From the Guidelines
The stepwise workup for shortness of breath should begin with a thorough history and physical examination, followed by basic diagnostic tests such as chest X-ray, ECG, and pulse oximetry, as recommended by the most recent study 1. The initial evaluation should focus on determining whether the cause is related to cardiovascular disease, pulmonary disease, a combination of both, or neither, as suggested by 1. Some key points to consider in the workup include:
- A thorough history and physical examination to identify potential causes of dyspnea, such as cardiovascular or pulmonary disease, as recommended by 1 and 1.
- Basic diagnostic tests, including chest X-ray, ECG, and pulse oximetry, to quickly identify common causes like pneumonia, heart failure, or COPD exacerbation, as suggested by 1 and 1.
- Blood tests, including complete blood count, basic metabolic panel, and BNP (for suspected heart failure), to further evaluate the cause of dyspnea, as recommended by 1.
- Advanced imaging, such as CT pulmonary angiogram, to rule out pulmonary embolism, especially if D-dimer is elevated, as suggested by 1.
- Specialized tests, such as echocardiogram or bronchoscopy, for persistent unexplained dyspnea, as recommended by 1. Throughout the workup, it is essential to be prepared to intervene with appropriate treatments based on findings, such as bronchodilators for bronchospasm, diuretics for heart failure, or antibiotics for pneumonia, as suggested by 1 and 1. The use of point-of-care ultrasonography (POCUS) can also improve the correctness of diagnosis in patients with acute dyspnea, as shown in 1 and 1. Overall, a systematic approach to the workup of shortness of breath, prioritizing the most likely and potentially serious causes, is crucial to ensure a thorough evaluation and appropriate treatment, as recommended by the most recent study 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Stepwise Workup for Dyspnea
The stepwise workup for dyspnea, as outlined in the literature, involves a series of assessments and tests to determine the underlying cause of the symptom. The following steps are recommended:
- Stage 1: History taking and physical examination, followed by simple tests such as:
- Pulse oximetry
- Spirometry
- Electrocardiography 2
- Stage 2: If the patient remains undiagnosed, the next stage includes investigations such as:
- Chest x-ray
- Thyroid function tests
- Full blood count
- NT-proBNP 2
- Stage 3: Patients who are still undiagnosed are referred for more advanced tests, including:
- Echocardiogram
- Thoracic CT 2
- Stage 4: If dyspnea remains unexplained, the final stage of assessment requires secondary care referral for more advanced diagnostic testing, such as exercise tests 2
Importance of History and Physical Examination
The medical history and physical examination are crucial components of the diagnostic process, with studies showing that they can lead to a diagnosis in a significant proportion of cases. For example, one study found that the history led to the final diagnosis in 76% of patients, while the physical examination led to the diagnosis in 12% of cases 3. Another study demonstrated that attending physicians can make a diagnosis based on initial evaluation, including history, physical examination, and ECG, in 63% of patients with transient loss of consciousness, with an overall diagnostic accuracy of 88% 4.
Role of Diagnostic Tests
Diagnostic tests, such as point-of-care ultrasound, can also play a significant role in the evaluation of patients with dyspnea. One study found that point-of-care ultrasound had equal or higher specificity to chest radiograph for several indications, and correctly identified all patients with pneumothorax, pleural effusion, and pericardial effusion 5. However, the use of additional testing should be guided by the clinical presentation and initial evaluation, and should not be relied upon as the sole means of diagnosis.