (eg,walking200 Hypoxemiaatrestordesaturationwithexertionindicatestheneedtopursue

feetandtwoflightsofstairs)* definitivediagnosis.ObtainfullPFTs,CXR,BNP,ECG,andpossibly
echocardiogram.
RefertoUpToDatetableonfollowuptestingbasedoninitialresults.

Chestradiograph Indicatedformostdyspneicpatients,particularlythosewhoareoverage40,
havesuspectedheartfailureorinterstitialdisease,orabnormalPFTs.Not
neededinroutineevaluationofasthma.

ECG Indicatedformostdyspneicpatientsoverage40.Notneededinyoungpatients
withcleardiagnosisofasthmaandresponsetotreatment.
RefertoUpToDatetableonfollowuptestingbasedoninitialresults.

PlasmaBNPorNTproBNP UsefulscreeningtestforHFalthoughnotentirelyspecificdyspneaduetoHFis
associatedwithplasmaBNP>400pg/mLhighnegativepredictivevaluefor
BNP<100pg/mL,althoughBNPincreaseswithage.

DLCO:diffusingcapacityofthelungsforcarbonmonoxideCOPD:chronicobstructivepulmonarydiseasePFTs:
pulmonaryfunctiontestsSpO 2 :pulseoxygensaturationCXR:chestradiographBNP:brainnatriureticpeptideECG:
electrocardiogramHF:heartfailure.
*StopexertionifSpO 2 decreasesto90percentorpatientbecomessymptomatic.

Graphic104818Version2.0
Pulmonaryfunctiontestingintheevaluationofchronicdyspnea
Abnormality
Airflowobstructionwithcomplete
reversibilityfollowinginhaled
bronchodilator
Airflowobstructionthatis
irreversibleorincompletely
reversiblefollowingbronchodilator
Normal(expiratory)spirometry
ReducedFVCwithnormalFEV 1 /FVC
LungvolumesnormalbutDLCO
reducedand/orSpO 2 <95%or
decreasesby>4%withexertion
Normalflowvolumeloop,lung
Pulmonaryfunctiontests
Interpretation
Likelyasthma:Institutetherapy
basedonseverityofobstruction
accordingtocurrentguidelines.
LikelyCOPD,especiallyinsmokers.
Chronic/severeasthmacancause
airflowlimitationthatisincompletely
reversiblewithbronchodilator,but
mayimproveovertimewithinhaled
ororalglucocorticoidtherapy.Less
commonlybronchiolitisor
bronchiectasis.
Normalspirometrydoesnotexclude
asthmaorupperairwayobstruction.
Dependingonclinicalsuspicion:
Reviewinspiratoryand
expiratoryflowvolumeloopfor
upperairwayflowlimitation
Obtainbronchoprovocation
challenge(eg,methacholine,
mannitol,exercise)
Obtainlungvolumes,DLCO,
SpO 2 withexercise(ifnot
alreadydone)
Evaluateforrestrictiveprocess
(pleural,chestwall,or
neuromuscular),interstitiallung
disease,orairtrapping.
Obtain/reviewlungvolumes
andDLCO
ExamineCXRre:pleural
effusion,kyphoscoliosis,or
hemidiaphragmelevation
PossibilitiesincludeearlyILDand
pulmonaryvasculardisease:Obtain
HRCT,BNP,andechocardiogram
withDopplerassessmentofPA
pressures.
Increasinglikelihoodofpreload
Furthertesting
Reassessdyspneaandspirometry
aftertreatmenttrial.
Reassessdyspneaandspirometry
aftertreatmenttrial/pulmonary
rehabilitation/smoking
cessation/removalofallergen
exposure.
Bronchiolitisshouldbesuspectedin
patientswithpoorresponseto
therapyforasthma/COPDorwiththe
combinationofairflowlimitationand
impairedgastransfer,mayneed
HRCTtolookforradiographic
evidenceofbronchiolitisor
bronchiectasis.
Positivebronchoprovocation:
Asthmaislikelycauseofdyspnea.
Reassessaftertreatmenttrial.
Bronchoprovocationnegativebut
flowvolumeloophasslowingon
inspiratoryphasesuggesting
possibleupperairwayobstruction
directvisualizationneededto
confirm.
Referto"Lungvolumesnormalbut
DLCOreducedand/orSpO 2 <95%
ordecreasesby>4%withexertion"
below.
Lungvolumes(FVCandTLC)
confirmrestrictivepattern,DLCO
normalorslightlylow:Consider
pleural,chestwall,and
neuromusculardisease.
ObtainMEP,MIP,MVV
Reviewimaging
Considerfluoroscopyfor
diaphragmdysfunction
ReducedDLCOandlungvolumes
suggestinterstitiallungdiseaseor
emphysema:ConsiderHRCT.
IncreasedRVorFRCsuggests
airtrapping(eg,duetoemphysema,
LAM,bronchiolitis)asacauseoflow
FVC.HRCTcanidentifyemphysema,
cysticchangesofLAM,mosaic
patternsuggestiveofbronchiolitis.
IfnoILDonHRCTandBNPand
echocardiogramsuggestpulmonary
hypertension,mayneedPA
catheterization.
Obtain/reviewCXR,echocardiogram.
 volumes,DLCO,ambulatorySpO 2 , dependentornonrespiratorycause MayneedCPET.
andbronchoprovocation ofdyspnea.

COPD:chronicobstructivepulmonarydiseaseHRCT:highresolutioncomputedtomographyDLCO:diffusingcapacity
ofthelungsforcarbonmonoxideSpO 2 :pulseoxygensaturationFVC:forcedvitalcapacityFEV 1 :forcedexpiratory
volumeinonesecondCXR:chestradiographTLC:totallungcapacityMEP:maximalexpiratorypressureMIP:
maximalinspiratorypressureMVV:maximalvoluntaryventilationRV:rightventricularFRC:functionalresidual
capacityLAM:lymphangioleiomyomatosisILD:interstitiallungdiseaseBNP:brainnatriureticpeptidePA:pulmonary
arteryCPET:cardiopulmonaryexercisetest.

Graphic104821Version2.0
Imagingintheevaluationofchronicdyspnea

Imaging

Abnormality Interpretation Furthertesting

Normalorincreasedreticular ReviewPFTsre:evidenceof ReviewHRCTpatterntodifferentiate

markingsonchestradiograph
restriction,abnormalDLCO,orlow
SpO 2 atrestorwithexertion.If
abnormalitiessuggestILD,obtain
HRCT.
typesofILDobtainappropriate
testsforrheumaticdiseases,HP,
pneumoconiosis.RefertoUpToDate
topicsonevaluationofinterstitial
lungdisease.

Hyperinflation DDxincludesCOPD/emphysema, CorrelatewithPFTs.

asthma,normalvariant,
bronchiolitis,
lymphangioleiomyomatosis,Marfan
syndrome,BirtHoggDube.
Ifairflowlimitation,empiric
bronchodilatortherapy.
ConsiderHRCT.

Pleuraleffusionorthickeningon Pleuraleffusion,trappedlung,and Evaluationusuallyrequires

chestradiograph fibrothoraxcanleadtodyspnea
throughalteredpleuralmechanics
andcompressiveatelectasis.
thoracentesisofpleuraleffusion,
sometimeswithmeasurementof
pleuralpressures.Inaddition,chest
computedtomographywithcontrast
isfrequentlypartoftheevaluation.

Abnormalspine,ribcage,or ReviewPFTstoassessdegreeof Forpatientswithchestwalldisease

diaphragm functionalimpairment. andanFVC<1L,consider
assessmentforhypercapnia.

Enlargedorabnormalheartcontour ObtainBNPandechocardiogram Ifechocardiogramnormal,consider

onchestradiograph withDopplerassessmentofPA MRIorCTscantoevaluateabnormal
pressures:Reviewpericardium, heartsize/contour.
systolic/diastolicfunction,valvular
function.

PFTs:pulmonaryfunctiontestsDLCO:diffusioncapacityofthelungsforcarbonmonoxideSpO 2 :pulseoxygen
saturationILD:interstitiallungdiseaseHRCT:highresolutioncomputedtomographyHP:hypersensitivity
pneumonitisDDx:differentialdiagnosisCOPD:chronicobstructivepulmonarydiseaseFVC:forcedvitalcapacityBNP:
brainnatriureticpeptidePA:pulmonaryarteryMRI:magneticresonanceimagingCT:computedtomography.

Graphic111477Version1.0
Cardiactestingintheevaluationofchronicdyspnea

Cardiacevaluation

Test Interpretation Followup

ECGshowsarrhythmia,conduction
disturbance,ormyocardialinjury
ECGabnormalitiesmaybeaclueto
underlyingcoronaryarteryor
myocardialdisease.Obtain
treadmill/otherstresstestand
echocardiogram.

Treadmillornuclearstresstestcan Somepatientsaremoreawareof TestingsuggestsCADevaluateand

behelpfuleveninabsenceofchest dyspneathanchestpressure. treat.
pain PatientswithCOPDmayreport
dyspneathatisduetocomorbid
cardiacdisease.

Transthoracicechocardiogram: Echocardiogramshowsreducedleft Evaluateforriskfactors.Initiate

Usefulintheidentificationofsystolic
anddiastolicventriculardysfunction,
hypertrophiccardiomyopathy,
valvulardisease,pericardialdisease,
andpulmonaryhypertension
ventricularsystolicfunction(HFrEF):
LikelycardiomyopathyorCAD.
Echocardiogramshowspreserved
ejectionfraction(HFpEF).Assess
severityandpotentialriskfactors
initiatetreatment.
treatment.
Dependingonresponseto
treatment,mayneedrightand/orleft
heartcatheterizationtoconfirm.

EchocardiogramshowselevatedPA
pressurewithnormalsystolicLV
function.DDxincludespulmonary
hypertension,CTEPH,HFpEF,
others.CheckBNP,assessforrisk
factors.
Considerrightheartcatheterization
toconfirmdiagnosisofPH(mean
PAP25andPAWP<15).Consider
V/Qscanre:CTEPH.Obtain
appropriatetestsforsecondaryPH
(eg,rheumaticdiseases,HBV,HCV,
HIV,PSG).

ECG:electrocardiogramCOPD:chronicobstructivepulmonarydiseaseCAD:coronaryarterydiseasePA:pulmonary
arteryLV:leftventricularDDx:differentialdiagnosisCTEPH:chronicthromboembolicpulmonaryhypertensionBNP:
brainnatriureticpeptidePH:pulmonaryhypertensionPAP:pulmonaryarterypressurePAWP:pulmonaryarterywedge
pressureV/Q:ventilationperfusionHBV:hepatitisBvirusHCV:hepatitisCvirusHIV:humanimmunodeficiencyvirus
PSG:polysomnography.

Graphic111478Version1.0
Evaluationofdyspnea:Advancedtesting

Patientswhorequirethisleveloftestingforundiagnoseddyspneamaybenefitfromreferraltoa
pulmonaryorcardiologyspecialist

Test Rationale Furthertesting

Revisitdescriptionofdyspnea Conditioningprogramwith Furthertestingasdescribedbelowif

Considerupperairwaycontribution reassessmentofsymptomsandPFTs noresponsetoconditioning
(includingnasalobstruction), at6to12monthintervals. programorpatientprefersmore
muscleweakness,orfatiguebeing immediateanswers.
interpretedasdyspnea

Exerciseechocardiography WallmotionandDopplerparameters Exerciserelatedpulmonary

aremonitoredduringtreadmillor
cycleexercisetoelicitexercise
relatedPH,identifysegmentalwall
motionabnormalitiessuggestiveof
CAD,orunmaskmitraloraortic
valvulardiseasethatis
hemodynamicallysignificantduring
exercise.
hypertensionmayneedfurther
evaluationwithinvasiveCPET,if
clinicallysignificantdyspnea.
CADandvalvulardiseasewillneed
appropriateevaluationand
treatment.

ObtainCPET CPETcanhelpidentify Patientswithnormaltesting

nonrespiratorycausesofexercise includinganormalCPETarelikelyto
limitation,mitochondrialdisease, havedeconditioningoraperceptual
andcanhelpdistinguishwhether orpsychologicalcausefordyspnea.
cardiacorrespiratoryproblemsare
causingthepatient'slimitationin
casesinwhichmorethanone
diseaseispresent.

Serumlactate(restandexercise) Plasmalactatelevelatrestand Furthercorrelationneededwith

fasting>2.5mmol/Lmaysuggest CPET,creatinekinase,andpossibly
mitochondrialdisease. musclebiopsy.

InvasiveCPET(witharterialline Dependingonthelevelofsuspicion iCPETislargelyusedtoidentifyor

and/orpulmonaryarterycatheterin andavailabilityoftesting,iCPETmay excludeexerciserelatedPH,HFpEF,
place) beperformeddirectlyorbasedon andpreloaddependentlimitationsto
exerciseechocardiogramfindings. cardiacoutput.

PFTs:pulmonaryfunctiontestsCPET:cardiopulmonaryexercisetestPH:pulmonaryhypertensionCAD:coronary
arterydiseaseiCPET:invasiveCPETHFpEF:heartfailurewithpreservedejectionfraction.

Graphic104824Version1.0
ContributorDisclosures
RichardMSchwartzstein,MD Nothingtodisclose TalmadgeEKing,Jr,MD Nothingtodisclose Helen
Hollingsworth,MD Nothingtodisclose

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.

Conflictofinterestpolicy