Investigate Shortness of Breath: Here’s How

If a patient calls their primary care provider and complains about shortness of breath, an in-office examination is generally warranted. Your patient may explain how they’re out of breath from everyday activities, like using stairs or getting winded from walking the dog, or just not being able to catch their breath.

“All new episodes of shortness of breath should be evaluated in real time by a clinician, ideally in person,” said Panagis Galiatsatos, MD, MHS, pulmonologist and associate professor, Division of Pulmonary and Critical Care Medicine at Johns Hopkins School of Medicine in Baltimore.

But if the patient has a diagnosed condition, a phone or virtual discussion could be enough. “The only time I can see foregoing an immediate clinic visit is if a known cardiopulmonary diagnosis exists,” Galiatsatos said.

For example, if you already know the patient has a pulmonary or cardiac condition and their dyspnea (shortness of breath) is similar to prior episodes of breathlessness, then an in-office appointment may not necessarily be needed, he said. Those could be managed by both an action plan that has already been discussed at prior visits.

A Red Flag During Office Visits

What if a patient is already in the office for another reason and casually mentions episodes of shortness of breath, how should the primary doctor proceed?

Even if dyspnea is mentioned casually, it warrants a thorough history and focused physical exam, especially if this is new or worsening. This could be an early sign of a more serious problem, said Lijo Illipparambil, MD, pulmonologist and assistant professor of Clinical Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia.

When discussing such symptoms, Illipparambil recommends these questions:

• When do episodes occur — during exertion vs rest?
• How long have these symptoms been occurring?
• Are there other symptoms, like fatigue, chest tightness, wheezing, cough, or swelling?
• How limiting are the symptoms? Is the patient able to climb stairs, and if so, how many? Is walking across a room or doing daily chores causing them to be dyspneic?

How to Be a Frontline Partner?

Primary care doctors are essential in identifying early signs of cardiopulmonary disease.

“Generally, they are the first physicians who meet the patients and do most of the work-up initially. They coordinate care, especially with specialists, provide lifestyle counseling, and monitor chronic conditions like COPD [chronic obstructive pulmonary disease], asthma, and congestive heart failure,” Illipparambil said.

In many ways, they are the real central component for care of patients with dyspnea, he affirmed. “They also have the advantage of longitudinal relationships, allowing them to notice changes over time and engage in shared decision-making to create sustainable health strategies and earlier intervention if needed,” Illipparambil said.

Assessment Protocol

Usually, a thorough physical exam, including checking vital signs, especially oxygen saturation and heart rate, is next, Illipparambil said. And additional testing should be considered including chest x-ray, EKG, and laboratory work-up, as well as referral to specialists if warranted.

Red flags that warrant further testing include:

• Dyspnea at rest is always a reason for further testing, he said. “It is not normal to be short of breath at rest; it is most often a sign of significant impending decompensation. Additionally, Illipparambil said, worsening shortness of breath over days/weeks can demonstrate a progressive process. Difficulty walking short distances or performing basic activities (eg, walking in the supermarket, pushing a stroller), especially as a change from their baseline, can be a sign of an active problem.
• Orthopnea or paroxysmal nocturnal dyspnea are signs of heart failure that need further investigation.
• Unilateral leg swelling should always have a differential that includes deep venous thrombosis and possible pulmonary embolism if present when a patient is short of breath, he said.

Expert Assessments and Symptoms

Consider the shortness-of-breath assessments below, according to Galiatsatos:

Airway diseases. COPD or asthma are examples. “I would recognize due to inability to walk incline or when holding groceries — not walking through the grocery store, but once their arms are engaged, their breathlessness is noticeable,” he explained.

Cardiac rhythm issues (especially low heart rates). Most people notice this breathlessness even within a few dozen feet or so of walking on flat surface, he cited.

Pulmonary embolism (lung blood clot). This is more acute in occurrence, and patients often describe a heaviness and uncomfortableness in their chest. “This is often accompanied by something that provoked the blood clot, long hours of sitting say from a long flight, or a trauma to the legs,” Galiatsatos continued.

Heart failure. The key symptom here is the inability to lay down flat, he asserted. Patients may note having to sleep with several pillows, prompting their head and upper torso to be more and more vertical or abandoning sleeping in a bed and sleeping in a recliner, he also explained.

Lifestyle Strategies

The key is to be empathetic, collaborative, and goal oriented.

“This is indeed a delicate yet vital conversation,” Illipparambil said. There are several reasons for shortness of breath and approaching patients this way can help with patient openness and discussion. One thing that helps is the use of motivational interviewing techniques. For instance, he recommends asking permission to discuss weight, tobacco use, or other lifestyle habits that may be affecting shortness of breath can help establish a partnering role in these goals.

Another way to approach, he continued, is focusing on functions such as walking without getting winded and changing habits toward a healthy lifestyle rather than just the number on the scale.

“Additionally, offering resources and referrals for nutrition, sleep study, physical therapy, etc., can go a long way. Medications, of course, can help, especially inhalers in COPD and asthma patients. Antihypertensives and other medications that help modify heart disease, and goal-directed medical therapy have been shown to improve symptoms in patients with heart failure,” Illipparambil also said.

How Does Obesity Intersect With Shortness of Breath?

Obesity is often linked to cardiopulmonary deconditioning, according to Trishul Siddharthan, MD, pulmonologist and associate professor of the Department of Medicine with the University of Miami Miller School of Medicine and the UHealth — University of Miami Health System, both in Miami.

“Extra weight is a significant cause of shortness of breath in the general population and interacts with respiratory diseases like asthma to worsen symptoms,” Siddharthan outlined.

Lifestyle changes and other strategies to cope are a shared decision, he said. “I ensure I address the underlying medical condition while addressing enablers and barriers to weight loss.”