Latest news with #dyspnea
Medscape
3 days ago
- Health
- Medscape
Investigate Shortness of Breath: Here's How
If a patient calls their primary care provider and complains about shortness of breath, an in-office examination is generally warranted. Your patient may explain how they're out of breath from everyday activities, like using stairs or 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, MHS, pulmonologist and associate professor, Division of Pulmonary and Critical Care Medicine at Johns Hopkins School of Medicine in Baltimore. But if the patient has a diagnosed condition, a phone or virtual discussion could be enough. 'The only time I can see foregoing an immediate clinic visit is if a known cardiopulmonary diagnosis exists,' Galiatsatos said. For example, if you already know the patient has a pulmonary or cardiac condition and their dyspnea (shortness of breath) is similar to prior episodes of breathlessness, then an in-office appointment may not necessarily be needed, he said. Those could be managed by both an action plan that has already been discussed at prior visits. A Red Flag During Office Visits What if a patient is already in the office for another reason and casually mentions episodes of shortness of breath, how should the primary doctor proceed? Panagis Galiatsatos, MD, MHS Even if dyspnea is mentioned casually, 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, said Lijo Illipparambil, MD, pulmonologist and assistant professor of Clinical Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia. When discussing such symptoms, Illipparambil recommends these questions: When do episodes occur — during exertion vs rest? How long have these symptoms been occurring? Are there other symptoms, like fatigue, chest tightness, wheezing, cough, or swelling? How limiting are the symptoms? Is the patient able to climb stairs, and if so, how many? Is walking across a room or doing daily chores causing them to be dyspneic? How to Be a Frontline Partner? 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. They coordinate care, especially with specialists, provide lifestyle counseling, and monitor chronic conditions like COPD [chronic obstructive pulmonary disease], asthma, and congestive heart failure,' Illipparambil said. Lijo Illipparambil, MD In many ways, they are the real central component for care of patients with dyspnea, he affirmed. '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 said. Assessment Protocol Usually, a thorough physical exam, including checking vital signs, especially oxygen saturation and heart rate, is next, Illipparambil said. And additional testing should be considered including chest x-ray, EKG, and laboratory work-up, as well as referral to specialists if warranted. Red flags that warrant further testing include: Dyspnea at rest is always a reason for further testing, he said. 'It is not normal to be short of breath at rest; it is most often a sign of significant impending decompensation. Additionally, Illipparambil said, worsening shortness of breath over days/weeks can demonstrate a progressive process. 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 possible pulmonary embolism if present when a patient is short of breath, he said. Expert Assessments and Symptoms Consider the shortness-of-breath assessments below, according to Galiatsatos: 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 explained. Cardiac rhythm issues (especially low heart rates). Most people notice this breathlessness even within a few dozen feet or so of walking on flat surface, he cited. Pulmonary embolism (lung blood clot). This is more acute in occurrence, and patients often describe a heaviness and uncomfortableness in their chest. 'This is often accompanied by something that provoked the blood clot, long hours of sitting say from a long flight, or a trauma to the legs,' Galiatsatos continued. Heart failure. The key symptom here is the inability to lay down flat, he asserted. Patients may note having to sleep with several pillows, prompting their head and upper torso to be more and more vertical or abandoning sleeping in a bed and sleeping in a recliner, he also explained. Lifestyle Strategies The key is to be empathetic, collaborative, and goal oriented. 'This is indeed a delicate yet vital conversation,' Illipparambil said. There are several reasons for shortness of breath and approaching patients this way can help with patient openness and discussion. One thing that helps is the use of motivational interviewing techniques. For instance, he recommends asking permission to discuss weight, tobacco use, or other lifestyle habits that may be affecting shortness of breath can help establish a partnering role in these goals. Another way to approach, he continued, is focusing on functions such as walking without getting winded and changing habits toward a healthy lifestyle rather than just the number on the scale. 'Additionally, offering resources and referrals for nutrition, sleep study, physical therapy, etc., can go a long way. Medications, of course, can help, especially inhalers in COPD and asthma patients. Antihypertensives and other medications that help modify heart disease, and goal-directed medical therapy have been shown to improve symptoms in patients with heart failure,' Illipparambil also said. How Does Obesity Intersect With Shortness of Breath? Obesity is often linked to cardiopulmonary deconditioning, according to Trishul Siddharthan, MD, pulmonologist and associate professor of the Department of Medicine with the University of Miami Miller School of Medicine and the UHealth — University of Miami Health System, both in Miami. '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 outlined. Lifestyle changes and other strategies to cope are a shared decision, he said. 'I ensure I address the underlying medical condition while addressing enablers and barriers to weight loss.'
Medscape
4 days ago
- Health
- Medscape
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.'
Medscape
05-06-2025
- Health
- Medscape
Dyspnea, Cough, and Extreme Fatigue in a Hiker
Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@ with the subject line "Case Challenge Suggestion." We look forward to hearing from you. Background and Initial Presentation A 32-year-old man presents to an emergency department in a remote mountain town after being rescued from a solo hiking expedition at 12,500 feet. He had been hiking for 3 days at high altitude with minimal acclimatization. Over the past 24 hours, he has developed progressive shortness of breath, a persistent dry cough, and extreme fatigue. The symptoms worsened overnight, and he was unable to continue hiking. He activated his personal emergency beacon and was airlifted to safety. Upon arrival at the hospital, he appeared dyspneic, with a resting oxygen saturation of 82% on room air. Physical Examination and Workup On examination, the patient was tachypneic (respiratory rate, 28 breaths/min) and tachycardic (heart rate, 112 beats/min). He was afebrile. Auscultation revealed bilateral inspiratory crackles, most prominent in the lower lung fields. There was no peripheral edema or jugular venous distension. Chest radiography is the most important initial test of those listed above because it provides rapid, noninvasive imaging to assess for pulmonary pathology and can help differentiate between potential causes of hypoxemia. Although ECG can help rule out cardiac causes, it is neither sensitive nor specific for the likely causes of this patient's symptoms. Similarly, although arterial blood gas analysis provides useful information about oxygenation and acid-base status, it does not identify the underlying cause of hypoxemia. CT pulmonary angiography is primarily used to evaluate for pulmonary embolism; however, given the low pretest probability based on the patient's history, a D-dimer should be obtained first. Initial workup included chest radiography, which demonstrated patchy alveolar infiltrates (Figure). Arterial blood gas analysis revealed hypoxemia (partial pressure of arterial oxygen, 58 mm Hg) and respiratory alkalosis (pH, 7.48). Bedside lung ultrasonography, performed shortly after presentation, showed diffuse B lines bilaterally. Cardiac biomarkers (troponin and B-type natriuretic peptide) were within normal limits, and ECG showed sinus tachycardia without ischemic changes. D-dimer was 0.3 mg/L (low probability). Figure. Chest radiograph showing patchy alveolar infiltrates. Discussion High-altitude pulmonary edema (HAPE) is a noncardiogenic pulmonary edema caused by hypoxia-induced pulmonary vasoconstriction at high altitudes.[1,2] It typically occurs above 8000 feet and is a leading cause of altitude-related mortality.[1] Risk factors include rapid ascent, lack of acclimatization, and strenuous physical exertion.[1-3] The diagnosis of HAPE is clinical and based on a history of recent ascent in an unacclimatized individual. Diagnosis, particularly in the field, relies primarily on characteristic reported symptoms such as dyspnea on exertion disproportional to previous experience, nonproductive cough, fatigue, and weakness, which can progress to dyspnea at rest. Objective findings, when available, aid in confirming the diagnosis and ruling out alternatives.[1] In well-resourced facilities, the presence of hypoxemia and either unilateral or diffuse bilateral alveolar opacities on plain chest radiography is sufficient to confirm the diagnosis in the appropriate clinical context. Objective findings include radiographic findings of pulmonary edema, often seen as patchy alveolar infiltrates on chest radiographs, and diffuse B lines on lung ultrasound, consistent with pulmonary congestion.[4] Arterial blood gas analysis frequently shows hypoxemia with respiratory alkalosis, and pulse oximetry can confirm hypoxemia, a key feature that distinguishes HAPE from other sources of dyspnea. The case patient had hypoxemia and respiratory alkalosis. This distinction can help differentiate between inflammatory and infectious causes of pulmonary infiltrates at altitude. Although HAPE can present with a low-grade fever, it typically lacks the high-grade fever, leukocytosis, and purulent sputum often associated with pneumonia. Differentiation from other conditions presenting with pulmonary edema is important.[1] Acute respiratory distress syndrome, while also a non-cardiogenic pulmonary edema, usually occurs in response to a systemic insult rather than altitude exposure. Pulmonary embolism is less likely given the absence of pleuritic chest pain, focal findings on imaging, and a normal D-dimer value but should not be excluded solely on clinical grounds. Treatment of HAPE The mainstay of HAPE treatment is immediate descent to lower altitude, which often leads to rapid improvement. Supplemental oxygen is highly effective in reversing hypoxemia. When descent is not possible, pharmacologic treatment with nifedipine (a pulmonary vasodilator) can reduce pulmonary hypertension and improve oxygenation. Portable hyperbaric chambers may also be used in remote settings. Beta-blockers are not recommended because they blunt the sympathetic response needed to maintain adequate cardiac output and oxygen delivery during hypoxia.[5] In addition, they do not address the underlying pulmonary hypertension that contributes to HAPE.[5] The patient was placed on high-flow oxygen, given oral nifedipine, and observed for 24 hours. He demonstrated significant improvement, with normalization of his oxygen saturation and resolution of dyspnea. He was advised to avoid rapid ascents in the future, which is a primary method for preventing HAPE. He was also advised to consider prophylactic nifedipine for future high-altitude activities. Tadalafil may be used in patients who are not candidates for nifedipine. Acetazolamide should not be used for HAPE prevention in those with a history of the disease, although it can be considered for prevention of reentry HAPE, which affects individuals who reside at high altitudes, travel to a lower elevation, and then develop HAPE upon rapid return to their residence.[1] Proper prevention strategies for altitude sickness include gradual ascent, often achieved through staged ascent and limiting daily altitude gain. For HAPE prevention in individuals with a history of the condition, nifedipine is the preferred medication, with tadalafil as an alternative.[1-3] The patient was discharged with instructions to avoid further high-altitude exposure until fully recovered and to seek medical guidance for future expeditions. HAPE is a potentially life-threatening condition, but with prompt recognition and treatment, the prognosis is generally excellent. When treated early with interventions including immediate descent to a lower altitude, supplemental oxygen, and sometimes medications such as nifedipine, most patients recover fully, without long-term complications.[1,2] The condition is typically self-limiting once altitude exposure is reduced, and most patients do not develop chronic lung disease. However, if left untreated or reexposure occurs without proper acclimatization, the condition can be fatal or lead to complications. Patients who experience HAPE should be educated on proper acclimatization strategies to prevent recurrence in future high-altitude activities, but with appropriate treatment, full recovery is common and long-term effects are rare.
