What is the best approach to assess a patient for dyspnea (shortness of breath)?

From the Guidelines

The best approach to assess a patient for dyspnea involves a systematic evaluation starting with a thorough history and physical examination, as this allows for the identification of the underlying cause and guides further diagnostic testing and management. When assessing a patient for dyspnea, it is crucial to begin by asking about the onset, duration, severity, and aggravating or alleviating factors of the shortness of breath, as well as inquiring about associated symptoms such as chest pain, cough, fever, or leg swelling 1. Assessing the patient's vital signs, including respiratory rate, oxygen saturation, heart rate, blood pressure, and temperature, is also essential, along with observing for signs of respiratory distress like accessory muscle use, nasal flaring, or cyanosis.

Key Components of Assessment

• A focused cardiopulmonary examination including lung auscultation for abnormal breath sounds, heart examination for murmurs or gallops, and assessment for peripheral edema
• Additional diagnostic tests such as pulse oximetry, arterial blood gas analysis, chest X-ray, electrocardiogram, pulmonary function tests, and blood tests like complete blood count, BNP, and D-dimer, depending on the clinical suspicion
• The use of validated dyspnea scales like the Modified Borg Scale or the Medical Research Council Dyspnea Scale to help quantify the severity of dyspnea

According to the most recent guidelines, for patients with dyspnea of suspected cardiac origin, diagnostic imaging should usually be started with chest radiography followed by resting TTE 1. However, the initial step in any case of dyspnea should always be a careful history and physical examination to guide the subsequent use of diagnostic tests and to identify the potential underlying cause of the dyspnea, which could range from pulmonary conditions to cardiac issues or other causes 1.

Diagnostic Imaging

• Chest radiography as the initial imaging test for suspected cardiac origin of dyspnea
• Resting TTE as a follow-up to chest radiography for further evaluation
• Consideration of stress echocardiography, stress MRI, stress SPECT, or stress PET to exclude ischemia in patients with dyspnea due to heart failure, with CT coronary angiography being an option in low- and intermediate-risk populations 1

From the Research

Assessing Shortness of Breath

To assess a patient for dyspnea (shortness of breath), the following steps can be taken:

• A detailed history and physical examination should be conducted to identify potential causes of dyspnea, such as cardiac or pulmonary diseases 2
• The assessment should include inspection, palpation, percussion, and auscultation of the chest, as well as consideration of the patient's environment and positioning 3, 4
• Vital signs, such as oxygen saturation and respiratory rate, should be evaluated as part of the assessment 5
• Further investigations, such as complete blood count, basic chemistry panel, electrocardiography, chest radiography, spirometry, and pulse oximetry, may be necessary to confirm or rule out suspected diagnoses 2

Physical Examination

The physical examination of the chest should follow a systematic approach, including:

• Inspection: a comprehensive visual assessment of the chest 3, 4
• Palpation: using touch to gather information about the chest and lungs 3, 4
• Percussion: striking the chest to determine the state of underlying tissues 3, 4
• Auscultation: listening to and interpreting sound transmission through the chest wall via a stethoscope 3, 4

Additional Considerations

• The six-minute walk test can be helpful in measuring the effect of ongoing intervention on dyspnea symptoms 2
• Care of patients with chronic dyspnea typically requires a multidisciplinary approach, with the primary care physician playing a key role in management 2