What is the workup for dyspnea (difficulty breathing)?

From the Guidelines

The workup for dyspnea should begin with a thorough history and physical examination to identify potential causes, followed by initial testing including pulse oximetry, complete blood count, basic metabolic panel, chest X-ray, and electrocardiogram, as recommended by the American College of Physicians 1. The diagnostic approach to dyspnea can be challenging due to the numerous potential underlying conditions, and a systematic approach is necessary to identify the correct underlying condition and provide appropriate treatment. Some key points to consider in the workup for dyspnea include:

• Initial testing should include pulse oximetry, complete blood count, basic metabolic panel, chest X-ray, and electrocardiogram.
• Pulmonary function tests are essential to evaluate for obstructive or restrictive lung diseases.
• Additional tests may include D-dimer to rule out pulmonary embolism, BNP or NT-proBNP for heart failure, arterial blood gases to assess gas exchange, and high-resolution CT scan of the chest for interstitial lung diseases.
• If cardiac causes are suspected, an echocardiogram should be performed to evaluate cardiac function and structure.
• For patients with risk factors for coronary artery disease, stress testing may be appropriate.
• In cases of suspected pulmonary embolism with elevated D-dimer, CT pulmonary angiography is indicated.
• For unexplained dyspnea despite initial testing, cardiopulmonary exercise testing can help differentiate between cardiac, pulmonary, or deconditioning causes. The use of point-of-care ultrasonography (POCUS) can also improve the correctness of diagnosis in patients with acute dyspnea, as it can help detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax 1. Overall, a thorough and systematic approach to the workup for dyspnea is essential to identify the underlying cause and provide appropriate treatment, and to improve patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Workup for Dyspnea

The workup for dyspnea typically involves a combination of medical history, physical examination, and diagnostic tests.

• A detailed history and physical examination should begin the workup, with results driving further testing 2, 3, 4, 5.
• Initial testing may include:
  • Complete blood count
  • Basic chemistry panel
  • Electrocardiography
  • Chest radiography
  • Spirometry
  • Pulse oximetry 2, 3, 5
• If no cause is identified, second-line noninvasive testing such as:
  • Echocardiography
  • Cardiac stress tests
  • Pulmonary function tests
  • Computed tomography scan of the lungs may be suggested 2, 3, 5
• Final options include more invasive tests that should be done in collaboration with specialty help 2

Diagnostic Considerations

The diagnosis of dyspnea can be complex, and a multifactorial approach is often necessary.

• The clinical presentation alone is adequate to make a diagnosis in 66 percent of patients with dyspnea 3.
• Measurement of brain natriuretic peptide levels may help exclude heart failure, and D-dimer testing may help rule out pulmonary emboli 3.
• Pulmonary function studies can be used to identify emphysema and interstitial lung diseases 3, 5.
• Computed tomography of the chest is the most appropriate imaging study for diagnosing suspected pulmonary causes of chronic dyspnea 3, 4, 5

Treatment and Management

The treatment and management of dyspnea depend on the underlying cause.

• The three main treatment and management goals are to correctly identify the underlying disease process and treat appropriately, optimize recovery, and improve the dyspnea symptoms 2.
• Nonpharmacotherapy options include supplemental oxygen, self-management with breathing exercises, and airway interventions with rapid sequence intubation in emergency situations 4.
• Pharmacotherapy options include opioids, benzodiazepines, corticosteroids, and bronchodilators 4.