Out Of Breath – When To Seek Help

Introduction

Shortness of breath, or dyspnea is a common symptom that affects almost 25% of patients who present to the emergency department. It can arise from a bevy of conditions, and is occasionally a manifestation of a serious underlying disease. Some of these underlying conditions are life-threatening, which warrants a prompt evaluation and targeted diagnostic studies. Shortness of breath, or dyspnea is defined by the American Thoracic Society as a “subjective experience of breathing discomfort that consists of qualitatively distinct sensations which vary in intensity”. If you are experiencing respiration that requires effort, a feeling of choking or a “hunger” for air, this would be in keeping with dyspnea. Dyspnea is not uncommon – 7.4% of all patients who are seen in the primary care setting (GP) complain of shortness of breath. This article will outline the various causes of shortness of breath, together with signs and symptoms that should prompt a visit to the emergency department.

Differential Diagnoses of Dyspnea

The causes of dyspnea or shortness of breath can be segregated into 5 main categories. These are respiratory causes, cardiovascular causes, neuromuscular causes, psychogenic causes and systemic causes.

Cardiovascular Causes:

  • Congestive Cardiac Failure
  • Pulmonary Edema
  • Acute Coronary Syndrome
  • Pericardial Tamponade
  • Cardiac Arrhythmia

Respiratory Causes:

  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Pulmonary Embolism
  • Pneumothorax

Neuromuscular Causes:

  • Chest Trauma
  • Spinal Cord Dysfunction
  • Myopathy
  • Neuropathy

Psychogenic Causes:

  • Hyperventilation Syndrome
  • Vocal Cord Dysfunction
  • Foreign Body Aspiration

Systemic Causes:

  • Anemia
  • Kidney Failure
  • Thyrotoxicosis
  • Liver Disease
  • Sepsis
  • Anaphylaxis (Severe allergic reaction)

Cardiovascular Causes of Dyspnea

Shortness of breath is an extremely common symptom that occurs in cardiovascular diseases. This is because the cardiovascular and respiratory systems work together to ensure that the tissues in our body are well oxygenated. Blood contains a vital compound called haemoglobin, to which oxygen binds. Oxygen from the lungs is delivered to the rest of our body by the arteries and arterioles which comprise the cardiovascular system. Our cells then use oxygen as fuel to generate ATP, which is the energy currency utilised by cellular mitochondria – the “powerhouses” of our cells. Hence, when cardiovascular disease manifests in the form of a myocardial infarction (heart attack), or when the heart fails as a pump which leads to a backup of fluid (congestive cardiac failure), the respiratory system works harder to maintain oxygenation of our tissues. This is why almost any cardiovascular pathology leads to shortness of breath as a symptom. Shortness of breath in the following contexts should prompt immediate medical attention:

  • Chest Pain
  • Giddiness/Loss of Consciousness
  • Swelling of lower limbs, upper limbs or face

Respiratory Causes

Respiratory diseases such as asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, pulmonary emboli and pneumonia are almost always accompanied by a certain degree of shortness of breath. This is because virtually all respiratory diseases adversely affect the lungs in some way or form, and consequently impact the effectiveness of oxygen transfer. Since all respiratory conditions cause shortness of breath, it may not be easy for patients to distinguish between symptoms that necessitate emergency medical attention, and those which can be attended to in a primary care setting, such as the General Practitioner’s office. Shortness of breath with the following characteristics should prompt immediate medical attention:

  • Sudden Onset
  • Chest Pain
  • Wheeze
  • Respiratory Distress
  • Altered Mental State

Neuromuscular Causes

Often times, blunt chest wall trauma or a fall can lead to chest wall fractures or deformities. The chest wall is vital in the process of breathing; indeed, the intercostal muscles between the ribs work together with the diaphragm to expand and contract the intra-thoracic cavity to stimulate inhalation and exhalation respectively. Hence, a disruption in the anatomy of the chest wall can sometimes lead to an impairment in breathing. Similarly, the spinal cord which innervates these muscles is also vitally crucial in enabling muscular contractions. Any disruption of the spinal cord (e.g. a spinal cord transection from trauma, a prolapsed intervertebral disc or even a spinal cord tumour) can impair muscular contraction. Lastly, primary diseases of the muscles (e.g. muscular dystrophy) or nerves (e.g. myasthenia gravis) can directly affect breathing for the reasons mentioned above. Shortness of breath in the following contexts should prompt immediate medical attention:

  • Trauma
  • Sudden Onset
  • Neurological Deficits (e.g. weakness & numbness)

Systemic Causes

Shortness of breath can also be caused by systemic illnesses that do not directly affect the respiratory system. For example, severe anaemia in the context of chronic bleeding, vitamin B12 deficiency or an auto-immune disease can manifest in shortness of breath. This is because there isn’t enough haemoglobin to oxygenate tissues, despite the lungs working perfectly well. Kidney failure can also result in shortness of breath, as the kidneys produce erythropoietin – a necessary pre-cursor in the production of haemoglobin. Shortness of breath in the following contexts should prompt immediate medical attention:

  • Severe bleeding
  • Giddiness/Loss of Consciousness
  • Altered Mental State

CH1ER Management

Community Health 1ST ER sees patients presenting with shortness of breath on a daily basis. We understand the need to rapidly diagnose and exclude the life-threatening conditions elucidated above. To that end, we have provided for a state-of-the-art on-site laboratory to perform rapid point-of-care haematological tests and a radiology service. Our tertiary-level radiology services include CT scans, X-Rays and ultrasounds which are routinely employed to diagnose these conditions. We also have a fully outfitted pharmacy to manage your conditions with common prescription medicines as well as niche therapeutics.