Shortness of Breath

Evaluating Shortness of Breath

Evaluating a patient with shortness of breath requires a detailed history and physical examination by Dr. Kamelhar or Dr. Teller. Concentration must focus on excluding potentially life-threatening conditions and then on the most common causes. Swelling in the feet or ankles, chest discomfort or pressure, fevers, chills, cough, wheezing, trouble breathing with slight activity or while at rest, and cyanosis (when the lips or fingertips turn blue) are symptoms that may accompany shortness of breath and point toward a specific cause. Similarly, frequent belching, heartburn or a sensation of food getting stuck suggests a problem originating from the esophagus. Difficulty walking, a weak cough or difficulty with speech points to a neurologic cause. Curvature of the spine, or scoliosis, can progress over time and inhibit the chest from expanding fully. There may be pressure on the lungs causing part of the lung to collapse and not contribute to effective breathing. This is a long list but certainly not the whole list!

Breathing tests or Pulmonary Function Tests (PFTs) help determine whether there is an abnormality in the bronchial tubes, the lung tissue, the exchange of oxygen/carbon dioxide or weakness of the muscles needed to breathe properly.

Chest imaging in the form of X-ray or CT scan, are useful in detecting an underlying cause. Is the cause related to changes in the bronchial tubes (i.e. bronchiectasis or COPD), lung tissue abnormalities (i.e. emphysema or interstitial disease), space that surrounds the lung (i.e pleural effusion or pneumothorax), or a blood clot in one of the blood vessels of the lung (i.e. pulmonary embolism).

Additional non-invasive tests may include:

• Heart: ECG, echocardiogram, Holter monitor (24 hour ECG recording), and cardiac stress test. These are performed under cardiologist supervision
  

• Esophagus: Modified barium swallow/esophagram are X-ray tests to assess the function of the esophagus
  

• Asthma: Bronchial provocation tests (i.e. methacholine challenge test) to detect subtle asthma

• Oxygen and carbon dioxide levels in the blood: Arterial blood sampling from the wrist
  

• Exercise-associated shortness of breath not otherwise diagnosed: Cardio-pulmonary exercise tests (CPET). This may be utilized for high-performing individuals noting difficulty at high levels of exercise

Invasive tests may also be necessary depending on the results of the non-invasive tests:

• Bronchoscopy and possible lung biopsy to directly examine the bronchial tubes and lung tissue.

• Left and Right cardiac catheterization to evaluate the arteries that supply blood to and from  the heart.

• Upper endoscopy, manometry and 24-hour measurement of esophageal acidity (pH) to further assess esophageal disorders

The determination of the cause may also be made by observing which specific therapy eliminates the shortness of breath (Therapeutic trial).

Points to Keep in Mind

• Listening carefully to the patient’s description of the symptom is most important! If the tests ordered are not the correct ones, the correct diagnosis will not be found.

• There is often more than one cause for the shortness of breath occurring at the same time.

• There are often numerous abnormalities in one patient. Finding a diagnosis is not the same as finding the diagnosis.

• Thorough evaluations by Dr. Kamelhar or Dr. Teller will determine what is causing your shortness of breath and provide proper treatment of the condition.