3 days ago
PCPs as Frontline in Dyspnea
When a patient calls a primary care provider due to shortness of breath symptoms, recommending an in-office examination is generally warranted. Your patient may explain how they are out of breath from everyday activities like using stairs, getting winded from walking the dog, or just not being able to catch their breath.
'All new episodes of shortness of breath should be evaluated in real time by a clinician, ideally in person,' said Panagis Galiatsatos, MD, a pulmonologist and associate professor in the Division of Pulmonary and Critical Care Medicine at Johns Hopkins School of Medicine in Baltimore. 'The only time I can see foregoing an immediate clinic visit is if a known cardiopulmonary diagnosis exists.'
For example, if a diagnosis is already known (eg, chronic obstructive pulmonary disease [COPD]) and their dyspnea (shortness of breath) is in accordance with prior episodes of similar breathlessness, a phone call or virtual discussion could be enough.
Such episodes could also be managed by an action plan that has already been discussed at prior clinic visits, Galiatsatos said.
If a patient, already in the office for another concern, casually mentions episodes of shortness of breath, how should the primary doctor proceed?
Even if dyspnea is mentioned nonchalantly, it warrants a thorough history and focused physical exam, especially if this is new or worsening. This could be an early sign of a more serious problem, according to Lijo Illipparambil, MD, a pulmonologist and assistant professor of clinical thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia.
When discussing symptoms, Illipparambil recommends these questions:
• Start the discussion related to context: When do episodes occur — exertion or rest?
• How long have these symptoms been occurring?
• Inquire about associated symptoms such as fatigue, chest tightness, wheezing, cough, or swelling.
• Review exercise limitations: are they able to climb stairs, and if so, how many? Is walking across a room or doing daily chores causing them to be dyspneic?
How can primary care doctors serve as frontline partners in managing patients' shortness of breath?
Primary care doctors are essential in identifying early signs of cardiopulmonary disease.
'Generally, they are the first physicians who meet the patients and do most of the work-up initially,' said Illipparambil. 'They coordinate care, especially with specialists, provide lifestyle counseling, and monitor chronic conditions like COPD, asthma, and congestive heart failure.'
In many ways, they are the real central component for care for patients with dyspnea, he said. 'They also have the advantage of longitudinal relationships, allowing them to notice changes over time and engage in shared decision-making to create sustainable health strategies and earlier intervention if needed,' Illipparambil explained.
Assessment Protocol
Usually, a thorough physical exam, including checking vital signs (especially oxygen saturation and heart rate) is next, according to Illipparambil. Additional testing should also be considered, including chest x-ray, EKG, and laboratory work-up, as well as referral to specialists if necessary.
Red flags that warrant further testing include:
• Dyspnea at rest: This is always a reason for further testing, according to Illipparambil. 'It is not normal to be short of breath at rest; it is most often a sign of significant impending decompensation,' he said. Worsening shortness of breath over days or weeks can demonstrate a progressive process, Illipparambil added. Difficulty walking short distances or performing basic activities (eg, walking in the supermarket, pushing a stroller), especially as a change from their baseline, can be a sign of an active problem.
• Orthopnea or paroxysmal nocturnal dyspnea are signs of heart failure that need further investigation.
• Unilateral leg swelling should always have a differential that includes deep venous thrombosis and, when a patient is short of breath, possible pulmonary embolism, Illipparambil said.
Expert Assessments and Symptoms
Consider the shortness of breath assessments below, according to Galiatsatos with Johns Hopkins.
Airway diseases. COPD or asthma are examples. 'I would recognize due to inability to walk incline or when holding groceries, not walking through the grocery store, but once their arms are engaged, their breathlessness is noticeable,' he said.
Cardiac rhythm issues. Especially at low heart rates, most people notice this breathlessness even after walking just a few dozen feet on a flat surface, he noted.
Pulmonary embolism (lung blood clot). This tends to occur more acutely, and patients often describe a heaviness and discomfort in their chest. 'This is often accompanied by something that provoked the blood clot — long hours of sitting (for example, during a long flight) — or trauma to the legs,' Galiatsatos said.
Heart failure. The key symptom here is the inability to lay down flat. Patients will note having to sleep with several pillows — propping their head and upper torso in an upright position — or abandoning their bed altogether in favor of a recliner, he explained.
How can a primary doctor discuss lifestyle changes, medications, or strategies to reduce shortness of breath?
The key is to be empathetic, collaborative, and goal oriented. 'This is indeed a delicate yet vital conversation,' Illipparambil said. There are several causes for shortness of breath and approaching patients this way can encourage openness and discussion.
One thing that helps is the use of motivational interviewing techniques. For instance, Illipparambil recommends asking permission to discuss weight, tobacco use, or other lifestyle habits that may be affecting shortness of breath.
Another approach is to focus on functions, such as walking without getting winded and changing habits toward a healthy lifestyle, rather than just the number on the scale.
Offering resources and referrals for issues like nutrition, sleep, and physical therapy can also go a long way, Illipparambil said.
'Medications, of course, can help, especially inhalers in COPD and asthma patients,' he said. 'Antihypertensives, other medications that help modify heart disease, and goal-directed medical therapy have been shown to improve symptoms in patients with heart failure.'
How does obesity affect with shortness of breath?
Obesity is often linked to cardiopulmonary deconditioning, according to Trishul Siddharthan, MD, a pulmonologist and associate professor of medicine with the University of Miami Miller School of Medicine, Miami, and the University of Miami Health System.
'Extra weight is a significant cause of shortness of breath in the general population and interacts with respiratory diseases, like asthma, to worsen symptoms,' Siddharthan said. 'I think most patients understand how weight can impair respiratory status, particularly if they are having shortness of breath. Lifestyle changes and other strategies to cope are a shared decision. I ensure I address the underlying medical condition while addressing enablers and barriers to weight loss.'
