Main topic Herz 2014 · 39:8–14 DOI 10.1007/s00059-014-4057-6 Published online: 9 February 2014 © Urban & Vogel 2014
S. Brenner · G. Güder Comprehensive Heart Failure Center—A9, Department of Internal Medicine I, University Hospital Würzburg, Würzburg
The patient with dyspnea Rational diagnostic evaluation
Definitions and basic science Dyspnea refers to the uncomfortable awareness of difficult breathing. It is an unignorable sensation similar to that of thirst or hunger. As a subjective experience, dyspnea must be differentiated from tachypnea, hyperpnea, and hyperventilation because these impartially describe the increase of ventilatory rate and minute volume [1]. In a consensus statement, the American Thoracic Society defines dyspnea as a“subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity” [2]. Chronic dyspnea is defined as shortness of breath lasting longer than 1 month [3]. Dyspnea regularly occurs on exertion but is considered to be pathologic when it limits a level of activity that was usually well tolerated [4]. In a population of 8,396 South Australians, the prevalence of chronic dyspnea limiting exertion was 8.9% [5]. Spontaneous respiration is regulated by a complex processing of signals from pulmonary vagal receptors, cerebral and vascular chemoreceptors, and mechanoreceptors in the chest wall and diaphragm [6]. In the brain stem, the respiratory drive is generated to maintain gas–blood and acid–base homeostasis, and motor neurons activate the respiratory muscles accordingly [6]. Under normal conditions, an individual is not aware of his or her respiratory effort. As long as the respiratory muscles are able to generate the required ventilation according to the metabolic needs, the rate and volume of ventilation may increase without the sensation of dyspnea. Dyspnea arises from a
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Herz 1 · 2014
mismatch between the efferent motor signal to respiratory muscles and the afferent feedback from mechanoreceptors of the respiratory system (. Fig. 1, [2, 7, 8]). Campbell and Howell proposed the basic concept for this theory of mismatch between motor signal and lung volume as early as 1963 [9]. Since then, numerous clinical observations are consistent with this theory [6].
Clinical significance Not before the respiratory muscles fail to respond to the neuronal command does the act of breathing come to the conscious level. The sensation of dyspnea therefore always indicates that compensatory mechanisms are exhausted and that, depending on the type of dyspnea and its severity, the underlying condition may be present much longer than the symptom of dyspnea itself. The mismatch between central respiratory drive and peripheral respiratory response can be induced by four general conditions: increased peripheral demand, decreased
ventilatory performance, disturbed alveolar gas exchange, and impaired circulation (. Tab. 1). In clinical situations, various disorders and diseases may cause dyspnea and frequently multiple etiologies are involved. However, in most cases the cause is of cardiac and/or pulmonary origin [10, 11]. In the emergency department of the Hospital Pitié-Salpetrière in Paris, a prospective cohort study was performed including 514 elderly (≥65 years) patients admitted with acute dyspnea and tachypnea, hypoxia, or hypercapnea [12]. Cardiogenic edema was the most frequent reason for the acute respiratory failure (. Fig. 2). . Tab. 2 summarizes the cardiac, pulmonary, cardiopulmonary, and noncardiopulmonary conditions that may cause dyspnea.
Diagnostic approach Dyspnea is a common symptom in the primary care setting and can be caused by multiple disorders and diseases. Underlying etiologies range from harmless
Fig. 1 8 Emergence of dyspnea: schematic illustration
Tab. 1 Conditions and clinical situations causing dyspnea Condition Increased peripheral demand
Decreased ventilatory performance
Disturbed alveolar gas exchange Impaired circulation
Clinical situation Exertion Febrile illness Metabolic acidosis Anemia Carbon monoxide poisoning Upper airway obstruction (angioedema, anaphylaxis, trauma, infection, foreign body aspiration) Pulmonary illness or injury Intrathoracic mass Abdominal mass (e.g., ascites, adipositas, pregnancy) Neuronal disorder (stroke, neuromuscular diseases) Pulmonary congestion Inflammatory diseases with alveolar affection Cardiac failure (ischemic, valvular, arrhythmic) Pulmonary embolism
Tab. 2 Cardiac, pulmonary, cardiopulmonary, and noncardiopulmonary diseases causing
dyspnea System Cardiac
Type Myocardial Valvular Arrhythmia
Pulmonary
Restrictive Alveolar Interstitial
Obstructive
Restrictive
Cardiopulmonary Noncardiopulmonary
Vascular Pulmonary arterial Upper airway Anemia Gastrointestinal Neurogenic Metabolic Psychological
Possible diagnosis Cardiomyopathies, coronary ischemia Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis Atrial fibrillation, inappropriate sinus tachycardia, sick sinus syndrome/bradycardia Constrictive pericarditis, pericardial effusion/tamponade Bronchoalveolar carcinoma, chronic pneumonia, pneumoconiosis, granulomatous disease Drugs (e.g., methotrexate, amiodarone) or radiation therapy, lymphangitic spread of malignancy, passive congestion, interstitial fibrosis Asthma/bronchitis/bronchiectasis, bronchiolitis obliterans, chronic obstructive pulmonary disease, intrabronchial neoplasm, tracheomalacia Kyphoscoliosis, obesity, pleural disease/effusion, pneumothorax Collagen vascular disease Cor pulmonale, pulmonary embolism, idiopathic pulmonary hypertension Deconditioning Polyps, septal deviation, enlarged tonsils, supraglottic or subglottic stricture Iron deficiency, hemolysis Gastroesophageal reflux disease/aspiration, neoplasia Stroke, amyotrophic lateral sclerosis, muscular dystrophies, phrenic nerve palsy, poliomyelitis, pain in the chest wall Acidosis, obesity Anxiety/hyperventilation, depression
to life threatening. Therefore, the timely establishment of a diagnosis is always challenging.
Ask the patient Dyspnea is a subjective experience and its perception is influenced by the subject’s state of mind. Some individuals with only minor physiologic alterations complain of severe shortness of breath; and others even deny the dyspneic sensation despite an advanced cardiopulmonary disorder. Nevertheless, in most cases, the intensity of the complaint correlates well with the severity of the underlying disease. When interrogating the affected patient, dyspnea must be differentiated from other dysphoric sensations in the chest and dyspnea on exertion from exertional fatigue or muscle weakness. Most frequent descriptions of dyspnea are“shortness of breath,”“tightness of chest,” and“inability to breathe deeply.” The patient interview should elaborate on the onset, progression, and duration of dyspnea, daytime or nighttime occurrence, exercise tolerance, its precipitating circumstances, as well as aggravating and ameliorating factors. The presence of concomitant symptoms such as cough, fever, pain, and palpitations should be determined. The patient’s history should be completely recorded focusing on cardiac and pulmonary conditions, smoking habits, allergies, hay fever, as well as occupational and environmental exposures. A comprehensive patient interview already provides important clues for identifying the underlying condition of dyspnea. . Tab. 3 summarizes most conditions according to the onset and progression of dyspnea with frequent concomitant symptoms and typical history. Usually, dyspnea occurs or is aggravated on exertion and limits the physical capacity of the affected patient. By contrast, dyspnea improving over time may indicate deconditioning, and dyspnea unaffected by exercise suggests functional causes [13]. Shortness of breath due to anxiety often occurs with paresthesias of the mouth and fingers. Nevertheless, organic etiologies should always be excluded first [14]. Herz 1 · 2014
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Main topic
Examine the patient First, evaluate the general appearance of the dyspneic patient and check his or her vital signs to correctly identify conditions that may require immediate intervention. Special attention should be addressed to skin color, respiratory rate and effort, ability to speak, and mental status. Stridor indicates an upper airway obstruction. Look for oropharyngeal or nasopharyngeal pathology narrowing the airways. Palpate the neck to reveal masses such as thyroid enlargement. Sideshifted trachea may suggest a tension pneumothorax. Jugular venous distention may indicate cardiac tamponade or may be caused by congestive heart failure or cor pulmonale due to chronic obstructive pulmonary disease (COPD) [15]. Carotid bruits indicate macrovascular disease and may suggest concomitant ischemic heart failure. Supraclavicular retractions may appear due to accessory muscle use for inspiration. Inspection of the chest may show an increased anteroposterior diameter, skeletal deformities, and evidence of trauma. Palpation of the chest may reveal subcutaneous emphysema. Pathologic findings on pulmonary percussion are dullness as an indicator of consolidations or effusion and hyper-resonance suggesting bullous emphysema or pneumothorax. Further, decreased diaphragmatic excursion may be revealed in COPD with hyperinflation or neuromuscular diseases. Auscultate the lungs to assess the character and symmetry of breath sounds. Bilateral crackles or rales are dominant in patients with bronchiectasis [16]. Unilateral rales and crackles are the typical finding in lobular pneumonia [17]. Bilateral basal rales may indicate pulmonary congestion in cardiac failure. Usually, expiratory wheezing indicates COPD or asthma but can also be caused by pulmonary edema or pulmonary embolism. Wheezing combined with low breath sounds supports the presence of COPD or asthma [18]. Absence of breath sounds or silent chest may be found in advanced COPD with severe hyperinflation, pneumothorax, pleural effusion, or malignancy. A pleural rub indicates pleurisy [19].
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Herz 1 · 2014
Abstract · Zusammenfassung Herz 2014 · 39:8–14 DOI 10.1007/s00059-014-4057-6 © Urban & Vogel 2014 S. Brenner · G. Güder
The patient with dyspnea. Rational diagnostic evaluation Abstract Dyspnea is the uncomfortable awareness of difficult breathing. It is a common symptom in primary and nonprimary care settings. Although multiple disorders and diseases may cause breathlessness, the majority of the conditions are of cardiac or pulmonary origin. The challenge is to establish the diagnosis timely and with minimized investigations. Frequently, information about onset, progression, and circumstances of occurrence considerably narrow the underlying etiology. In most cases, a carefully taken history and a comprehensive physical examination lead to the correct diagnosis. Nevertheless, one should be aware of concomitant conditions and not be satisfied with a diag-
nosis if comorbidity may still be a candidate in causing dyspnea. Otherwise, it has been observed that chronic obstructive pulmonary disease was over-diagnosed in patients with systolic heart failure and dyspnea. A prudential use of investigating modalities for confirmation and exclusion of a questionable diagnosis is the key for allocating the correct therapy and achieving fast symptom relief in patients with dyspnea. Keywords Common symptom · Various etiologies · Diagnostic approach · Comorbidities · Dyspnea
Der Patient mit Dyspnoe. Diagnostisches Vorgehen Zusammenfassung Dyspnoe ist die Wahrnehmung der erschwer ten Atmung. Atemnot ist ein weit verbreite tes Symptom sowohl in der Erstversorgung von Akutpatienten als auch in der Routinebetreuung. Obwohl unterschiedlichste Erkrankungen zu Dyspnoe führen können, sind oft das Herz-Kreislauf-System und die Atmungsorgane betroffen, wobei das kardiogene Lungenödem die häufigste Ursache darstellt. Die Herausforderung besteht darin, rechtzeitig und ohne unnötig aufwendige Untersuchungen den Grund für eine Atemnot zu identifizieren. Oft lassen sich bereits anhand von Beginn, Verlauf und Begleitum ständen der Dyspnoe die möglichen Diagnosen stark einschränken. In den meisten Fällen verweisen eine genaue Anamnese und eine sorgfältige körperliche Untersuchung bereits auf die korrekte Diagnose. Nichts-
Auscultation of the heart may reveal abnormality of the heart rate and rhythm, murmurs, or extra heart sounds. Distant heart sounds may occur in cardiac tamponade, pulmonary hyperexpansion, and obesity [20]. Tachycardia may be caused by anemia, hyperthyroidism, or agitation. Atrial fibrillation is detected by an irregular rhythm and frequently accompanies other cardiac conditions. Murmurs suggest valvular pathology, atrial septal defect, or ventricular shunts. A third heart sound may indicate left ventricular systolic dysfunction in congestive heart fail-
destotrotz sollten plausible Komorbiditäten als Ursache für eine Dyspnoe ebenso in Betracht gezogen werden. Andererseits wurde bereits gezeigt, dass eine chronisch obstruktive Lungenerkrankung bei Patienten mit systolischer Herzinsuffizienz und Dyspnoe häufig überdiagnostiziert wird. Das heißt, ein besonnener Einsatz der diagnostischen Modalitäten zum Nachweis oder Ausschluss fragwürdiger Ursachen ist von Nöten, um die korrekte Therapie einzuleiten und eine schnelle Symptombesserung für den Patien ten mit Atemnot zu erzielen. Schlüsselwörter Häufiges Symptom · Verschiedene Ursachen · Diagnostisches Vorgehen · Begleiterkrankungen · Dyspnoe
ure. A parasternal rub is an atypical finding in pericarditis. Abdominal examination should focus on the liver size and look for ascites. Hepatomegaly, positive hepatojugular reflux test, and ascites are typical signs of rightsided heart failure and pulmonary hypertension. On extremities, peripheral perfusion should be evaluated by assessment of the pulses and capillary refill time. The presence of cyanosis or digital clubbing should trigger the exclusion of a congenital heart defect, lung cancer, bronchiectasis, or idiopathic pulmonary fibrosis [21].
1%
2% 3%
10% 28%
12%
21%
23%
Cardiogenic pulmonary edema Community-acquired pneumonia Exacerbation of chronic respiratory disease Pulmonary embolism Bronchitis Acute asthma Others No diagnosis
Fig. 2 8 Acute respiratory failure in the elderly: frequencies of underlying diseases [12]
Check the lower extremities for edema and any signs of deep venous thrombosis [22]. Finally, be aware of indicators for psychiatric conditions such as tremulousness, sweating, or hyperventilation [23]. A carefully taken history and a comprehensive physical examination are often already likely to lead the clinician toward the correct diagnosis, and the results of minimized investigations then finally have a confirmative character.
Measure the severity The assessment of severity is part of the physical examination and includes the evaluation of the ability to talk, the breathing rate, and the mental state but also the level of oxygen desaturation and blood gas alterations. The level of hemoglobin oxygen saturation is usually determined by pulse oximetry. This is a rapid and widely available method that additionally reveals the pulse rate. Although its accuracy is limited because the measurement is influenced by temperature, pH, and arterial carbon monoxide or dioxide level, pulse oximetry is a valuable first approach in most clinical situations. Further, the sensitivity of pulse oximetry is limited since the patient may perceive shortness of breath although the oxygen saturation is still normal. Arterial blood gas measurement is indicated in acute dyspnea and may reveal an altered pH, hypercapnia, hypocapnia, or hypoxemia. A partial pressure of arterial oxygen
S. Brenner · G. Güder Comprehensive Heart Failure Center—A9, Department of Internal Medicine I, University Hospital Würzburg, Würzburg
The patient with dyspnea Rational diagnostic evaluation
Definitions and basic science Dyspnea refers to the uncomfortable awareness of difficult breathing. It is an unignorable sensation similar to that of thirst or hunger. As a subjective experience, dyspnea must be differentiated from tachypnea, hyperpnea, and hyperventilation because these impartially describe the increase of ventilatory rate and minute volume [1]. In a consensus statement, the American Thoracic Society defines dyspnea as a“subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity” [2]. Chronic dyspnea is defined as shortness of breath lasting longer than 1 month [3]. Dyspnea regularly occurs on exertion but is considered to be pathologic when it limits a level of activity that was usually well tolerated [4]. In a population of 8,396 South Australians, the prevalence of chronic dyspnea limiting exertion was 8.9% [5]. Spontaneous respiration is regulated by a complex processing of signals from pulmonary vagal receptors, cerebral and vascular chemoreceptors, and mechanoreceptors in the chest wall and diaphragm [6]. In the brain stem, the respiratory drive is generated to maintain gas–blood and acid–base homeostasis, and motor neurons activate the respiratory muscles accordingly [6]. Under normal conditions, an individual is not aware of his or her respiratory effort. As long as the respiratory muscles are able to generate the required ventilation according to the metabolic needs, the rate and volume of ventilation may increase without the sensation of dyspnea. Dyspnea arises from a
8 |
Herz 1 · 2014
mismatch between the efferent motor signal to respiratory muscles and the afferent feedback from mechanoreceptors of the respiratory system (. Fig. 1, [2, 7, 8]). Campbell and Howell proposed the basic concept for this theory of mismatch between motor signal and lung volume as early as 1963 [9]. Since then, numerous clinical observations are consistent with this theory [6].
Clinical significance Not before the respiratory muscles fail to respond to the neuronal command does the act of breathing come to the conscious level. The sensation of dyspnea therefore always indicates that compensatory mechanisms are exhausted and that, depending on the type of dyspnea and its severity, the underlying condition may be present much longer than the symptom of dyspnea itself. The mismatch between central respiratory drive and peripheral respiratory response can be induced by four general conditions: increased peripheral demand, decreased
ventilatory performance, disturbed alveolar gas exchange, and impaired circulation (. Tab. 1). In clinical situations, various disorders and diseases may cause dyspnea and frequently multiple etiologies are involved. However, in most cases the cause is of cardiac and/or pulmonary origin [10, 11]. In the emergency department of the Hospital Pitié-Salpetrière in Paris, a prospective cohort study was performed including 514 elderly (≥65 years) patients admitted with acute dyspnea and tachypnea, hypoxia, or hypercapnea [12]. Cardiogenic edema was the most frequent reason for the acute respiratory failure (. Fig. 2). . Tab. 2 summarizes the cardiac, pulmonary, cardiopulmonary, and noncardiopulmonary conditions that may cause dyspnea.
Diagnostic approach Dyspnea is a common symptom in the primary care setting and can be caused by multiple disorders and diseases. Underlying etiologies range from harmless
Fig. 1 8 Emergence of dyspnea: schematic illustration
Tab. 1 Conditions and clinical situations causing dyspnea Condition Increased peripheral demand
Decreased ventilatory performance
Disturbed alveolar gas exchange Impaired circulation
Clinical situation Exertion Febrile illness Metabolic acidosis Anemia Carbon monoxide poisoning Upper airway obstruction (angioedema, anaphylaxis, trauma, infection, foreign body aspiration) Pulmonary illness or injury Intrathoracic mass Abdominal mass (e.g., ascites, adipositas, pregnancy) Neuronal disorder (stroke, neuromuscular diseases) Pulmonary congestion Inflammatory diseases with alveolar affection Cardiac failure (ischemic, valvular, arrhythmic) Pulmonary embolism
Tab. 2 Cardiac, pulmonary, cardiopulmonary, and noncardiopulmonary diseases causing
dyspnea System Cardiac
Type Myocardial Valvular Arrhythmia
Pulmonary
Restrictive Alveolar Interstitial
Obstructive
Restrictive
Cardiopulmonary Noncardiopulmonary
Vascular Pulmonary arterial Upper airway Anemia Gastrointestinal Neurogenic Metabolic Psychological
Possible diagnosis Cardiomyopathies, coronary ischemia Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis Atrial fibrillation, inappropriate sinus tachycardia, sick sinus syndrome/bradycardia Constrictive pericarditis, pericardial effusion/tamponade Bronchoalveolar carcinoma, chronic pneumonia, pneumoconiosis, granulomatous disease Drugs (e.g., methotrexate, amiodarone) or radiation therapy, lymphangitic spread of malignancy, passive congestion, interstitial fibrosis Asthma/bronchitis/bronchiectasis, bronchiolitis obliterans, chronic obstructive pulmonary disease, intrabronchial neoplasm, tracheomalacia Kyphoscoliosis, obesity, pleural disease/effusion, pneumothorax Collagen vascular disease Cor pulmonale, pulmonary embolism, idiopathic pulmonary hypertension Deconditioning Polyps, septal deviation, enlarged tonsils, supraglottic or subglottic stricture Iron deficiency, hemolysis Gastroesophageal reflux disease/aspiration, neoplasia Stroke, amyotrophic lateral sclerosis, muscular dystrophies, phrenic nerve palsy, poliomyelitis, pain in the chest wall Acidosis, obesity Anxiety/hyperventilation, depression
to life threatening. Therefore, the timely establishment of a diagnosis is always challenging.
Ask the patient Dyspnea is a subjective experience and its perception is influenced by the subject’s state of mind. Some individuals with only minor physiologic alterations complain of severe shortness of breath; and others even deny the dyspneic sensation despite an advanced cardiopulmonary disorder. Nevertheless, in most cases, the intensity of the complaint correlates well with the severity of the underlying disease. When interrogating the affected patient, dyspnea must be differentiated from other dysphoric sensations in the chest and dyspnea on exertion from exertional fatigue or muscle weakness. Most frequent descriptions of dyspnea are“shortness of breath,”“tightness of chest,” and“inability to breathe deeply.” The patient interview should elaborate on the onset, progression, and duration of dyspnea, daytime or nighttime occurrence, exercise tolerance, its precipitating circumstances, as well as aggravating and ameliorating factors. The presence of concomitant symptoms such as cough, fever, pain, and palpitations should be determined. The patient’s history should be completely recorded focusing on cardiac and pulmonary conditions, smoking habits, allergies, hay fever, as well as occupational and environmental exposures. A comprehensive patient interview already provides important clues for identifying the underlying condition of dyspnea. . Tab. 3 summarizes most conditions according to the onset and progression of dyspnea with frequent concomitant symptoms and typical history. Usually, dyspnea occurs or is aggravated on exertion and limits the physical capacity of the affected patient. By contrast, dyspnea improving over time may indicate deconditioning, and dyspnea unaffected by exercise suggests functional causes [13]. Shortness of breath due to anxiety often occurs with paresthesias of the mouth and fingers. Nevertheless, organic etiologies should always be excluded first [14]. Herz 1 · 2014
| 9
Main topic
Examine the patient First, evaluate the general appearance of the dyspneic patient and check his or her vital signs to correctly identify conditions that may require immediate intervention. Special attention should be addressed to skin color, respiratory rate and effort, ability to speak, and mental status. Stridor indicates an upper airway obstruction. Look for oropharyngeal or nasopharyngeal pathology narrowing the airways. Palpate the neck to reveal masses such as thyroid enlargement. Sideshifted trachea may suggest a tension pneumothorax. Jugular venous distention may indicate cardiac tamponade or may be caused by congestive heart failure or cor pulmonale due to chronic obstructive pulmonary disease (COPD) [15]. Carotid bruits indicate macrovascular disease and may suggest concomitant ischemic heart failure. Supraclavicular retractions may appear due to accessory muscle use for inspiration. Inspection of the chest may show an increased anteroposterior diameter, skeletal deformities, and evidence of trauma. Palpation of the chest may reveal subcutaneous emphysema. Pathologic findings on pulmonary percussion are dullness as an indicator of consolidations or effusion and hyper-resonance suggesting bullous emphysema or pneumothorax. Further, decreased diaphragmatic excursion may be revealed in COPD with hyperinflation or neuromuscular diseases. Auscultate the lungs to assess the character and symmetry of breath sounds. Bilateral crackles or rales are dominant in patients with bronchiectasis [16]. Unilateral rales and crackles are the typical finding in lobular pneumonia [17]. Bilateral basal rales may indicate pulmonary congestion in cardiac failure. Usually, expiratory wheezing indicates COPD or asthma but can also be caused by pulmonary edema or pulmonary embolism. Wheezing combined with low breath sounds supports the presence of COPD or asthma [18]. Absence of breath sounds or silent chest may be found in advanced COPD with severe hyperinflation, pneumothorax, pleural effusion, or malignancy. A pleural rub indicates pleurisy [19].
10 |
Herz 1 · 2014
Abstract · Zusammenfassung Herz 2014 · 39:8–14 DOI 10.1007/s00059-014-4057-6 © Urban & Vogel 2014 S. Brenner · G. Güder
The patient with dyspnea. Rational diagnostic evaluation Abstract Dyspnea is the uncomfortable awareness of difficult breathing. It is a common symptom in primary and nonprimary care settings. Although multiple disorders and diseases may cause breathlessness, the majority of the conditions are of cardiac or pulmonary origin. The challenge is to establish the diagnosis timely and with minimized investigations. Frequently, information about onset, progression, and circumstances of occurrence considerably narrow the underlying etiology. In most cases, a carefully taken history and a comprehensive physical examination lead to the correct diagnosis. Nevertheless, one should be aware of concomitant conditions and not be satisfied with a diag-
nosis if comorbidity may still be a candidate in causing dyspnea. Otherwise, it has been observed that chronic obstructive pulmonary disease was over-diagnosed in patients with systolic heart failure and dyspnea. A prudential use of investigating modalities for confirmation and exclusion of a questionable diagnosis is the key for allocating the correct therapy and achieving fast symptom relief in patients with dyspnea. Keywords Common symptom · Various etiologies · Diagnostic approach · Comorbidities · Dyspnea
Der Patient mit Dyspnoe. Diagnostisches Vorgehen Zusammenfassung Dyspnoe ist die Wahrnehmung der erschwer ten Atmung. Atemnot ist ein weit verbreite tes Symptom sowohl in der Erstversorgung von Akutpatienten als auch in der Routinebetreuung. Obwohl unterschiedlichste Erkrankungen zu Dyspnoe führen können, sind oft das Herz-Kreislauf-System und die Atmungsorgane betroffen, wobei das kardiogene Lungenödem die häufigste Ursache darstellt. Die Herausforderung besteht darin, rechtzeitig und ohne unnötig aufwendige Untersuchungen den Grund für eine Atemnot zu identifizieren. Oft lassen sich bereits anhand von Beginn, Verlauf und Begleitum ständen der Dyspnoe die möglichen Diagnosen stark einschränken. In den meisten Fällen verweisen eine genaue Anamnese und eine sorgfältige körperliche Untersuchung bereits auf die korrekte Diagnose. Nichts-
Auscultation of the heart may reveal abnormality of the heart rate and rhythm, murmurs, or extra heart sounds. Distant heart sounds may occur in cardiac tamponade, pulmonary hyperexpansion, and obesity [20]. Tachycardia may be caused by anemia, hyperthyroidism, or agitation. Atrial fibrillation is detected by an irregular rhythm and frequently accompanies other cardiac conditions. Murmurs suggest valvular pathology, atrial septal defect, or ventricular shunts. A third heart sound may indicate left ventricular systolic dysfunction in congestive heart fail-
destotrotz sollten plausible Komorbiditäten als Ursache für eine Dyspnoe ebenso in Betracht gezogen werden. Andererseits wurde bereits gezeigt, dass eine chronisch obstruktive Lungenerkrankung bei Patienten mit systolischer Herzinsuffizienz und Dyspnoe häufig überdiagnostiziert wird. Das heißt, ein besonnener Einsatz der diagnostischen Modalitäten zum Nachweis oder Ausschluss fragwürdiger Ursachen ist von Nöten, um die korrekte Therapie einzuleiten und eine schnelle Symptombesserung für den Patien ten mit Atemnot zu erzielen. Schlüsselwörter Häufiges Symptom · Verschiedene Ursachen · Diagnostisches Vorgehen · Begleiterkrankungen · Dyspnoe
ure. A parasternal rub is an atypical finding in pericarditis. Abdominal examination should focus on the liver size and look for ascites. Hepatomegaly, positive hepatojugular reflux test, and ascites are typical signs of rightsided heart failure and pulmonary hypertension. On extremities, peripheral perfusion should be evaluated by assessment of the pulses and capillary refill time. The presence of cyanosis or digital clubbing should trigger the exclusion of a congenital heart defect, lung cancer, bronchiectasis, or idiopathic pulmonary fibrosis [21].
1%
2% 3%
10% 28%
12%
21%
23%
Cardiogenic pulmonary edema Community-acquired pneumonia Exacerbation of chronic respiratory disease Pulmonary embolism Bronchitis Acute asthma Others No diagnosis
Fig. 2 8 Acute respiratory failure in the elderly: frequencies of underlying diseases [12]
Check the lower extremities for edema and any signs of deep venous thrombosis [22]. Finally, be aware of indicators for psychiatric conditions such as tremulousness, sweating, or hyperventilation [23]. A carefully taken history and a comprehensive physical examination are often already likely to lead the clinician toward the correct diagnosis, and the results of minimized investigations then finally have a confirmative character.
Measure the severity The assessment of severity is part of the physical examination and includes the evaluation of the ability to talk, the breathing rate, and the mental state but also the level of oxygen desaturation and blood gas alterations. The level of hemoglobin oxygen saturation is usually determined by pulse oximetry. This is a rapid and widely available method that additionally reveals the pulse rate. Although its accuracy is limited because the measurement is influenced by temperature, pH, and arterial carbon monoxide or dioxide level, pulse oximetry is a valuable first approach in most clinical situations. Further, the sensitivity of pulse oximetry is limited since the patient may perceive shortness of breath although the oxygen saturation is still normal. Arterial blood gas measurement is indicated in acute dyspnea and may reveal an altered pH, hypercapnia, hypocapnia, or hypoxemia. A partial pressure of arterial oxygen
