Diagnostic Evaluation of Dyspnea

WALTER C. MORGAN, M.D., Kaiser Permanente Medical Center, Riverside, California

HEIDI L. HODGE, M.D., Kaiser Permanente Medical Offices, Longview, Washington
Am Fam Physician. 1998 Feb 15;57(4):711-716.

Dyspnea is a common symptom and, in most cases, can be effectively managed in the office by
the family physician. The differential diagnosis is composed of four general categories: cardiac,
pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary. Most cases of dyspnea
are due to cardiac or pulmonary disease, which is readily identified with a careful history and
physical examination. Chest radiographs, electrocardiograph and screening spirometry are easily
performed diagnostic tests that can provide valuable information. In selected cases where the test
results are inconclusive or require clarification, complete pulmonary function testing, arterial
blood gas measurement, echocardiography and standard exercise treadmill testing or complete
cardiopulmonary exercise testing may be useful. A consultation with a pulmonologist or
cardiologist may be helpful to guide the selection and interpretation of second-line testing

Dyspneaisdefinedasabnormaloruncomfortablebreathinginthecontextofwhatisnormalfora
personaccordingtohisorherleveloffitnessandexertionalthresholdforbreathlessness. Dyspnea
isacommonsymptomandcanbecausedbymanydifferentconditions.Itoftenhasmultiple
etiologies.Althoughothercausesmaycontribute,thecardiacandpulmonaryorgansystemsaremost
frequentlyinvolvedintheetiologyofdyspnea.
14

Pathophysiology
Thephysiologyofnormalrespirationandgasexchangeiscomplex,andthatofdyspneaisevenmore
so.Ventilationisrelatedtothemetabolicdemandsofoxygenconsumptionandcarbondioxide
eliminationnecessarytomeetagivenlevelofactivity.
Thecarotidandaorticbodiesandcentralchemoreceptorsrespondtothepartialpressureofoxygen
(PO ),partialpressureofcarbondioxide(PCO )andpHofthebloodandcerebrospinalfluid. When
stimulated,thesereceptorscausechangesintherateofventilation.Therateandpatternofbreathing
arealsoinfluencedbysignalsfromneuralreceptorsinthelungparenchyma,largeandsmallairways,
respiratorymusclesandchestwall.
2

Forexample,inapatientwithpulmonaryedema,theaccumulatedfluidactivatesneuralfibersinthe
alveolarinterstitiumandreflexivelycausesdyspnea. Inhaledsubstancesthatareirritatingcan
activatereceptorsintheairwayepitheliumandproducerapid,shallowbreathing,coughingand
bronchospasm.Thecentralnervoussystem,inresponsetoanxiety,canalsoincreasetherespiratory
rate. Inapatientwhoexperienceshyperventilation,subsequentcorrectionofthedecreased
PCO alonemaynotalleviatethesensationofbreathlessness.Thisreflectstheinteractionbetween
chemicalandneuralinfluencesonbreathing.
2

2,3

Etiology
Thebroaddifferentialdiagnosisofdyspneacontainsfourgeneralcategories:cardiac,pulmonary,
mixedcardiacorpulmonary,andnoncardiacornonpulmonary(Table1).

TABLE 1

Differential Diagnosis of Dyspnea

Cardiac

Congestive heart failure (right, left or biventricular)

Coronary artery disease

Myocardial infarction (recent or past history)

Cardiomyopathy

Valvular dysfunction

Left ventricular hypertrophy

Asymmetric septal hypertrophy

Pericarditis

Arrhythmias

Pulmonary

COPD

Asthma

Restrictive lung disorders

Hereditary lung disorders

Pneumothorax

Mixed cardiac or pulmonary

COPD with pulmonary hypertension and cor pulmonale

Deconditioning

Chronic pulmonary emboli

Trauma

Noncardiac or nonpulmonary

Metabolic conditions (e.g., acidosis)

Pain

Neuromuscular disorders

Otorhinolaryngeal disorders

Functional

Anxiety

Panic disorders

Hyperventilation

COPD = chronic obstructive pulmonary disease.

Cardiaccausesofdyspneaincluderight,leftorbiventricularcongestiveheartfailurewithresultant
systolicdysfunction,coronaryarterydisease,recentorremotemyocardialinfarction,
cardiomyopathy,valvulardysfunction,leftventricularhypertrophywithresultantdiastolic
dysfunction,asymmetricseptalhypertrophy,pericarditisandarrhythmias.
Pulmonarycausesincludeobstructiveandrestrictiveprocesses.Themostcommonobstructive
causesarechronicobstructivepulmonarydisease(COPD)andasthma.Restrictivelungproblems
includeextrapulmonarycausessuchasobesity,spineorchestwalldeformities,andintrinsic
pulmonarypathologysuchasinterstitialfibrosis,pneumoconiosis,granulomatousdiseaseorcollagen
vasculardisease.
Mixedcardiacandpulmonarydisordersarealsocommonsourcesofdyspnea andincludeCOPD
withpulmonaryhypertensionandcorpulmonale,deconditioning,pulmonaryemboliandtrauma.
6,7

Noncardiacornonpulmonarydiseasemustbeconsideredinpatientswithminimalriskfactorsfor
pulmonarydiseaseandnoclinicalevidenceofcardiacorpulmonarydisease.Thesedisordersinclude
metabolicconditionssuchasanemia,diabeticketoacidosisandother,lesscommoncausesof
metabolicacidosis,paininthechestwallorelsewhereinthebody,andneuromusculardisorderssuch
asmultiplesclerosisandmusculardystrophy.Obstructiverhinolaryngealproblemsincludenasal
obstructionduetopolypsorseptaldeviation,enlargedtonsilsandsupraglotticorsubglotticairway
stricture.
Dyspneacanalsooccurasasomaticmanifestationofpsychiatricdisorders,suchasananxiety
disorder,withresultanthyperventilation.

History
Aswithallundifferentiatedsymptoms,acarefullytakenhistoryisimportantbecauseityieldsclues,
ifnottheactualdiagnosis,inmanycases(Table2).
TABLE 2

History and Physical Examination Clues to Conditions That Cause Dyspnea

Findings

Condition

History

Dyspnea on exertion

Cardiac or pulmonary disease, deconditioning

Findings

Condition

Dyspnea during rest

Severe cardiopulmonary disease or noncardiopulmonary disease

(e.g., acidosis)

Orthopnea, paroxysmal nocturnal

dyspnea, edema

Congestive heart failure, chronic obstructive pulmonary disease

Medications

Beta blockers may exacerbate bronchospasm or limit exercise

tolerance. Pulmonary fibrosis is a rare side effect of some
medications

Smoking

Emphysema, chronic bronchitis, asthma

Allergies, wheezing, family history

of asthma

Asthma

Coronary artery disease

Dyspnea as anginal equivalent

High blood pressure

Left ventricular hypertrophy, congestive heart failure

Anxiety

Hyperventilation, panic attack

Lightheadedness, tingling in fingers Hyperventilation

and perioral area

Recent trauma

Pneumothorax, chest-wall pain limiting respiration

Occupational exposure to dust,

asbestos or volatile chemicals

Interstitial lung disease

Physical examination

Anxiety

Anxiety disorder

Findings

Condition

Nasal polyp, septal deviation

Dyspnea due to nasal obstruction

Postnasal discharge

Allergies/asthma

Jugular vein distention

Congestive heart failure

Decreased pulse or bruits

Peripheral vascular disease with concomitant coronary artery

disease

Increased anteroposterior chest

diameter

Emphysema

Wheezing

Asthma, pulmonary edema

Rales

Alveolar fluid (edema, infection, etc.)

Tachycardia

Anemia, hypoxia, heart failure, hyperthyroidism

Congestive heart failure

Murmur

Valvular dysfunction

Hepatomegaly, hepatojugular
reflux, edema

Congestive heart failure

Cyanosis, clubbing

Chronic severe hypoxemia

S = third heart sound.

3

Pertinentqueriescanprovidevaluableinformationanddiagnosticcluestothecauseofdyspnea.
Factorssuchasthedurationofthedyspnea,precipitatingcircumstancessuchasexertion,daytimeor
nighttimeoccurrence,thepresenceofchestpainorpalpitations,thenumberofpillowsthepatient
usesduringsleep,howwellthepatientsleeps,concomitantcoughing,exercisetolerance,andthe
abilitytokeepupwithpeerscanallhelpnarrowthedifferentialdiagnosis.
8,9

Otherfactorstobeconsideredincludepastandcurrentuseoftobacco,exercisetolerance,
environmentalallergies,occupationalhistoryandthepresenceofasthma,coronaryarterydisease,
congestiveheartfailureorvalvularheartproblems.Afamilyhistoryofasthma,lungproblems(e.g.,
chronicbronchitis,bronchiectasis,seriouspulmonaryinfections),allergiesorhayfevermustalsobe
considered.
9

Whenevaluatingapatientwithapossiblepsychiatriccomponentofdyspnea,itishelpfultoknowif
thefeelingsofdyspneaandanxietyareconcurrent,ifassociatedparesthesiasofthemouthand
fingersexist,andiftheanxietyprecedesorfollowsdyspnea.

Physical Examination
Acompletephysicalexamination,likeacarefullytakenhistory,islikelytoleadthecliniciantoward
theproperdiagnosisandminimizeunnecessarylaboratorytesting(Table2).
Oropharyngealornasopharyngealpathologymaybefoundbyidentifyingagrosslyobstructive
abnormalityofthenasalpassagesorpharynx.Palpationoftheneckmayrevealmasses,suchasin
thyromegaly,whichcancontributetoairwayobstruction.Neckbruitsareindicativeofmacrovascular
diseaseandsuggestconcomitantdiseaseofthecoronaryarteries,especiallyifthepatienthasa
historyofdiabetes,hypertensionorsmoking.
Examinationofthethoraxmayrevealanincreasedanteroposteriordiameter,anelevatedrespiratory
rate,spinedeformitiessuchaskyphosisorscoliosis,evidenceoftraumaandtheuseofaccessory
musclesforbreathing.Kyphosisandscoliosiscancausepulmonaryrestriction.Auscultationofthe
lungsprovidesinformationregardingthecharacterandsymmetryofbreathsoundssuchasrales,
rhonchi,dullnessorwheezing.Ralesorwheezingcanindicatecongestiveheartfailure,and
expiratorywheezingalonemayindicateobstructivelungdisease.
Cardiovascularexaminationmayrevealmurmurs,extraheartsounds,anabnormallocationofthe
pointofmaximumimpulseoranabnormalityoftheheartrateorrhythm.Asystolicmurmurcan
indicateaorticstenosisormitralinsufficiency;athirdheartsoundcanindicatecongestiveheart
failureandanirregularrhythmcanindicateatrialfibrillation.Peripheralperfusionoftheextremities
shouldbeevaluatedbyassessingpulses,capillaryrefilltime,edemaandhairgrowthpattern.
Psychiatricexaminationcanrevealanxietyaccompaniedbytremulousness,sweatingor
hyperventilation.
2,4,8

Diagnostic Examination
Manydiagnosticmodalitiesusedtoevaluatedyspneacanbeperformedinthefamilyphysician's
office. Thebasicevaluationisdirectedbytheprobablecausessuggestedinthehistoryandphysical
examination.Themostcommonorganiccausesofdyspneaarecardiacandpulmonarydisorders.
10

Themostusefulmethodsofevaluatingdyspneaaretheelectrocardiogramandchestradiographs.
Theseinitialmodalitiesareinexpensive,safeandeasilyaccomplished.Theycanhelpconfirmor
excludemanycommondiagnoses.
Theelectrocardiogramcanshowabnormalitiesoftheheartrateandrhythm,orevidenceofischemia,
injuryorinfarction.Voltageabnormalitysuggestsleftorrightventricularhypertrophyifthevoltage
isexcessive,orpericardialeffusionorobstructivelungdiseasewithincreasedchestdiameterifthe
voltageisdiminished.
Achestradiographcanidentifyskeletalabnormalities,suchasscoliosis,osteoporosisorfractures,or
parenchymalabnormalities,suchashyperinflation,masslesions,infiltrates,atelectasis,pleural
effusionorpneumothorax.Anincreasedcardiacsilhouettecanbecausedbyincreasedpericardial
sizeorincreasedchambersize.
Afingerstickhemoglobindeterminationoracompletebloodcountcanquantifytheseverityof
suspectedanemia.Thyroidabnormalitiesrarelypresentwithdyspneaandcanbeassessedby
measurementoftheserumthyroidstimulatinghormonelevel.
4,8

Thehistory,physicalexaminationandpreliminarydiagnosticmodalitiessuchaschestradiography
andelectrocardiographyusuallyrevealtheunderlyingcauseorcausesofdyspnea,butinselected
casesfurtherdiagnosticevaluationmaybeneeded.Usefulsecondlinetestsincludespirometry,pulse
oximetryandexercisetreadmilltesting.Thesetestscanclarifythediagnosisifinitialmodalities
indicateanabnormalityorareinconclusive.
SPIROMETRY

Spirometrydependsonpatienteffort;ifthepatientisunabletogiveamaximaleffort,thetesthas
limitedvalue.Toperformthetest,mostpatientsrequirespecificdemonstrationoftheappropriate
techniqueandcoachingduringthetestinordertoproduceamaximaleffort.Thepatientexhales
fully,thentakesamaximuminhalationandblowsoutashardandasfastaspossible,continuingthe
exhalationaslongaspossibletoensurethatmaximalvolumesaremeasured.Thetestmaybe
repeateduntiltheresultsareconsistent.Spirometryisextremelysafeandhasvirtuallynoriskof
seriouscomplications. Themostcommonerrorsintechniquearefailuretoexhaleasfastaspossible
andfailuretocontinueexhalationaslongaspossible.
4,9

Spirometrycanhelpdifferentiateobstructivelungdiseasefromrestrictivelungdisease(Table3).
COPD(chronicbronchitisoremphysema)andasthmaarethemostcommoncausesofanobstructive
spirometrypattern.Arestrictivepatterncanbecausedbyextrapulmonaryfactors,suchasobesity;by
skeletalabnormalities,suchaskyphosisorscoliosis;bycompressingpleuraleffusion,andby
neuromusculardisorders,suchasmultiplesclerosisormusculardystrophy.Anumberofsystemic
diseases,suchasrheumatoidarthritis,systemiclupuserythematosusandsarcoidosis,cancause
interstitiallungdisease,whichleadstoarestrictivepatternonspirometry.Othercausesofinterstitial
diseaseincludefarmer'slungandotherpneumoconioses,infiltratingmalignancy,fibrosisduetoside
effectsofsomemedications(e.g.,somechemotherapeuticagents,amiodarone[Cordarone])and
idiopathicinterstitialfibrosis,whichconstitutesthelargestsinglecategoryofinterstitiallung
disease.
9

TABLE 3

Spirometric Parameters Used to Distinguish Obstructive from Restrictive

Pulmonary Disease

Type of disease

Screening spirometry
FVC
FEV
FEV /FVC

Complete lung volume

TLC
RV

Obstructive lung disease

or N

or N or

Restrictive lung disease

or

or

N or

= mildly decreased; = moderately to severely decreased; = increased; N = normal; FVC = forced vital
capacity; FEV = forced expiratory volume in one second; TLC = total lung capacity; RV = residual volume.
1

PULSE OXIMETRY

Pulseoximetryusesaninfraredlightsourcetodeterminethehemoglobinoxygensaturation.
However,thepercentageofoxygensaturationdoesnotalwayscorrespondtothepartialpressureof
arterialoxygen(PaO ).Thehemoglobindesaturationcurvecanbeshiftedtotheleftorright
dependingonthepH,temperature(e.g.,oximeterusedonacoolextremity)orarterialcarbon
monoxideorcarbondioxidelevel.Thus,aborderlinenormaloxygensaturationpercentagemay
actuallyreflectanabnormallylowPaO insomecases. Pulseoximetryis,however,valuableasa
rapid,widelyavailableandnoninvasivemeansofassessmentandisaccurateinmostclinical
situations.
2

10

ARTERIAL BLOOD GASES

ArterialbloodgasmeasurementcanprovideinformationaboutalteredpH,hypercapnia,hypocapnia
orhypoxemia.Thismeasurementismorecommonlyusedfortheevaluationofacutedyspneabutit
canalsobeusedintheevaluationofpatientswhohavegraduallybecomedyspneicorwhoare
chronicallydyspneic.Arterialbloodgasmeasurementcanbenormal,however,inpatientswith
clinicallysignificantpulmonarydisease.Anabnormalityofarterialbloodgasparametersmay
sometimesbeseenonlyduringexercise,witharapidreturntonormalduringrest.Normalarterial
bloodgasmeasurementsdonotexcludecardiacorpulmonarydiseaseasacauseofdyspnea.
2

COMPLETE PULMONARY FUNCTION TESTING

Completepulmonaryfunctiontestingcanbeobtainedifscreeningofficespirometryisinconclusive.
Measurementofalltypesoflungvolume,suchastotallungcapacityandresidualvolume,canshow
combinationsofobstructiveandrestrictivedisease(Table3).Thediffusingcapacityofthelungfor
carbonmonoxide(DLCO)isoftenincludedincompletepulmonaryfunctiontesting.TheDLCOis
usedtoindirectlymeasurethegasexchangeofoxygenandcarbondioxideacrossthealveolar
surface.Reduceddiffusingcapacitycanoccurinavarietyofalveolarorinterstitialabnormalities,
suchasedema,inflammation,infection,infiltrationandmalignancy.Reducedoxygendiffusioncan
markedlycontributetodyspnea;however,itusuallyoccurswithsomespirometricabnormality.
2,4,10

EXERCISE TREADMILL TESTING

Exercisetreadmilltestingcantargetischemiaasacauseofdyspnea. Thistestcanbeperformed
whensymptomsareatypicalforexertionalanginaorwhensilentischemiaissuspectedasacauseof
dyspneaonexertion.Apatient'sabilitytoperformatreadmilltestcanbelimitedbypooraerobic
conditioning,bylowerextremitypathologysuchasarthritis,claudicationoredema,orby
coincidentalpulmonarydisease.Exercisetreadmilltestingisrelativelysafeandhasfewrisks:only
onein10,000patientsdiesofmalignantarrhythmiaoracutemyocardialinfarction,andonlytwoin
10,000haveseriousbutnonfatalarrhythmiaoranothercomplication.
11

11

Thenormalphysiologicresponsetoexercisetestingisanincreaseinbloodpressureandheartrate.
Toachievemaximaleffort,theheartrateshouldreachatleast85percentofthetargetheartratefor
thepatient'sage.UnderlyingheartdiseasemaybesignifiedbySTsegmentchanges,byarrhythmias
orbyinappropriatebloodpressurechangesduringexercise.Therearelimitationstothesensitivity
andspecificityoftreadmilltesting,however,andinterpretationoftheresultsmayvary.Negative
resultsontreadmillexercisetestinginapatientwhohasdyspneabutnochestpainorothercardiac
riskfactorssuggestthatdyspneaiscausedbysomethingotherthancoronaryarterydisease.When
theresultsareequivocalordifficulttointerpret,furtherdiagnostictestingorconsultationshouldbe
considered.
7,8

ECHOCARDIOGRAPHY

Echocardiographycandetectavalvularabnormalityandmaybediagnosticallyhelpfulinpatients
withquestionablemurmursinthecontextofdyspnea.Chambersize,hypertrophyandleftventricular
ejectionfractioncanalsobeassessed.Amultigatedcardiacacquisition(MUGA)scanor
radionucleotideventriculographycanalsobeusedtoquantifytheejectionfraction.
CARDIOPULMONARY EXERCISE TESTING

Cardiopulmonaryexercisetestingquantifiescardiacfunction,pulmonarygasexchange,ventilation
andphysicalfitness.Cardiopulmonaryexercisetestingmaybeusedinselectedcaseswhenthe
diagnosisisstillunclearaftertheinitalexamination.Itcanbeparticularlyusefulincaseswhere
obesity,anxiety,deconditioning,exerciseinducedasthmaorotherproblemsprecludestandard
exercisetreadmilltesting.
Thetestisusuallyperformedonatreadmillorbicycleergometerandrequiresthatthepatientbreathe
intoamouthpieceduringexercise.Thepatientperformsprogressivelymoredifficultexercisetothe
pointofexhaustion.Duringexercise,oxygenationismeasuredbyusingeitherapulseoximeteroran
arterialline,andinterpretationofthecompletetestrequiresanalysisofoxygenconsumption,carbon
dioxideproduction,anaerobicthreshold,heartrateandrhythm,bloodpressure,minuteventilation,
continuousmonitoringofgasexchange,severityofperceivedexertion,dyspnea,chestpainandleg
discomfort.Cardiopulmonaryexercisetestingcanhelpdefinewhetheranabnormalityliesinthe
pulmonary,cardiacorskeletalmusclesystems.
2,4

Final Comment
Inmostpatients,thecauseorcausesofdyspneacanbedeterminedinastraightforwardfashionby
usingthehistoryandphysicalexaminationtoidentifycommoncardiacorpulmonaryetiologies.In

selectedcases,specificdiagnostictestingorconsultationmaybeneededtoconfirmthediagnosisor
toprovideassistancewiththerapeuticmanagement.

The Authors
WALTER C. MORGAN, M.D., is program director of the Family Medicine Residency Program of Kaiser Permanente
Medical Center in Riverside, Calif., and clinical assistant professor of family medicine at the University of Southern
California School of Medicine, Los Angeles. He received his medical degree from the University of Washington
School of Medicine, Seattle, and completed a residency in family medicine at San Bernardino (Calif.) County Medical
Center. Dr. Morgan has a certificate of added qualification in geriatric medicine.
HEIDI L. HODGE, M.D., is currently staff physician in the Department of Family Medicine at the Kaiser Permanente
Medical Offices in Longview, Wash. She received her medical degree from the University of Tennessee, Memphis,
College of Medicine and completed a residency in family medicine at the Kaiser Permanente Medical Center in
Riverside, Calif., where she was chief resident during her last year of residency.
Address correspondence to Walter C. Morgan, M.D., Department of Family Medicine, Kaiser Permanente Medical
Center, 10800 Magnolia Blvd., Riverside, CA 92505-3043. Reprints are not available from the authors.
The authors thank the Medical Editing Department of the Kaiser Foundation Research Institute, Oakland, Calif., for
providing editorial assistance.

REFERENCES
1. Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990.
2. Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed. Baltimore: Williams & Wilkins,
1986.

3. Tobin MJ. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med.
1990;150:160413.

4. Silvestri GA, Mahler DA. Evaluation of dyspnea in the elderly patient. Clin Chest Med. 1993;14:393404.
5. Cockcroft A, Adams L, Guz A. Assessment of breathlessness. Q J Med. 1989;72:66976.
6. Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern
Med. 1993;8:38392.

7. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997.
8. Fauci AS, ed. Harrison's Principles of internal medicine. 14th ed. New York: McGraw-Hill, 1997.
9. Enright PL, Hyatt RE, eds. Office spirometry: a practical guide to the selection and use of spirometers.
Philadelphia: Lea & Febiger, 1987:253.

10. Baum GL, Wolinsky E, eds. Textbook of pulmonary diseases. 4th ed. Boston: Little, Brown, 1989: 15952102.
11. Rubenstein E, Federman DD, eds. Respiratory medicine. In: Scientific American medicine. New York: Scientific
American, 1995.

http://www.aafp.org/afp/1998/0215/p711.html