Latest news with #shortnessofbreath
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
24-07-2025
- Health
- Medscape
A Puzzling Pneumothorax in a 36-Year-Old Woman
A 36-year-old woman with no significant medical history presented with recurrent spontaneous pneumothorax accompanied by acute chest pain and shortness of breath, an unusual occurrence, particularly in non-smokers without underlying lung disease. The case was reported by Farman H. Fatah, MD, and colleagues from the University of Sulaymaniyah, Sulaymaniyah, Iraq. The Patient and Her History The patient presented to the emergency department with acute left-sided chest pain and shortness of breath. She had a history of asthma and right-sided spontaneous pneumothorax 7 years earlier, which was treated with video-assisted thoracoscopic surgery (VATS) and pleurodesis. Her family history was notable for asthma on her mother's side and colonic cancer on her father's side. She denied any history of smoking or environmental exposures. On physical examination, breath sounds were markedly decreased over the left hemithorax. A chest x-ray was performed, revealing a left-sided apical pneumothorax characterised by a region of radiolucency with absent lung markings, indicating air accumulation in the pleural space. A pigtail catheter was inserted to relieve the pneumothorax. Despite appropriate pigtail placement and conservative management, the pneumothorax persisted. The patient was referred for surgical evaluation and underwent VATS with pleurodesis and wedge resection. Intraoperatively, a ruptured subpleural bleb in the left upper lobe was identified and excised. Histopathology of the resected tissue was non-specific and showed no malignancy. A chest CT was performed to investigate the underlying cause. Imaging revealed the site of the bleb rupture and multiple thin-walled cysts scattered throughout the lung parenchyma. Given the history of recurrent spontaneous pneumothorax, presence of bilateral pulmonary cysts, and family history of cancer, Birt-Hogg-Dubé syndrome (BHDS) was suspected. Findings and Diagnosis Genetic testing for mutations in the FLCN gene confirmed the diagnosis. The test included sequencing and deletion/duplication analyses of FLCN . A pathogenic mutation in FLCN , confirmed by molecular testing, established a diagnosis of BHDS. BDHS is a rare autosomal dominant disorder caused by mutations in the FLCN gene and is characterised by a clinical triad of pulmonary cysts with spontaneous pneumothorax, cutaneous fibrofolliculomas, and renal tumours. Although the estimated prevalence of BHDS is approximately two cases per million, its actual incidence is believed to be higher due to frequent underdiagnosis and highly variable clinical presentations, even among members of the same family. BHDS is often suspected in patients presenting with cystic lung lesions, a family history of related manifestations, recurrent pneumothorax, and characteristic dermatologic findings. A definitive diagnosis is established through genetic testing to confirm pathogenic variants in the FLCN gene. The patient had no known renal or dermatologic manifestations at the time of diagnosis of the disease. She continued to experience mild postoperative dyspnoea and chest discomfort but resumed her daily activities and returned to work. She was scheduled for routine follow-up, including pulmonary function testing and renal surveillance imaging, according to the BHDS management guidelines. Discussion Pulmonary manifestations are often the earliest and most prominent clinical features of BHDS, frequently preceding skin and renal findings. The syndrome is characterised by multiple bilateral pulmonary cysts that tend to be irregular, thin-walled, and predominantly located in the basal and subpleural regions of the lungs. These cysts predispose affected individuals to spontaneous pneumothorax, which can be the first and sometimes the only presenting symptom. One of the key challenges in diagnosing BHDS is its variable presentations. While the classical triad includes skin fibrofolliculomas, renal tumours, and pulmonary cysts, some individuals, like our patient, may present solely with pulmonary involvement. This phenotypic variability can lead to delayed or missed diagnoses, particularly when cutaneous or renal signs are absent or subtle. Approximately 41% of pulmonary cysts present with spontaneous pneumothorax, with a recurrence rate of 41%. The majority of patients (> 90%) develop multiple fibrofolliculomas, especially on the face and upper trunk, in the second or third decade of life, with dermatologic findings serving as the first clinical clue in 25%-50% of cases. Renal tumours are observed in nearly 30% of patients, at a mean age of 50 years. Although the estimated prevalence of BHDS is approximately two cases per million, its actual incidence is believed to be higher due to frequent underdiagnosis and highly variable clinical presentations, even among members of the same family. This highlights the importance of considering BHDS in the differential diagnosis of spontaneous pneumothorax, particularly when it is recurrent or associated with atypical cystic lung disease. Genetic confirmation through FLCN mutation testing is crucial not only to establish a definitive diagnosis but also to initiate appropriate long-term surveillance for potentially life-threatening renal malignancies. Surgical intervention, such as VATS pleurodesis, may be necessary when conservative approaches fail. This case underscores the importance of considering BHDS in patients presenting with recurrent spontaneous pneumothorax, particularly when bilateral pulmonary cysts are evident and no other clear aetiology is identified.
