Chronic Dyspnea: Diagnosis and Evaluation

 

Am Fam Physician. 2020 May 1;101(9):542-548.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/shortness-of-breath.

Author disclosure: No relevant financial affiliations.

Dyspnea is a symptom arising from a complex interplay of diseases and physiologic states and is commonly encountered in primary care. It is considered chronic if present for more than one month. As a symptom, dyspnea is a predictor for all-cause mortality. The likeliest causes of dyspnea are disease states involving the cardiac or pulmonary systems such as asthma, chronic obstructive pulmonary disease, heart failure, pneumonia, and coronary artery disease. A detailed history and physical examination should begin the workup; results should drive testing. Approaching testing in stages beginning with first-line tests, including a complete blood count, basic chemistry panel, electrocardiography, chest radiography, spirometry, and pulse oximetry, is recommended. If no cause is identified, second-line noninvasive testing such as echocardiography, cardiac stress tests, pulmonary function tests, and computed tomography scan of the lungs is suggested. Final options include more invasive tests that should be done in collaboration with specialty help. There are three main treatment and management goals: correctly identify the underlying disease process and treat appropriately, optimize recovery, and improve the dyspnea symptoms. The six-minute walk test can be helpful in measuring the effect of ongoing intervention. Care of patients with chronic dyspnea typically requires a multidisciplinary approach, which makes the primary care physician ideal for management.

Dyspnea is a complex symptom, resulting from environmental, physiologic, and psychological factors. The American Thoracic Society defines dyspnea as a subjective experience of breathing discomfort that comprises qualitative distinct sensations that vary in intensity.1 If symptoms persist for more than one month, the condition is considered chronic.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Smoking history and exposure should be assessed, and cessation should be encouraged regardless of duration of use.20,21,47

C

Observational studies and disease-oriented study evaluating lung function

Electrocardiography, brain natriuretic peptide, and cardiac ultrasonography should be obtained if heart failure is suspected.16,18,22,26,28,29

C

Clinical reviews and a small disease-oriented prospective study

Initial testing with chest radiography and then spirometry should be performed when a pulmonary cause is suspected.16,24,26,32,33

C

Clinical reviews

High-resolution noncontrast computed tomography of the chest should be performed if the diagnosis of dyspnea is unclear and pulmonary etiology is suspected.24,26,27,34

C

Clinical review articles

Supplemental oxygen has not been shown to reduce death or hospitalization in stable patients with chronic obstructive pulmonary disease and moderate hypoxia.40

B

Single randomized clinical trial showing no reduction in mortality or hospitalization


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Smoking history and exposure should be assessed, and cessation should be encouraged regardless of duration of use.20,21,47

C

Observational studies and disease-oriented study evaluating lung function

Electrocardiography, brain natriuretic peptide, and cardiac ultrasonography should be obtained if heart failure is suspected.16,18,22,26,28,29

C

Clinical reviews and a small disease-oriented prospective study

Initial testing with chest radiography and then spirometry should be performed when a pulmonary cause is suspected.16,24,26,32,33

C

Clinical reviews

High-resolution noncontrast computed tomography of the chest should be performed if the diagnosis of dyspnea is unclear and pulmonary etiology is suspected.24,26,27,34

C

Clinical review articles

Supplemental oxygen has not been shown to reduce death or hospitalization in stable patients with chronic obstructive pulmonary disease and moderate hypoxia.40

B

Single randomized clinical trial showing no reduction in mortality or hospitalization


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The prevalence of dyspnea in the primary care setting has been difficult to quantify. Various studies estimate that up to 2.5% of all family physician visits and up to 8.4% of emergency department visits account for the management of dyspnea.3 In those patients older than 65, approximately 30% report some degree of challenge in breathing

The Authors

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NITIN BUDHWAR, MD, is vice chair for Clinical Services in Family Medicine and associate professor in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center, Dallas....

ZUBAIR SYED, MD, is program director of the Family Medicine Residency Program and assistant professor in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center.

Address correspondence to Nitin Budhwar, MD, 5920 Forest Park Rd., Ste. 601, Dallas, TX 75390 (email: Nitin.Budhwar@UTsouthwestern.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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