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Continua a fare acquisti Pagamento Continua a fare acquisti. Chi ama i libri sceglie Kobo e inMondadori. Mostra anteprima Anteprima salvata Salva anteprima Visualizza la sinossi. Disponibile in Russia Acquista da: Russia per comprare questo prodotto. Aggiungi al carrello Acquista ora Aggiungi alla lista desideri Rimuovi dalla Wishlist. New chapters on congenital diaphragmatic hernia and congenital heart disease NEW!

Valutazioni e recensioni 0 0 valutazioni con stelle 0 recensioni. Valutazione complessiva Ancora nessuna valutazione 0. Chiudi Segnala una recensione Noi di Kobo ci assicuriamo che le recensioni pubblicate non contengano un linguaggio scurrile e sgradevole, spoiler o dati personali dei nostri recensori. Vuoi dare un altro sguardo a questa recensione? Hai segnalato con successo questa recensione. Ti ringraziamo per il feedback. Scrivi la tua recensione. Abnormally low CO diffusion indicates emphysema. A plain chest x-ray reveals flattened diaphragm shadows and often rarefaction of the pulmonary vasculature.

The occurrence of exacerbations that necessitate hospitalization is associated with a worse outcome. COPD shares risk factors with left heart failure and is often found together with it 28 , Many current or past smokers suffer from symptoms resembling those of COPD without meeting the classic definition for it. It was shown, in a recently published study, that these patients have exacerbations, diminished activity in everyday life, and anatomical evidence of airway changes thickened airway walls just as COPD patients do. They are often treated with drugs against airway obstruction, although evidence for this practice is lacking Pleuritic pain, fever, and cough are typical symptoms of pneumonia.

The physical findings include tachypnea, inspiratory rales, and sometimes bronchial breathing. Pneumonia— Dyspnea is the main symptom of pneumonia primarily in patients over age 65 ca. Pleuritic pain, fever, and cough are typical accompanying symptoms. Examination reveals tachypnea, inspiratory rales, and sometimes bronchial breathing. Laboratory testing inflammatory parameters; hypoxemia in arterial blood gas analysis, in severe cases , chest x-ray, and in some cases chest CT are diagnostically helpful. The CRB score is used to assess the severity of pneumonia.

One point is awarded for each item present: This score can serve as a guide to the need for hospitalization. Patients with a score of 0 can generally be treated outside the hospital; those with a score of 1 should be hospitalized if they have hypoxemia and comorbidities; and those with a score of 2 or more should always be admitted to the hospital 32 , Interstitial lung diseases— Patients report chronic shortness of breath and nonproductive cough, and they are often smokers Examination reveals crackling rales at the bases, and sometimes also digital clubbing and hourglass nails. The differential diagnosis of interstitial lung diseases is complex, and the prognosis and treatment differ from one type of interstitial lung disease to another.

Consultation with a pneumonologist is advisable 29 , Pulmonary embolism— The clinical picture of acute pulmonary embolism is often characterized by dyspnea of acute onset. Patients often report pleuritic pain and sometimes have hemoptysis. Examination reveals shallow breathing and tachycardia.

There is often evidence of a deep venous thrombosis of the lower limb as the source of the pulmonary embolism Aside from dyspnea, patients also have other symptoms including fatigue, lessened physical performance, and fluid retention. Congestive heart failure— Along with dyspnea, there are other symptoms including fatigue, diminished exercise tolerance, and fluid retention The common causes are advanced coronary heart disease, primary cardiomyopathy, hypertension, and valvular heart disease.

In all types of congestive heart failure, the stroke volume and cardiac output are diminished. Echocardiographic criteria for congestive heart failure with reduced or preserved left ventricular ejection fraction HFrEF and HFpEF, respectively and the new category with so-called mid-range ejection fraction HFmrEF ; modified from 17 , Echocardiography is the principal diagnostic test. The findings presented above suggest a cardiac cause of dyspnea. Because the patient is a smoker, pulmonary function tests are performed; these reveal mild obstruction not reversible with a bronchospasmolytic agent.

Echocardiography reveals normal systolic function and grade 2 impairment of diastolic function, with left ventricular hypertrophy. Mild mitral insufficiency is found, corresponding to the heart murmur. As a differential diagnostic consideration, the mild obstruction seen on pulmonary function testing might also be due to chronic pulmonary congestion. It can be present simultaneously with angina pectoris, or as the predominant or sole symptom of coronary heart disease, e. The history, particularly the timing and setting of the onset of dyspnea stress, cold, etc.

Patients with dyspnea of unclear origin should be evaluated for possible coronary heart disease. The assessment includes conventional ergometry as well as stress tests in combination with imaging studies, such as stress echocardiography, myocardial perfusion scintigraphy, and stress magnetic resonance tomography. Suggestive findings should be followed up by cardiac catheterization Dyspnea more typically arises as part of the constellation of symptoms in an acute coronary syndrome or myocardial infarction, as well as in cardiogenic shock as a consequence of low cardiac output 18 , Valvular heart disease — Among elderly patients in particular, valvular heart disease is a further possible cause of dyspnea.

The most common valvular diseases are aortic valvular stenosis and mitral insufficiency Typical findings of aortic valvular stenosis include diminished physical performance, episodes of collapse, syncope, and dizziness, and, sometimes, chest pain resembling angina pectoris. Auscultation often points to the diagnosis a rough systolic heart murmur heard loudest parasternally over second intercostal space, with projection into the carotid arteries. Patients with mitral insufficiency present with signs of heart failure.

The ECG often reveals atrial fibrillation due to volume overload of the left atrium. Here, too, auscultation points to the diagnosis a holosystolic murmur over the cardiac apex, sometimes projected into the axilla. Echocardiography is the definitive diagnostic study.

Heart and lung diseases are often present in the same patient at the same time. If a cause for dyspnea is found in one of these two organ systems, the search must continue for a possible additional cause in the other organ system, as comorbidity is very common. There is no sharp threshold value of Hb below which anemic patients become dyspneic. Aortic valvular stenosis and mitral insufficiency are the most common valvular diseases causing dyspnea.

Diseases of the ears, nose, and throat that affect the airways can also cause dyspnea. In disturbances of the upper airways, the main symptom other than dyspnea is stridor expiratory in bronchopulmonary airway compromise, inspiratory in supraglottic airway compromise, biphasic in airway compromise at or just below the glottis.

Possible causes include congenital malformations, infections, trauma, neoplasia, and neurogenic disturbances.

The Differential Diagnosis of Dyspnea

In most cases, these diseases have other neurological manifestations aside from dyspnea. Improvement of dyspnea with distraction or physical exercise may be a clue to a disturbance of this type. Finally, iatrogenic pharmacological causes of dyspnea deserve mention as well. Nonsteroidal anti-inflammatory drugs that inhibit cyclo-oxygenase 1 lead to increased conversion of arachidonic acid to leukotrienes through the activity of lipo-oxygenases; leukotrienes, in turn, can cause bronchoconstriction.

Moreover, acetylsalicylic acid a member of this group of drugs , if given in high doses, can also induce dyspnea via central receptors. Dyspnea due to the platelet aggregation inhibitor ticagrelor is surely a rare event in routine practice, although the initial PLATO study e2 revealed that it arose in The effect is probably mediated by adenosine receptors.

The EFN must be entered in the appropriate field in the cme. What ist the commonest cause of dyspnea in general medical practice? What percentage of patients in general medical practice complain of dyspnea on marked exertion?

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What biomarker is now well-established for the exclusion of clinically relevant congestive heart failure? A patient with dyspnea has had an acute myocardial infarction ruled out. She has a high Wells score. What is the most likely diagnosis? What test should always be performed if lung disease is suspected as the cause of dyspnea? What diagnostic test is most suitable for distinguishing betwen cardiac and pulmonary causes of dyspnea? What blood tests should be obtained initially in the basic diagnostic evaluation of chronic dyspnea of unknown cause?

Conflict of interest statement. National Center for Biotechnology Information , U. Journal List Dtsch Arztebl Int v. Published online Dec 9. Dominik Berliner , Dr. Author information Article notes Copyright and License information Disclaimer. Received May 30; Accepted Aug This article has been cited by other articles in PMC. Methods This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines.

Results The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. Conclusion The many causes of dyspnea make it a diagnostic challenge. Learning goals This article should enable the reader to: Illustrative case study A year-old woman presents to her family doctor complaining of progressive shortness of breath on exertion. Epidemiology Dyspnea is a common symptom both in general practice and in hospital emergency rooms.

Additional symptoms and signs Differential diagnostic considerations Bradycardia SA or AV block, overdose of drugs that slow the heart rate Brainstem signs, neurologic deficits brain tumor, cerebral hemorrhage, cerebral vasculitis, encephalitis Cough nonspecific; mainly reflects diseases affecting the airways and the lung parenchyma Cyanosis respiratory failure acute heart defect with right-to-left shunt, Eisenmenger syndrome chronic Diminished or absent breathing sounds COPD, severe asthma, tension pneumothorax, pleural effusion, hematothorax Distention of the neck veins with rales in the lungs acutely decompensated congestive heart failure, acute respiratory failure with normal auscultatory findings pericardial tamponade, acute pulmonary arterial embolism Dizziness, syncope valvular heart disease e.

Open in a separate window. Illustrative case study—continuation I This patient is suffering from an acute exacerbation of chronic dyspnea. Acute dyspnea Dyspnea of acute onset may be a manifestation of a life-threatening condition. Additional symptoms and signs Differential diagnostic considerations Diminished or absent breathing sounds COPD, severe asthma, tension pneumothorax, pleural effusion, hematothorax Distention of the neck veins with rales in the lungs ADHF, ARDS with normal auscultatory findings pericardial tamponade, acute pulmonary arterial embolism Dizziness, syncope valvular heart disease e.

The role of biomarkers An acute myocardial infarction or cardiac arrhythmia can be detected with an ECG. Natriuretic peptides A potentially life-threatening problem. Troponins If the clinical evidence points to an acute coronary syndrome as the cause of dyspnea, serial determination of cardiac troponin troponin I or troponin T is helpful. D-dimers D-dimers are fibrin degradation products generated by fibrinolysis; they are found in higher concentrations after thrombotic events. Original version Simplified version Prior pulmonary embolism or deep venous thrombosis 1.

The importance of emotional factors. Chronic dyspnea Chronic dyspnea is usually due to one of a small number of causes: Acute dyspnea Chronic dyspnea angioedema. The more common causes of chronic dyspnea. Illustrative case study—continuation II Difficulties. The diagnostic evaluation of chronic dyspnea, modified from 3 , 9 , 22 , 24 BNP: N-terminal prohormone brain natriuretic peptide TSH: Specific diseases Dyspnea due to diseases of the respiratory system Bronchial asthma — The cause is chronic inflammation of the airways leading to variable airway obstruction.

Learning goals

Dyspnea due to diseases of the cardiovascular system Congestive heart failure as a cause of dyspnea. Illustrative case study—continuation III The findings presented above suggest a cardiac cause of dyspnea. A fundamental consideration in the evaluation of dyspnea Heart and lung diseases are often present in the same patient at the same time. Dyspnea due to diseases outside the respiratory and cardiovascular systems The World Health Organization WHO defines anemia as a hemoglobin Hb value below 8. Drugs that can cause dyspnea. Further Information on CME. Please answer the following questions to participate in our certified Continuing Medical Education program.

Only one answer is possible per question. Please select the most appropriate answer. Footnotes Conflict of interest statement The authors state that they have no conflicts of interest. An official American Thoracic Society statement: Ewert R, Glaser S. Chief complaints in medical emergencies: Dyspnea as the reason for encounter in general practice. J Clin Med Res. Presentations of shortness of breath in Australian general practice.

The epidemiology and outcome of prehospital respiratory distress. Acad Emerg Med; ; Schneider A, Niebling W. Dyspnoe In Allgemeinmedizin und Familienmedizin. Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study.

The prognostic significance of respiratory rate in patients with pneumonia: Acute respiratory failure in the elderly: Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure.