What is the best approach to managing a patient presenting with dyspnea, potentially due to chronic obstructive pulmonary disease (COPD) or heart failure?

Approach to Dyspnea

The initial approach to dyspnea must prioritize optimizing treatment of the underlying disease—bronchodilators and corticosteroids for COPD/asthma, diuretics and afterload reduction for heart failure, or antibiotics for pneumonia—before considering symptomatic management of breathlessness itself. 1

Initial Diagnostic Evaluation

History and Physical Examination

The evaluation begins with targeted assessment of specific clinical features rather than generic history-taking:

• Medication review: Elicit use of psychoactive drugs (benzodiazepines, opioids, anticholinergics) that may contribute to respiratory symptoms 1
• Cardiac examination: Assess for murmurs, extra heart sounds, irregular rhythm, and peripheral edema indicating cardiac or pulmonary disease 1
• Respiratory distress signs: Evaluate for accessory muscle use, nasal flaring, tachypnea, paradoxical breathing, and fearful facial expression 1

Initial Diagnostic Testing

Chest radiography is the first-line imaging modality for chronic dyspnea (symptoms >2 weeks), providing sufficient diagnostic information to guide further management. 2, 3

The initial laboratory and imaging workup should include:

• Chest radiograph (CXR) as the primary imaging study 2, 3
• Electrocardiography to evaluate cardiac causes 4, 5
• Spirometry with bronchodilator to assess airflow obstruction 4, 5
• Complete blood count to identify anemia 5
• Basic metabolic panel and thyroid function tests 4, 5
• Brain natriuretic peptide (BNP) when heart failure is suspected 2, 5

Important caveat: Chest radiography misses up to 50% of pulmonary nodules and metastases compared to CT 3. If CXR is abnormal or shows indeterminate findings, proceed to chest CT without contrast for further characterization 3. If CXR is normal but clinical suspicion remains high, chest CT is indicated 3.

Etiology-Based Framework

Approximately 85% of chronic dyspnea cases are attributable to heart failure, myocardial ischemia, or COPD, with more than 30% being multifactorial 2. Two-thirds of cases result from pulmonary or cardiac disorders 4, 6.

Advanced Testing When Initial Workup is Non-Diagnostic

• Comprehensive pulmonary function testing including lung volumes and diffusion capacity 4, 5
• Echocardiography to evaluate cardiac function and valvular disease 4, 5
• Cardiopulmonary exercise testing is critical for unexplained dyspnea when initial tests are non-diagnostic 4, 6
• Chest CT is the most appropriate imaging study for diagnosing suspected pulmonary causes 5
• Inspiratory and expiratory CT to evaluate for air trapping in small airways disease (asthma, COPD, post-COVID) 2

Disease-Specific Treatment

Obstructive Airway Disease (COPD/Asthma)

• Optimized inhaled bronchodilator regimens (e.g., ipratropium bromide produces bronchodilation within 15-30 minutes, peaks at 1-2 hours, and persists 4-5 hours) 1, 7
• Inhaled corticosteroids for persistent inflammation 1
• Systemic corticosteroids and antibiotics for acute exacerbations 1
• Combined therapy with anticholinergics and beta-agonists produces additional improvement in FEV1 with median duration of 5-7 hours versus 3-4 hours with beta-agonist alone 7

Heart Failure

• Diuretics for volume overload 1
• Afterload reduction, beta-blockers, and aldosterone antagonists for systolic dysfunction 1
• Timely referral to heart failure specialists when patients develop advanced HF (NYHA class III-IV despite optimal therapy, severe cardiac dysfunction, recurrent hospitalizations) 2

Critical timing consideration: Referral should occur before end-organ dysfunction or cardiogenic shock develops, as patients may no longer qualify for advanced therapies (LVAD, transplantation) after these complications 2.

Symptomatic Management of Refractory Dyspnea

When disease-specific treatment is insufficient or the patient has advanced disease:

Non-Pharmacological Interventions (First-Line)

• Optimal positioning 1
• Cool air directed at the face using a fan 2, 1
• Environmental modifications 1
• Pulmonary rehabilitation early in the disease course 2

Pharmacological Management

Opioids are first-line pharmacological therapy for refractory dyspnea, administered orally, subcutaneously, or intravenously 2, 1. Dosing should be titrated to symptom relief while monitoring for side effects 2.

• Benzodiazepines as second-line adjunctive therapy, particularly when anxiety or fear contributes to respiratory distress 1
• Glycopyrrolate as the preferred agent for managing excessive secretions due to low delirium risk 1

Advanced Respiratory Support

• Supplemental oxygen for hypoxemia 2
• Noninvasive positive-pressure ventilation (BiPAP/CPAP) for hypercapnic patients, used only in appropriate settings with trained staff 2, 1
• High-flow nasal cannula or mechanical ventilation for time-limited trials in severe reversible conditions 1

Important caveat: Noninvasive ventilation should be used until adequate sedation is achieved or when sedation is inadequate, not as a substitute for appropriate palliative pharmacotherapy 1.

Special Considerations

Point-of-Care Ultrasound (POCUS)

POCUS is an extension of physical examination for rapid assessment when diagnostic imaging access is limited or patient mobility precludes transportation 2. It should be performed by trained professionals for specific pulmonary and cardiovascular indications 2.

Palliative Care Context

For patients with advanced disease or limited prognosis, treatment focuses on symptom relief rather than prolonging life 2. Visual or analog dyspnea scales should be used to assess severity and treatment effects 2. Family members' assessments of symptoms are generally helpful and should be incorporated 2.