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{{SignSymptom infobox |
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{{Infobox Symptom
Name = Dyspnea |
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| Name = Dyspnea
Image = |
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| Image =
Caption = |
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DiseasesDB = 15892 |
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| DiseasesDB = 15892
ICD10 = {{ICD10|R|06|8|r|06}}|
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| ICD10 = {{ICD10|R|06|0|r|00}}
ICD9 = {{ICD9|786.0}} |
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| ICD9 = {{ICD9|786.09}}
ICDO = |
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| ICDO =
OMIM = |
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| OMIM =
MedlinePlus = 003075 |
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| MedlinePlus = 003075
eMedicineSubj = |
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eMedicineTopic = |
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| eMedicineTopic =
MeshID = D004417 |
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| MeshID = D004417
 
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'''Dyspnea''' or '''dyspnoea''' (pronounced ''disp-nee-ah'', [[IPA]] /dɪsp'niə/), from [[Latin language|Latin]] ''dyspnoea'', from [[Greek language|Greek]] ''dyspnoia'' from ''dyspnoos'', shortness of breath) or '''shortness of breath''' (SOB) is perceived to be difficulty of breathing or painful breathing. It is an aspect of [[respiration]] and is a common symptom of numerous [[disorders]].
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'''Dyspnea''' ({{IPAc-en|d|ɪ|s|p|ˈ|n|iː|ə}} {{respell|disp|NEE|ə}}; also '''dyspnoea'''; [[Latin language|Latin]]: ''dyspnoea''; [[Greek language|Greek]]: ''δύσπνοια'', ''dýspnoia''), '''shortness of breath''' (SOB), or '''air hunger''',<ref>[http://copd.about.com/od/glossaryofcopdterms/g/dyspnea.htm About.com Health's Disease and Condition content > Dyspnea] By Deborah Leader. Updated August 05, 2008</ref> is the subjective symptom of ''breathlessness''.<ref name=Shiber06>{{cite journal |author=Shiber JR, Santana J |title=Dyspnea |journal=Med. Clin. North Am. |volume=90 |issue=3 |pages=453–79 |year=2006 |month=May |pmid=16473100 |doi=10.1016/j.mcna.2005.11.006 |url=}}</ref><ref name=Pal2010/>
   
'''Dyspnea on exertion''' ('''DOE''' or '''exertional dyspnea''') indicates dyspnea that occurs (or worsens) during [[Exercise|physical activity]]. Dyspnea on exertion is considered medically normal and does not warrant the ICD-9 786.09.{{Fact|date=November 2008}}
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It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations.<ref name=Shiber06/> In 85% of cases it is due to either [[asthma]], [[pneumonia]], [[cardiac ischemia]], [[interstitial lung disease]], [[congestive heart failure]], [[chronic obstructive pulmonary disease]], or [[psychogenic]] causes.<ref name=Sarkar2006/> Treatment typically depends on the underlying cause.<ref name=Z2009/>
   
==Disorders of the lungs==
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From a psychological point of view the symptom can be very [[anxiety]] provoking, which can in turn interefere with the management of the causal conditions. In addition the symptoms can be produced by anxiety and [[hyperventilation]].
===Obstructive lung diseases===
 
* [[Asthma]]
 
* [[Bronchitis]]
 
* [[Chronic obstructive pulmonary disease]]
 
* [[Cystic fibrosis]]
 
* [[Emphysema]]
 
* [[larynx|Laryngeal]] [[edema]] due to [[allergies]]
 
* [[Hookworm disease]]
 
   
===Diseases of lung parenchyma and pleura===
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==Definition==
====Contagious====
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The [[American Thoracic Society]] defines dyspnea as: "A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity."<ref name=AmericanThoracicSociety>{{cite journal |author=American Heart Society |title=Dyspnea mechanisms, assessment, and management: a consensus statement |journal=Am Rev Resp Crit Care Med |volume=159 |pages=321–340 |year=1999 |doi=10.1164/ajrccm.159.1.ats898}}</ref> Other definitions describe it as "difficulty in breathing",<ref>[http://www.thefreedictionary.com/dyspnea TheFreeDictionary], retrieved on Dec 12, 2009. Citing:The American Heritage Dictionary of the English Language, Fourth Edition by Houghton Mifflin Company. Updated in 2009.Ologies & -Isms. The Gale Group 2008</ref> "disordered or inadequate breathing",<ref name=Uptodate>{{cite web |url=http://www.uptodate.com/online/content/topic.do?topicKey=adult/6520&selectedTitle=2~150&source=search_result |title=UpToDate Inc. |work= |accessdate=}}</ref> "uncomfortable awareness of breathing",<ref name=Pal2010/> and as the experience of "breathlessness" (which may be either acute or chronic).<ref name=Shiber06/><ref name=Z2009>{{cite journal |author=Zuberi, T. |title=Acute breathlessness in adults |journal=InnovAiT |volume=2 |issue=5 |pages=307–15 |year=2009 |doi=10.1093/innovait/inp055 |url=http://rcgp-innovait.oxfordjournals.org.cyber.usask.ca/content/2/5/307.full |display-authors=1 |last2=Simon |first2=C.}}</ref><ref>{{cite web |url=http://www.gpnotebook.co.uk/simplepage.cfm?ID=825557022 |title=dyspnea - General Practice Notebook |work= |accessdate=}}</ref>
* [[Anthrax]] through inhalation of ''[[Bacillus anthracis]]''
 
* [[Pneumonia]]
 
   
====Non-contagious====
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Dyspnea is distinct from [[labored breathing]], which is a common physical presentation of respiratory distress.{{citation needed|date=February 2012}}
* Fibrosing [[alveolitis]]
 
* [[Atelectasis]]
 
* [[Hypersensitivity pneumonitis]]
 
* [[Interstitial lung disease]]
 
* [[Lung cancer]]
 
* [[Pleural effusion]]
 
* [[Pneumoconiosis]]
 
* [[Pneumothorax]]
 
* Non-cardiogenic [[pulmonary edema]] or [[acute respiratory distress syndrome]]
 
* [[Sarcoidosis]]
 
   
===Pulmonary vascular diseases===
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==Differential diagnosis==
* Acute or recurrent [[Pulmonary embolism|pulmonary emboli]]
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{{Further|List of causes of shortness of breath}}
* [[Pulmonary hypertension]], primary or secondary
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While shortness of breath is generally caused by disorders of the [[cardiovascular system|cardiac]] or [[respiratory system]], other systems such as [[neurological]],<ref name="ch8139" /> [[musculoskeletal system|musculoskeletal]], [[endocrine system|endocrine]], [[Hematopoietic system|hematologic]], and psychiatric may be the cause.<ref name=Sarkar2006>{{cite journal |author=Sarkar S, Amelung PJ |title=Evaluation of the dyspneic patient in the office |journal=Prim. Care |volume=33 |issue=3 |pages=643–57 |year=2006 |month=September |pmid=17088153 |doi=10.1016/j.pop.2006.06.007 |url=}}</ref> [[DiagnosisPro]], an online medical expert system, listed 497 distinct causes in October 2010.<ref>http://en.diagnosispro.com/differential_diagnosis-for/poisoning-specific-agent-dyspnea/25103-154-100.html</ref> The most common cardiovascular causes are [[acute myocardial infarction]] and [[congestive heart failure]] while common pulmonary causes include [[chronic obstructive pulmonary disease]], [[asthma]], [[pneumothorax]],pulmonary edema and [[pneumonia]].<ref name=Shiber06/> On a pathophysiological basis the causes can be divided into: (1) an increased awareness of normal breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3) an abnormality in the ventilatory system.<ref name="ch8139">{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 8 | volume = 4 | editors = Willy E. Hammon III | publisher = Mosby Elsevier | year = 2006 | pages = 139}}</ref>
* Pulmonary [[veno-occlusive disease]]
 
* [[Superior vena cava syndrome]]
 
   
==Other causes of diminished breathing==
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===Acute coronary syndrome===
===Obstruction of the airway===
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[[Acute coronary syndrome]] frequently presents with retrosternal [[chest pain|chest discomfort]] and difficulty catching the breath.<ref name=Shiber06/> It however may atypically present with shortness of breath alone.<ref name=Old2007/> Risk factors include old age, [[smoking]], [[hypertension]], [[hyperlipidemia]], and [[diabetes]].<ref name=Old2007/> An [[electrocardiogram]] and [[cardiac enzymes]] are important both for diagnosis and directing treatment.<ref name=Old2007/> Treatment involves measures to decrease the oxygen requirement of the heart and efforts to increase blood flow.<ref name=Shiber06/>
* [[Cancer]] of the [[larynx]] or [[pharynx]]
 
* [[Empty nose syndrome]]
 
* [[Pulmonary aspiration]]
 
* [[Epiglottitis]]
 
   
===Immobilization of the diaphragm===
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===Congestive heart failure===
* Lesion of the [[phrenic nerve]]
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[[Congestive heart failure]] frequently presents with shortness of breath with exertion, [[orthopnea]], and [[paroxysmal nocturnal dyspnea]].<ref name=Shiber06/> It affects between 1-2% of the general United States population and occurs in 10% of those over 65&nbsp;years old.<ref name=Shiber06/><ref name=Old2007/> Risk factors for [[Acute decompensated heart failure|acute decompensation]] include high dietary [[salt]] intake, medication noncompliance, cardiac ischemia, [[Cardiac dysrhythmia|dysrhythmias]], [[renal failure]], pulmonary emboli, [[hypertension]], and infections.<ref name=Old2007/> Treatment efforts are directed towards decreasing lung congestion.<ref name=Shiber06/>
* [[Polycystic liver disease]]
 
* [[Tumor]] in the diaphragm
 
   
===Restriction of the chest volume===
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===Chronic obstructive pulmonary disease===
* [[Ankylosing spondylitis]]
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People with [[chronic obstructive pulmonary disease]] (COPD), most commonly [[emphysema]] or [[chronic bronchitis]], frequently have chronic shortness of breath and a chronic productive cough.<ref name=Shiber06/> An [[Acute exacerbation of chronic obstructive pulmonary disease|acute exacerbation]] presents with increased shortness of breath and [[sputum]] production.<ref name=Shiber06/> [[COPD]] is a risk factor for [[pneumothorax]]; thus this condition should be ruled out.<ref name=Shiber06/> In an acute exacerbation treatment is with a combination of [[anticholinergics]], [[beta2-adrenergic agonist|beta<sub>2</sub>-adrenoceptor agonists]], [[steroids]] and possibly [[positive pressure ventilation]].<ref name=Shiber06/>
* [[Bone fracture|Broken]] ribs
 
* [[Kyphosis]] of the spine
 
* [[Obesity]]
 
* [[Pregnancy]]
 
* [[Pectus excavatum]]
 
* [[Scoliosis]]
 
   
===Disorders of the cardiovascular system===
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===Asthma===
* [[Aortic dissection]]
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[[Asthma]] is the most common reason for presenting to the emergency with shortness of breath.<ref name=Shiber06/> It is the most common lung disease in both developing and developed countries affecting about 5% of the population.<ref name=Shiber06/> Other symptoms include [[wheezing]], tightness in the chest, and a non productive cough.<ref name=Shiber06/>
* [[Cardiomyopathy]]
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Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate.<ref>{{cite web |url=http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/treatment.html |title=How Is Asthma Treated and Controlled? |work= |accessdate=}}</ref> Acute symptoms are treated with short-acting bronchodilators.
* [[Congenital heart disease]]
 
* [[CREST syndrome]]
 
* [[Heart failure]]
 
* [[Ischaemic heart disease]]
 
* [[Malignant hypertension]]
 
* [[Pericardium]] disorders, including:
 
** [[Cardiac tamponade]]
 
** [[Constrictive pericarditis]]
 
** [[Pericardial effusion]]
 
* [[Pulmonary edema]]
 
* [[Pulmonary embolism]]
 
* [[Valvular heart disease]]
 
   
===Disorders of the blood and metabolism===
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===Pneumothorax===
* [[Anemia]]
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{{Main|Pneumothorax}}
* [[Hypothyroidism]]
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[[Pneumothorax]] presents typically with [[pleuritic chest pain]] of acute onset and shortness of breath not improved with oxygen.<ref name=Shiber06/> Physical findings may include absent breath sounds on one side of the chest, [[jugular venous distension]], and tracheal deviation.<ref name=Shiber06/>
* [[Metabolic acidosis]]
 
* [[Sepsis]]
 
* [[Leukemia]]
 
   
===Disorders affecting breathing nerves and muscles ===
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===Pneumonia===
* [[Amyotrophic lateral sclerosis]]
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{{Main|Pneumonia}}
* [[Guillain-Barré syndrome]]
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The symptoms of [[pneumonia]] are [[fever]], [[productive cough]], shortness of breath, and [[pleuritic chest pain]].<ref name=Shiber06/> Inspiratory [[crackles]] may be heard on exam.<ref name=Shiber06/> A chest x-ray can be useful to differential pneumonia from congestive heart failure.<ref name=Shiber06/> As the cause is usually a bacterial infections [[antibiotics]] are typically used for treatment.<ref name=Shiber06/>
* [[Multiple sclerosis]]
 
* [[Myasthenia gravis]]
 
* [[Parsonage Turner syndrome]]
 
* [[Eaton-Lambert syndrome]]
 
   
===Psychological conditions===
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===Pulmonary embolism===
* [[Anxiety disorder]]s and [[panic attack]]s
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[[Pulmonary embolism]] classically presents with an acute onset of shortness of breath.<ref name=Shiber06/> Other presenting symptoms include [[pleuritic chest pain]], cough, [[hemoptysis]], and [[fever]].<ref name=Shiber06/> Risk factors include [[deep vein thrombosis]], recent surgery, [[cancer]], and previous [[thromboembolism]].<ref name=Shiber06/> It must always be considered in those with acute onset of shortness of breath owing to its high risk of mortality.<ref name=Shiber06/> Diagnosis however may be difficult.<ref name=Shiber06/> Treatment is typically with [[anticoagulants]].<ref name=Shiber06/>
===Medications===
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* [[Fentanyl]]
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Pulmonary Edema link to COPD, Asthma and Heart failure.
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  +
===Anaemia===
  +
[[Anaemia]] caused by low hemoglobin levels is often a cause of dyspnea. Menstruation, particularly if excessive, can contribute to anaemia and to consequential dyspnea in women. Headaches are also a symptom of dyspnea in patients suffering from anaemia, some patients report a numb sensation in their head, and others have reported blurred vision caused by hypotension behind the eye due to a lack of oxygen and pressure, these patients have also reported severe head pain many of which lead to permanent brain damage, symptoms of this can be loss of concentration, focus, fatigue, language faculty impairment and memory loss.
  +
{{Citation needed|date=November 2012}}
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  +
===Other===
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Other important or common causes of shortness of breath include [[cardiac tamponade]], [[anaphylaxis]], [[interstitial lung disease]], [[panic attack]]s,<ref name=Sarkar2006/><ref name=Z2009/><ref name=Will2010>{{cite journal |author=Wills CP, Young M, White DW |title=Pitfalls in the evaluation of shortness of breath |journal=Emerg. Med. Clin. North Am. |volume=28 |issue=1 |pages=163–81, ix |year=2010 |month=February |pmid=19945605 |doi=10.1016/j.emc.2009.09.011 |url=}}</ref> and [[pulmonary hypertension]]. [[Cardiac tamponade]] presents with dyspnea, tachycardia, elevated jugular venous pressure, and [[pulsus paradoxus]].<ref name=Will2010/> The gold standard for diagnosis is [[ultrasound]].<ref name=Will2010/> [[Anemia]], that develops gradually, usually presents with exertional dyspnea, fatigue, weakness, and tachycardia.<ref name=Will2010/> It may lead to [[heart failure]].<ref name=Will2010/> [[Anaphylaxis]] typically begins over a few minutes in a person with a previous history of the same.<ref name=Z2009/> Other symptoms include [[urticaria]], [[angioedema|throat swelling]], and gastrointestinal upset.<ref name=Z2009/> The primary treatment is [[epinephrine]].<ref name=Z2009/> [[Interstitial lung disease]] presents with gradual onset of shortness of breath typically with a history of a predisposing environmental exposure.<ref name=Sarkar2006/> Shortness of breath is often the only symptom in those with [[tachydysrhythmias]].<ref name=Old2007/> [[Panic attack]]s typically present with [[hyperventilation]], sweating, and [[Paresthesia|numbness]].<ref name=Z2009/> They are however a [[diagnosis of exclusion]].<ref name=Sarkar2006/> Around 2/3 of women experience shortness of breath as a part of a normal [[pregnancy]].<ref name=Uptodate/> Neurological conditions such as spinal cord injury, phrenic nerve injuries, [[Guillain-Barre syndrome]], [[amyotrophic lateral sclerosis]], [[multiple sclerosis]] and [[muscular dystrophy]] can all cause an individual to experience shortness of breath.<ref name="ch8139" /> A relatively unknown condition involving shortness of breath is [[empty nose syndrome]].
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==Pathophysiology==
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Different physiological pathways may lead to shortness of breath including via [[chemoreceptor]]s, [[mechanoreceptor]]s, and [[lung receptor]]s.<ref name=Old2007>{{cite journal |author=Torres M, Moayedi S |title=Evaluation of the acutely dyspneic elderly patient |journal=Clin. Geriatr. Med. |volume=23 |issue=2 |pages=307–25, vi |year=2007 |month=May |pmid=17462519 |doi=10.1016/j.cger.2007.01.007 |url=}}</ref>
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It is thought that three main components contribute to dyspnea: afferent signals, efferent signals, and central information processing. It is believed the central processing in the brain compares the afferent and efferent signals; and dyspnea results when a "mismatch" occurs between the two: such as when the need for ventilation (afferent signaling) is not being met by physical breathing (efferent signaling).<ref name=Harrisons />
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  +
Afferent signals are sensory neuronal signals that ascend to the brain. Afferent neurons significant in dyspnea arise from a large number of sources including the [[carotid bodies]], [[medulla oblongata|medulla]], [[lungs]], and [[chest wall]]. Chemoreceptors in the carotid bodies and medulla supply information regarding the blood gas levels of O<sub>2</sub>, CO<sub>2</sub> and H<sup>+</sup>. In the lungs, [[juxtacapillary (J) receptors]] are sensitive to pulmonary interstitial edema, while stretch receptors signal bronchoconstriction. [[Muscle spindles]] in the chest wall signal the stretch and tension of the respiratory muscles. Thus, poor ventilation leading to [[hypercapnia]], [[Heart_failure#Left-sided_failure|left heart failure]] leading to interstitial edema (impairing gas exchange), [[asthma]] causing bronchoconstriction (limiting airflow) and muscle fatigue leading to ineffective respiratory muscle action could all contribute to a feeling of dyspnea.<ref name=Harrisons />
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Efferent signals are the motor neuronal signals descending to the [[muscles of respiration|respiratory muscles]]. The most important respiratory muscle is the [[thoracic diaphragm|diaphragm]]. Other respiratory muscles include the external and internal [[intercostal muscles]], the abdominal muscles and the accessory breathing muscles.
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As the brain receives its plentiful supply of afferent information relating to ventilation, it is able to compare it to the current level of respiration as determined by the efferent signals. If the level of respiration is inappropriate for the body's status then dyspnea might occur. There is also a psychological component to dyspnea, as some people may become aware of their breathing in such circumstances but not experience the distress typical of dyspnea.<ref name=Harrisons />
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==Evaluation==
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{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
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|+mMRC Breathlessness Scale
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|-
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! Grade
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! Degree of dyspnea
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|-
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| 0
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| no dyspnea except with strenuous exercise
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|-
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| 1
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| dyspnea when walking up an incline or hurrying on the level
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|-
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| 2
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| walks slower than most on the level, or stops after 15 minutes of walking on the level
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|-
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| 3
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| stops after a few minutes of walking on the level
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|-
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| 4
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| with minimal activity such as getting dressed, too dyspneic to leave the house
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|}
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The initial approach to evaluation begins by assessment of the [[ABC (medicine)|airway, breathing, and circulation]] followed by a [[medical history]] and [[physical examination]].<ref name=Shiber06/> Signs that represent significant severity include [[hypotension]], [[hypoxemia]], [[Tracheal Deviation|tracheal deviation]], altered mental status, unstable [[Cardiac dysrhythmia|dysrhythmia]], [[stridor]], intercostal indrawing, [[cyanosis]], [[Tripod position|Tripod Positioning]], pronounced use of accessory muscles ([[Sternocleidomastoid]], [[Scalene muscles|Scalenes]]) and absent breath sounds.<ref name=Sarkar2006/>
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A number of scales may be used to quantify the degree of shortness of breath.<ref name=Rate2007>{{cite journal |author=Saracino A |title=Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool? |journal=Emerg Med Australas |volume=19 |issue=5 |pages=394–404 |year=2007 |month=October |pmid=17919211 |doi=10.1111/j.1742-6723.2007.00999.x |url=}}</ref> It may be subjectively rated on a scale from 1 to 10 with descriptors associated with the number (The Modified Borg Scale).<ref name=Rate2007/> Alternatively a scale such as the MRC Breathlessness Scale might be used - it suggests five different grades of dyspnea based on the circumstances in which it arises.<ref name=Stenton>{{cite journal |author=Stenton C |title=The MRC breathless scale |journal=Occup Med |year=2008 |volume=58 |pages=226–7 |doi=10.1093/occmed/kqm162 |pmid=18441368 |issue=3}}</ref>
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===Blood tests===
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A number of labs may be helpful in determining the cause of shortness of breath. [[D-dimer]] while useful to rule out a pulmonary embolism in those who are at low risk is not of much value if it is positive as it may be positive in a number of conditions that lead to shortness of breath.<ref name=Old2007/> A low level of [[brain natriuretic peptide]] is useful in ruling out congestive heart failure; however, a high level while supportive of the diagnosis could also be due to advanced age, [[renal failure]], acute coronary syndrome, or a large pulmonary embolism.<ref name=Old2007/>
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===Imaging===
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A [[chest x-ray]] is useful to confirm or rule out a pneumothorax, [[pulmonary edema]], or pneumonia.<ref name=Old2007/> Spiral [[computed tomography]] with intravenous [[radiocontrast]] is the imaging study of choice to evaluate for pulmonary embolism.<ref name=Old2007/>
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==Treatment==
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In those who are not [[palliative]] the primary treatment of shortness of breath is directed at its underlying cause.<ref name=Z2009/> Extra [[oxygen]] is effective in those with [[Hypoxia (medical)|hypoxia]]; however, this has no effect in those with normal [[oxygen saturation|blood oxygen saturation]]s, even in those who are palliative.<ref name=Pal2010/><ref>{{cite journal |author=Abernethy AP |title=Effect of palliative oxygen versus medical (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind randomized controlled trial |journal=Lancet |volume=376 |issue=9743 |pages=784–93 |year=2010 |month=September |pmid=20816546 |doi=10.1016/S0140-6736(10)61115-4 |url= |author-separator=, |author2=McDonald CF |author3=Frith PA |display-authors=3 |last4=Clark |first4=Katherine |last5=Herndon |first5=James E |last6=Marcello |first6=Jennifer |last7=Young |first7=Iven H |last8=Bull |first8=Janet |last9=Wilcock |first9=Andrew |pmc=2962424}}</ref>
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===Physiotherapy===
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Individuals can benefit from a variety of [[physical therapy]] interventions.<ref>{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 8 | volume = 4 | editors = Willy E. Hammon III | publisher = Mosby Elsevier | year = 2006}}</ref> Persons with neurological/neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal, abdominal and/or other muscles needed for [[Ventilation (physiology)|ventilation]].<ref>{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 22 | volume = 4 | editors = Donna Frownfelter and Mary Massery | publisher = Mosby Elsevier | year = 2006 | pages = 368}}</ref> Some physical therapy interventions for this population include active assisted [[cough]] techniques,<ref>{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 22 | volume = 4 | editors = Donna Frownfelter and Mary Massery | publisher = Mosby Elsevier | year = 2006 | pages = 368–371}}</ref> volume augmentation such as breath stacking,<ref name="ch32">{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 32 | volume = 4 | publisher = Mosby Elsevier | year = 2006 | pages = 569–581}}</ref> education about body position and ventilation patterns<ref>{{cite book | last1 = Frownfelter | first1 = Donna | last2 = Dean | first2 = Elizabeth | title = Cardiovascular and Pulmonary Physical Therapy | chapter = 23 | volume = 4 | editors = Donna Frownfelter and Mary Massery | publisher = Mosby Elsevier | year = 2006}}</ref> and movement strategies to facilitate breathing.<ref name="ch32" />
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===Palliative===
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Along with the measure above, systemic immediate release [[opioids]] are beneficial in reducing the symptom of shortness of breath due to both cancer and non cancer causes.<ref name=Pal2010/><ref>{{cite journal |author=Naqvi F, Cervo F, Fields S |title=Evidence-based review of interventions to improve palliation of pain, dyspnea, depression |journal=Geriatrics |volume=64 |issue=8 |pages=8–10, 12–4 |year=2009 |month=August |pmid=20722311 |doi= |url=}}</ref> There is a lack of evidence to recommend [[midazolam]], nebulised opioids, the use of gas mixtures, or [[cognitive-behavioral therapy]].<ref>{{Cite journal | last1 = DiSalvo | first1 = WM. | last2 = Joyce | first2 = MM. | last3 = Tyson | first3 = LB. | last4 = Culkin | first4 = AE. | last5 = Mackay | first5 = K. | title = Putting evidence into practice: evidence-based interventions for cancer-related dyspnea | url = http://ons.metapress.com/content/c21324512r838824/fulltext.pdf | format = PDF | journal = Clin J Oncol Nurs | volume = 12 | issue = 2 | pages = 341–52 | month = Apr | year = 2008 | doi = 10.1188/08.CJON.341-352 | pmid = 18390468 }}</ref>
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==Epidemiology==
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Shortness of breath is the primary reason 3.5% of people present to the [[emergency department]] in the United States. Of these approximately 51% are admitted to hospital and 13% are dead within a year.<ref>{{cite book |author=Stephen J. Dubner; Steven D. Levitt |title=SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes |publisher=William Morrow |location=New York |year=2009 |pages=77 |isbn=0-06-088957-8 |oclc= |doi= |accessdate=}}</ref> Some studies have suggested that up to 27% of people suffer from dyspnea,<ref name=Murray>Murray and Nadel's Textbook of Respiratory Medicine, 4th Ed. Robert J. Mason, John F. Murray, Jay A. Nadel, 2005, Elsevier</ref> while in dying patients 75% will experience it.<ref name=Harrisons>Harrison's Principles of Internal Medicine (Kasper DL, Fauci AS, Longo DL, et al (eds)) (16th ed.). New York: McGraw-Hill.</ref> Acute shortness of breath is the most common reason people requiring [[palliative]] care visit an emergency department.<ref name=Pal2010>{{cite journal |author=Schrijvers D, van Fraeyenhove F |title=Emergencies in palliative care |journal=Cancer J |volume=16 |issue=5 |pages=514–20 |year=2010 |pmid=20890149 |doi=10.1097/PPO.0b013e3181f28a8d |url=}}</ref>
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==Etymology==
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Dyspnea ({{IPAc-en|d|ɪ|s|p|ˈ|n|iː|ə}} {{respell|disp|NEE|ə}}; from [[Latin language|Latin]] ''dyspnoea'', from [[Greek language|Greek]] ''dyspnoia'' from ''dyspnoos'') literally means disordered breathing.<ref name=Sarkar2006/>
   
 
==See also==
 
==See also==
* [[Air hunger]]
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*[[List of terms of lung size and activity]]
* [[Apnea]], absence of respiration
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*[[Orthopnea]]
* [[Bradypnea]], slow respiration
 
* [[Cardiovascular disorders]]
 
* [[Eupnea]], normal respiration
 
* [[Lung disorders]]
 
* [[Orthopnea]]
 
* [[Somatoform disorders]]
 
* [[Tachypnea]], fast respiration
 
* [[Trepopnea]]
 
* [[Paroxysmal nocturnal dyspnea]]
 
   
 
==References==
 
==References==
{{cite book| last = Lippincott Williams & Wilkins | title =Stedman's Medical Dictionary, 28th Edition| publisher =Julie K. Stegman| date =2006| location =[[Baltimore, Maryland]]| pages =601| isbn = 0-7817-3390-1}}
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{{reflist|2}}
   
 
==External links==
 
==External links==
 
* {{GPnotebook|825557022|Dyspnea}}
 
* {{GPnotebook|825557022|Dyspnea}}
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*[http://www.strengthessence.com/disease/Dyspnoea.html Dyspnea]
   
 
{{Circulatory and respiratory system symptoms and signs}}
 
{{Circulatory and respiratory system symptoms and signs}}
   
[[Category:Respiratory tract disorders]]
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[[Category:Abnormal respiration]]
[[Category:Reepiritory distress]]
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[[Category:Symptoms and signs: Respiratory system]]
[[Category:Symptoms]]
 
   
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Name of Symptom/Sign:
Dyspnea
[[Image:|190px|center|]]
ICD-10 R060
ICD-O:
ICD-9 786.09
OMIM [1]
MedlinePlus 003075
eMedicine /
DiseasesDB 15892

Dyspnea (/dɪspˈnə/ Template:Respell; also dyspnoea; Latin: dyspnoea; Greek: δύσπνοια, dýspnoia), shortness of breath (SOB), or air hunger,[1] is the subjective symptom of breathlessness.[2][3]

It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations.[2] In 85% of cases it is due to either asthma, pneumonia, cardiac ischemia, interstitial lung disease, congestive heart failure, chronic obstructive pulmonary disease, or psychogenic causes.[4] Treatment typically depends on the underlying cause.[5]

From a psychological point of view the symptom can be very anxiety provoking, which can in turn interefere with the management of the causal conditions. In addition the symptoms can be produced by anxiety and hyperventilation.

DefinitionEdit

The American Thoracic Society defines dyspnea as: "A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity."[6] Other definitions describe it as "difficulty in breathing",[7] "disordered or inadequate breathing",[8] "uncomfortable awareness of breathing",[3] and as the experience of "breathlessness" (which may be either acute or chronic).[2][5][9]

Dyspnea is distinct from labored breathing, which is a common physical presentation of respiratory distress.[citation needed]

Differential diagnosisEdit

Further information: List of causes of shortness of breath

While shortness of breath is generally caused by disorders of the cardiac or respiratory system, other systems such as neurological,[10] musculoskeletal, endocrine, hematologic, and psychiatric may be the cause.[4] DiagnosisPro, an online medical expert system, listed 497 distinct causes in October 2010.[11] The most common cardiovascular causes are acute myocardial infarction and congestive heart failure while common pulmonary causes include chronic obstructive pulmonary disease, asthma, pneumothorax,pulmonary edema and pneumonia.[2] On a pathophysiological basis the causes can be divided into: (1) an increased awareness of normal breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3) an abnormality in the ventilatory system.[10]

Acute coronary syndromeEdit

Acute coronary syndrome frequently presents with retrosternal chest discomfort and difficulty catching the breath.[2] It however may atypically present with shortness of breath alone.[12] Risk factors include old age, smoking, hypertension, hyperlipidemia, and diabetes.[12] An electrocardiogram and cardiac enzymes are important both for diagnosis and directing treatment.[12] Treatment involves measures to decrease the oxygen requirement of the heart and efforts to increase blood flow.[2]

Congestive heart failureEdit

Congestive heart failure frequently presents with shortness of breath with exertion, orthopnea, and paroxysmal nocturnal dyspnea.[2] It affects between 1-2% of the general United States population and occurs in 10% of those over 65 years old.[2][12] Risk factors for acute decompensation include high dietary salt intake, medication noncompliance, cardiac ischemia, dysrhythmias, renal failure, pulmonary emboli, hypertension, and infections.[12] Treatment efforts are directed towards decreasing lung congestion.[2]

Chronic obstructive pulmonary diseaseEdit

People with chronic obstructive pulmonary disease (COPD), most commonly emphysema or chronic bronchitis, frequently have chronic shortness of breath and a chronic productive cough.[2] An acute exacerbation presents with increased shortness of breath and sputum production.[2] COPD is a risk factor for pneumothorax; thus this condition should be ruled out.[2] In an acute exacerbation treatment is with a combination of anticholinergics, beta2-adrenoceptor agonists, steroids and possibly positive pressure ventilation.[2]

AsthmaEdit

Asthma is the most common reason for presenting to the emergency with shortness of breath.[2] It is the most common lung disease in both developing and developed countries affecting about 5% of the population.[2] Other symptoms include wheezing, tightness in the chest, and a non productive cough.[2] Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate.[13] Acute symptoms are treated with short-acting bronchodilators.

PneumothoraxEdit

Main article: Pneumothorax

Pneumothorax presents typically with pleuritic chest pain of acute onset and shortness of breath not improved with oxygen.[2] Physical findings may include absent breath sounds on one side of the chest, jugular venous distension, and tracheal deviation.[2]

PneumoniaEdit

Main article: Pneumonia

The symptoms of pneumonia are fever, productive cough, shortness of breath, and pleuritic chest pain.[2] Inspiratory crackles may be heard on exam.[2] A chest x-ray can be useful to differential pneumonia from congestive heart failure.[2] As the cause is usually a bacterial infections antibiotics are typically used for treatment.[2]

Pulmonary embolismEdit

Pulmonary embolism classically presents with an acute onset of shortness of breath.[2] Other presenting symptoms include pleuritic chest pain, cough, hemoptysis, and fever.[2] Risk factors include deep vein thrombosis, recent surgery, cancer, and previous thromboembolism.[2] It must always be considered in those with acute onset of shortness of breath owing to its high risk of mortality.[2] Diagnosis however may be difficult.[2] Treatment is typically with anticoagulants.[2]

Pulmonary Edema link to COPD, Asthma and Heart failure.

AnaemiaEdit

Anaemia caused by low hemoglobin levels is often a cause of dyspnea. Menstruation, particularly if excessive, can contribute to anaemia and to consequential dyspnea in women. Headaches are also a symptom of dyspnea in patients suffering from anaemia, some patients report a numb sensation in their head, and others have reported blurred vision caused by hypotension behind the eye due to a lack of oxygen and pressure, these patients have also reported severe head pain many of which lead to permanent brain damage, symptoms of this can be loss of concentration, focus, fatigue, language faculty impairment and memory loss. [citation needed]

OtherEdit

Other important or common causes of shortness of breath include cardiac tamponade, anaphylaxis, interstitial lung disease, panic attacks,[4][5][14] and pulmonary hypertension. Cardiac tamponade presents with dyspnea, tachycardia, elevated jugular venous pressure, and pulsus paradoxus.[14] The gold standard for diagnosis is ultrasound.[14] Anemia, that develops gradually, usually presents with exertional dyspnea, fatigue, weakness, and tachycardia.[14] It may lead to heart failure.[14] Anaphylaxis typically begins over a few minutes in a person with a previous history of the same.[5] Other symptoms include urticaria, throat swelling, and gastrointestinal upset.[5] The primary treatment is epinephrine.[5] Interstitial lung disease presents with gradual onset of shortness of breath typically with a history of a predisposing environmental exposure.[4] Shortness of breath is often the only symptom in those with tachydysrhythmias.[12] Panic attacks typically present with hyperventilation, sweating, and numbness.[5] They are however a diagnosis of exclusion.[4] Around 2/3 of women experience shortness of breath as a part of a normal pregnancy.[8] Neurological conditions such as spinal cord injury, phrenic nerve injuries, Guillain-Barre syndrome, amyotrophic lateral sclerosis, multiple sclerosis and muscular dystrophy can all cause an individual to experience shortness of breath.[10] A relatively unknown condition involving shortness of breath is empty nose syndrome.

PathophysiologyEdit

Different physiological pathways may lead to shortness of breath including via chemoreceptors, mechanoreceptors, and lung receptors.[12]

It is thought that three main components contribute to dyspnea: afferent signals, efferent signals, and central information processing. It is believed the central processing in the brain compares the afferent and efferent signals; and dyspnea results when a "mismatch" occurs between the two: such as when the need for ventilation (afferent signaling) is not being met by physical breathing (efferent signaling).[15]

Afferent signals are sensory neuronal signals that ascend to the brain. Afferent neurons significant in dyspnea arise from a large number of sources including the carotid bodies, medulla, lungs, and chest wall. Chemoreceptors in the carotid bodies and medulla supply information regarding the blood gas levels of O2, CO2 and H+. In the lungs, juxtacapillary (J) receptors are sensitive to pulmonary interstitial edema, while stretch receptors signal bronchoconstriction. Muscle spindles in the chest wall signal the stretch and tension of the respiratory muscles. Thus, poor ventilation leading to hypercapnia, left heart failure leading to interstitial edema (impairing gas exchange), asthma causing bronchoconstriction (limiting airflow) and muscle fatigue leading to ineffective respiratory muscle action could all contribute to a feeling of dyspnea.[15]

Efferent signals are the motor neuronal signals descending to the respiratory muscles. The most important respiratory muscle is the diaphragm. Other respiratory muscles include the external and internal intercostal muscles, the abdominal muscles and the accessory breathing muscles.

As the brain receives its plentiful supply of afferent information relating to ventilation, it is able to compare it to the current level of respiration as determined by the efferent signals. If the level of respiration is inappropriate for the body's status then dyspnea might occur. There is also a psychological component to dyspnea, as some people may become aware of their breathing in such circumstances but not experience the distress typical of dyspnea.[15]

EvaluationEdit

mMRC Breathlessness Scale
Grade Degree of dyspnea
0 no dyspnea except with strenuous exercise
1 dyspnea when walking up an incline or hurrying on the level
2 walks slower than most on the level, or stops after 15 minutes of walking on the level
3 stops after a few minutes of walking on the level
4 with minimal activity such as getting dressed, too dyspneic to leave the house

The initial approach to evaluation begins by assessment of the airway, breathing, and circulation followed by a medical history and physical examination.[2] Signs that represent significant severity include hypotension, hypoxemia, tracheal deviation, altered mental status, unstable dysrhythmia, stridor, intercostal indrawing, cyanosis, Tripod Positioning, pronounced use of accessory muscles (Sternocleidomastoid, Scalenes) and absent breath sounds.[4]

A number of scales may be used to quantify the degree of shortness of breath.[16] It may be subjectively rated on a scale from 1 to 10 with descriptors associated with the number (The Modified Borg Scale).[16] Alternatively a scale such as the MRC Breathlessness Scale might be used - it suggests five different grades of dyspnea based on the circumstances in which it arises.[17]

Blood testsEdit

A number of labs may be helpful in determining the cause of shortness of breath. D-dimer while useful to rule out a pulmonary embolism in those who are at low risk is not of much value if it is positive as it may be positive in a number of conditions that lead to shortness of breath.[12] A low level of brain natriuretic peptide is useful in ruling out congestive heart failure; however, a high level while supportive of the diagnosis could also be due to advanced age, renal failure, acute coronary syndrome, or a large pulmonary embolism.[12]

ImagingEdit

A chest x-ray is useful to confirm or rule out a pneumothorax, pulmonary edema, or pneumonia.[12] Spiral computed tomography with intravenous radiocontrast is the imaging study of choice to evaluate for pulmonary embolism.[12]

TreatmentEdit

In those who are not palliative the primary treatment of shortness of breath is directed at its underlying cause.[5] Extra oxygen is effective in those with hypoxia; however, this has no effect in those with normal blood oxygen saturations, even in those who are palliative.[3][18]

PhysiotherapyEdit

Individuals can benefit from a variety of physical therapy interventions.[19] Persons with neurological/neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal, abdominal and/or other muscles needed for ventilation.[20] Some physical therapy interventions for this population include active assisted cough techniques,[21] volume augmentation such as breath stacking,[22] education about body position and ventilation patterns[23] and movement strategies to facilitate breathing.[22]

PalliativeEdit

Along with the measure above, systemic immediate release opioids are beneficial in reducing the symptom of shortness of breath due to both cancer and non cancer causes.[3][24] There is a lack of evidence to recommend midazolam, nebulised opioids, the use of gas mixtures, or cognitive-behavioral therapy.[25]

EpidemiologyEdit

Shortness of breath is the primary reason 3.5% of people present to the emergency department in the United States. Of these approximately 51% are admitted to hospital and 13% are dead within a year.[26] Some studies have suggested that up to 27% of people suffer from dyspnea,[27] while in dying patients 75% will experience it.[15] Acute shortness of breath is the most common reason people requiring palliative care visit an emergency department.[3]

EtymologyEdit

Dyspnea (/dɪspˈnə/ Template:Respell; from Latin dyspnoea, from Greek dyspnoia from dyspnoos) literally means disordered breathing.[4]

See alsoEdit

ReferencesEdit

  1. About.com Health's Disease and Condition content > Dyspnea By Deborah Leader. Updated August 05, 2008
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 Shiber JR, Santana J (May 2006). Dyspnea. Med. Clin. North Am. 90 (3): 453–79.
  3. 3.0 3.1 3.2 3.3 3.4 Schrijvers D, van Fraeyenhove F (2010). Emergencies in palliative care. Cancer J 16 (5): 514–20.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Sarkar S, Amelung PJ (September 2006). Evaluation of the dyspneic patient in the office. Prim. Care 33 (3): 643–57.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Zuberi, T. (2009). Acute breathlessness in adults. InnovAiT 2 (5): 307–15.
  6. American Heart Society (1999). Dyspnea mechanisms, assessment, and management: a consensus statement. Am Rev Resp Crit Care Med 159: 321–340.
  7. TheFreeDictionary, retrieved on Dec 12, 2009. Citing:The American Heritage Dictionary of the English Language, Fourth Edition by Houghton Mifflin Company. Updated in 2009.Ologies & -Isms. The Gale Group 2008
  8. 8.0 8.1 UpToDate Inc..
  9. dyspnea - General Practice Notebook.
  10. 10.0 10.1 10.2 (2006) "8" Cardiovascular and Pulmonary Physical Therapy, 139, Mosby Elsevier.
  11. http://en.diagnosispro.com/differential_diagnosis-for/poisoning-specific-agent-dyspnea/25103-154-100.html
  12. 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 Torres M, Moayedi S (May 2007). Evaluation of the acutely dyspneic elderly patient. Clin. Geriatr. Med. 23 (2): 307–25, vi.
  13. How Is Asthma Treated and Controlled?.
  14. 14.0 14.1 14.2 14.3 14.4 Wills CP, Young M, White DW (February 2010). Pitfalls in the evaluation of shortness of breath. Emerg. Med. Clin. North Am. 28 (1): 163–81, ix.
  15. 15.0 15.1 15.2 15.3 Harrison's Principles of Internal Medicine (Kasper DL, Fauci AS, Longo DL, et al (eds)) (16th ed.). New York: McGraw-Hill.
  16. 16.0 16.1 Saracino A (October 2007). Review of dyspnoea quantification in the emergency department: is a rating scale for breathlessness suitable for use as an admission prediction tool?. Emerg Med Australas 19 (5): 394–404.
  17. Stenton C (2008). The MRC breathless scale. Occup Med 58 (3): 226–7.
  18. Abernethy AP (September 2010). Effect of palliative oxygen versus medical (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind randomized controlled trial. Lancet 376 (9743): 784–93.
  19. (2006) "8" Cardiovascular and Pulmonary Physical Therapy, Mosby Elsevier.
  20. (2006) "22" Cardiovascular and Pulmonary Physical Therapy, 368, Mosby Elsevier.
  21. (2006) "22" Cardiovascular and Pulmonary Physical Therapy, 368–371, Mosby Elsevier.
  22. 22.0 22.1 (2006) "32" Cardiovascular and Pulmonary Physical Therapy, 569–581, Mosby Elsevier.
  23. (2006) "23" Cardiovascular and Pulmonary Physical Therapy, Mosby Elsevier.
  24. Naqvi F, Cervo F, Fields S (August 2009). Evidence-based review of interventions to improve palliation of pain, dyspnea, depression. Geriatrics 64 (8): 8–10, 12–4.
  25. (Apr 2008). Putting evidence into practice: evidence-based interventions for cancer-related dyspnea. Clin J Oncol Nurs 12 (2): 341–52.
  26. Stephen J. Dubner; Steven D. Levitt (2009). SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes, 77, New York: William Morrow.
  27. Murray and Nadel's Textbook of Respiratory Medicine, 4th Ed. Robert J. Mason, John F. Murray, Jay A. Nadel, 2005, Elsevier

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