MRCP PACES Approaches Approach to Dyspnoea

Differential diagnoses

  • Cardiac
    • Congestive cardiac failure
    • Arrhythmia
    • Cyanotic spells
    • Constrictive pericarditis
    • Cardiac tamponade
  • Respiratory
    • Pulmonary embolism
    • Pneumothorax
    • Asthma / COPD
    • Pneumonia
      • HIV: PCP
    • Tuberculosis
    • Interstitial lung disease
      • Idiopathic pulmonary fibrosis
      • Occupational lung disease
      • Connective tissue disease
      • ANCA-associated vasculitis
      • Drug induced
      • Radiation fibrosis
    • Bronchiectasis
    • Lung cancer
    • Pleural effusion
    • Air embolism
    • Primary pulmonary hypertension
    • Extra-thoracic restrictive lung disease
      • Obesity hypoventilation syndrome
      • Kyphoscoliosis
      • Ankylosing spondylitis / other seronegative spondyloarthropathy
  • Haematological
    • Anaemia – GI blood loss
  • Neurological
    • Myasthenia gravis
    • Botulinism
    • Guillain-Barre syndrome
  • Fluid overload
    • Liver failure
    • Nephrotic syndrome
    • Renal failure
  • Endocrine
    • Diabetic ketoacidosis (respiratory compensation)
    • Hyperthyroidism

Relevant points in the history

  • Dyspnoea
    • Do you feel breathless at the moment?
    • What were you doing when you noticed the breathlessness?
    • Did it come on suddenly, or does it get worse and worse?
    • Is the breathlessness constant, or does it come and go?
    • If intermittent: how frequently do you become breathless?
    • Do you have any other symptoms other than the dyspnoea?
    • Is there any chest pain?
    • Do you feel light-headed?
    • Do you feel sweaty or nauseous?
    • Does anything make the breathlessness worse?
    • Does anything make it better?
    • How far are you able to walk before you become breathless?
    • Are you able to climb stairs without feeling breathless?
    • Are you able to speak when you have this breathlessness, or is it so bad that you have to sit down?
    • When did you last feel well? Have you ever had this before?
    • How has this been affecting your life?
  • Cardiac
    • Do you ever get chest pain on walking?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you noticed any leg swelling?
    • Have you ever noticed an irregular heartbeat or your heart skipping a beat?
    • Have you ever fainted or felt like you were about to faint?
    • Have you ever noticed your fingers or lips turning blue?
  • Respiratory
    • Infections / bronchiectasis
      • Have you noticed a fever recently?
      • Do you have a cough?
      • How long have you had the cough for?
      • Do you bring up any phlegm with the cough?
      • What colour is the phlegm?
      • Have you ever coughed up blood?
      • Have you noticed any sweating at night?
      • Did you have any repeated chest infections as a child?
      • Are you sexually active?
      • How many sexual partners have you had?
      • Are they male or female?
      • Do you use protection?
      • If MSM: what kind of sexual activity do you engage in?
      • When you engage in anal sex, are you the receptive partner or the penetrative one?
      • Have you ever injected recreational drugs through a vein?
    • Obstructive airways disease
      • Have you ever noticed a cough at night?
      • Have you noticed that this breathlessness is brought on by specific triggers?
      • Have you ever noticed a wheezing noise when you feel breathless?
      • Do you notice that your chest feels tight?
      • Have you ever tried an inhaler?
        • What inhalers have you tried?
        • Has the dose or number of puffs changed recently?
        • How do you use the inhaler?
        • Do you take your inhaler every day as prescribed?
      • Do you have eczema?
      • Have you noticed intermittent episodes of a runny nose?
      • Does anyone in the family have eczema, asthma or a runny nose?
      • Do you keep any pets at home?
      • Do you, or have you ever smoked?
    • Pulmonary fibrosis (asked about cough above under infection)
      • Occupational lung disease
        • What is your job?
        • Have you ever worked in an industry which exposed you to dusts such as asbestos?
      • Connective tissue disease
        • Have you noticed that the skin of your hands or face is unusually tight?
        • Have you noticed any rashes anywhere on your body?
        • Do you find any difficulty in swallowing?
        • Have you noticed any whitish bumps on your fingertips?
        • Do your hands go white or blue in the cold?
        • Do you have any mouth ulcers?
        • Have you noticed your hair dropping moreso than usual?
        • When you wake up in the morning, do you notice hair on your pillow?
        • Have you noticed any joint pains?
        • Do you feel stiff early in the morning?
        • Have you noticed that your eyes or mouth are unusually dry?
      • Iatrogenic
        • Do you take any medicines?
        • Have you ever had chemotherapy?
        • Have you ever taken a medicine called amiodarone, methotrexate or nitrofurantoin?
        • Have you ever received radiation to the chest?
      • Post-infectious
        • Have you ever had tuberculosis?
        • Have you had any other chest infections before?
    • Pulmonary embolism
      • Does the pain get worse when you breathe in?
      • Have you noticed that one leg has been swollen or painful?
      • Have you been on any long flights recently?
      • Have you had any recent operations?
      • Do you use the oral contraceptive pill?
      • Have you ever had a clot in your leg or your lung?
      • Have you ever been pregnant?
      • How many times have you been pregnant?
      • How many children do you have?
    • Neoplastic
      • Have you lost any weight?
      • How is your appetite?
      • When soaping yourself, have you noticed any bumps in your neck or armpits?
      • Do you or have you ever smoked?
    • Extra-thoracic restrictive lung disease
      • Have you noticed any back pain?
      • Have you noticed any back stiffness?
      • Do you feel that you are getting more hunched?
      • Have you ever had an itchy rash?
      • Have you ever had boughts of diarrhoea or tummy pain?
      • Has anyone ever told you that you might have trouble with your spine?
      • Have you ever had any operations on your back?
  • Haematological
    • Do you feel tired all the time?
    • Have you or any of your friends noticed that you are looking pale?
    • Have you noticed any change in your periods?
    • Are your periods more heavy than usual?
    • How often do you usually go to pass motion?
    • Has this changed recently?
    • Have you noticed a change in the colour of your stool?
    • Have you noticed any blood in your stool?
  • Neurological
    • Have you ever noticed your eyelids drooping?
    • Do you feel weak?
    • Do you find that your eyes get tired after reading?
    • Have you ever had double vision?
    • Does this get worse throughout the day?
    • Do you ever choke on your food?
    • Have you noticed any tingling in your hands and feet?
    • Aside from the breathlessness, have you been ill recently?
    • Have you had any diarrhoea?
  • Fluid overload
    • Have you felt bloated or noticed your arms and legs swelling?
    • What about your face and eyes?
    • Have you ever noticed any bubbles in your urine?
    • Any blood?
    • Have you noticed that the whites of your eyes look a bit yellow?
    • What about your skin?
    • Do your palms look more red than usual?
    • Do you drink any alcohol?
    • Did you use to?

Examination

  • General
    • Cachexia, general posture
    • Respiratory rate / signs of respiratory distress
    • Cyanosis
    • Pallor
    • Telangiectasia
  • Hands and wrist
    • Clubbing
    • Peripheral cyanosis
    • Pulse – rate and rhythm
    • CO2 retention flap
  • Cardiovascular
    • Jugular venous pulsation
    • Apex beat – displaced suggests cardiac failure
    • Right ventricular heave (pulmonary hypertension secondary to underlying lung disease)
    • Auscultate for any murmurs (PSM of ischaemic MR, ESM of aortic stenosis)
    • Listen for loud P2 (pulmonary hypertension)
  • Respiratory
    • Fine end-inspiratory crepitations (pulmonary fibrosis – apical or basal)
    • Coarse crepitations (pneumonia, bronchiectasis)
    • Wheeze (obstructive airways disease)
    • Cervical lymphadenopathy (underlying malignancy)
  • Neurology
    • Ptosis
    • Proximal weakness
    • Fatigability
    • Count to 20 while looking upwards
  • Abdomen for ascites and stigmata of chronic liver disease if history suggests or generally oedematous
  • Legs
    • Peripheral oedema
    • Unilateral swelling suggesting DVT

Investigations

  • Arterial blood gas to look for type of respiratory failure
  • Full blood count to look for anaemia, leukocytosis in infection
  • Renal function, liver function as these can cause fluid overloaded states
  • Electrocardiogram to look for evidence of ischaemic heart disease, sinus tachycardia / S1Q3T3 in PE
  • Chest radiograph
    • Cardiomegaly
    • Consolidation
    • Pulmonary oedema
    • Reticulonodular shadowing in pulmonary fibrosis
    • Tram-lining and ring shadows in bronchiectasis
    • Hyper-expanded lungs in obstructive airways disease
  • Spirometry
    • Define restrictive or obstructive defect
    • Reduced total lung capacity, FVC (due to restrictive defect) with preserved FEV1/FVC ratio (may even increase because of the relative decrease in FVC)
      • Reduced DLCO
    • COPD (GOLD Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 ≥ 80% predicted: mild
      • FEV1 50 – 80% predicted: moderate
      • FEV1 30 – 50% predicted: severe
      • FEV1 <30% predicted: very severe
    • Asthma (GINA Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 increases by more than 12% and 200ml post-bronchodilator, or
      • FEV1 increases by more than 12% and 200ml after anti-inflammatory treatment
      • Methacholine challenge if index of suspicion high and initial spirometry normal
    • High resolution computed tomography scan of the lungs
      • Honey-combing, reticular septal thickening in pulmonary fibrosis
        • May or may not have traction bronchiectasis
      • Signet ring sign in bronchiectasis (dilated bronchioles next to adjacent pulmonary arteriole)
    • Consider computed tomography pulmonary angiogram if index of suspicion high for PE
    • Bronchoscopy + bronchoalveolar lavage if pneumonia is severe
      • Gram stain and culture for bacteria
      • Acid fast bacilli smear and culture, molecular detection of MTB
      • Cytology for pneumocystis jirovecii
      • Cytology for malignancy
      • Can obtain biopsy from endobronchial tumour, or para-tracheal lymph nodes
    • Trans-thoracic echocardiogram to look at ejection fraction, valve abnormalities
    • Repetitive nerve stimulation test for myasthenia gravis
    • Nerve conduction studies for Guillain-Barré syndrome
    • Negative inspiratory force to judge severity of respiratory compromise
    • Auto-antibodies
      • Anti-centromere, anti-topoisomerase (Scl-70): systemic sclerosis
      • Anti-nuclear antibody, anti-dsDNA (SLE)
      • Rheumatoid factor, anti-cyclic citrullinated peptide (RA)
      • Extractible nuclear antigens (Sjogren’s)
      • Anti-nicotinic acetylcholine receptor, anti-muscle specific kinase (MG)

Management

  • Multidisciplinary team approach
  • Patient education
  • Cardiopulmonary rehabilitation
  • Long-term oxygen therapy if indicated (PaO2 < 55mmHg or SpO2 < 88% RA, or 60mmHg/90% if polycythaemia / cor pulmonale present)
  • Congestive cardiac failure
    • Acute episodes with diuretics
    • Beta blockers
    • ACE inhibitors for remodeling
    • Spironolactone for class IV symptoms
    • Control of cardiovascular risk factors
  • Pulmonary fibrosis
    • Stop smoking
    • Regular immunizations
    • Treat underlying cause
    • Consider Pirfenidone for idiopathic pulmonary fibrosis
    • Treat acute exacerbations
  • Bronchiectasis
    • Postural drainage
    • Antibiotic treatment of acute exacerbations based on previous cultures
    • Consider surgical treatment if localized
  • Obstructive airways disease
    • Bronchodilators
    • Inhaled corticosteroids
  • Neurological
    • Intubation if NIF < 30
    • Immunosuppression – IVIG, steroids
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