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DYSPNOEA AT REST AND DYSPNOEA ON EXERTION
OP KAPOOR
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Family Physicians often come across patients complaining of dyspnoea at rest or on exertion. The office diagnosis is often very easy, though much easier, if you are sitting in a small nursing home or a hospital, where extra facilities of blood tests, X-ray chest and echo cardiography are available.
The method of diagnosing such patients in my clinic is as follows:
1. Bronchial Asthma is diagnosed only by (a) long history of symptoms, (b) positive family history, (c) associated symptoms of nasal allergy and severe cough (d) presence (eliciting) of symptoms of dust allergy and allergy to smoke, masala smell, pest control, etc. (e) patient's routine blood count often showing some evidence of peripheral eosinophilia. (f) on fluoroscopy (counter part of X-ray chest) the chest is clear (g) patients having chronic bronchial asthma often complain of dyspnoea on exertion.
2. Cardiac Asthma - I spend more time on examination rather than history taking. Clinically, there have to be some abnormal signs of enlargement of the heart (confirmed by inspection and palpation) or some disease of the valves confirmed by auscultation which may or may not be related to a weak myocardium. A good auscultation is as good as a rough echo cardiography report.
ECG has to be abnormal because usually a normal ECG is against the diagnosis of cardiac dyspnoea (exceptions like pericardial effusion etc.) and thus doing echo cardiography is not necessary in majority of the patients. The fluoroscopy of the chest will show enlargement of the heart and typical picture of LVF in patients who have dyspnoea at rest, unless there is a large pericardial effusion. In these patients the electrocardiogram and fluoroscopy are never normal and invariably show signs of involvement of the heart.
3. Renal Asthma - A patient of renal asthma is spotted by me, if on general examination, I find:
(a) the patient has severe anaemia with no obvious cause
(b) he has associated moderate or severe hypertension
(c) I can see the patient doing deep breathing rather than dyspnoea (Kussmaul breathing) as against the short fast breaths of a patient of cardiac failure.
It is worth remembering that this patient can also have associated symptoms of enlargement of the heart and cardiac failure. The blood count will confirm my impression of severe anaemia and the most important finding will be the presence of albumin in the urine in moderate to severe amount.
In retrospect, if I put the patient again on the table, I may:
(a) find an enlarged kidney (polycystic or hydronephrotic kidney).
(b) in a very elderly patient a grossly enlarged prostate or even enlarged urinary bladder felt in the hypogastrium.
(c) a bruit over one or two renal arteries.
(d) history of consumption of any pain killers.
(e) history of swelling of the eyelids and face in childhood or a few years back.
(f) a long history of diabetes or hypertension in the past.
It is worth remembering that all these are the causes of renal failure which is often silent and where the patient presents to the doctor for complaints of dyspnoea on exertion and the doctors can misdiagnose him as a Cardiac case.
4. Anaemia : It is the cause of dyspnoea on exertion and is very easy to diagnose. The patient is usually a female (rarely a male having an underlying sinister disease). On examination, she shows evidence of severe anaemia and the examination of the heart shows some enlargement and the presence of murmurs detected by a stethoscope. The ECG and fluoroscopy examination will show some enlargement and the routine blood count confirms severe anaemia.
5. COPD : It is extremely easy to diagnose because the patient is a male and is a heavy smoker with a long history of cough with sputum. The clinical examination is often normal but a few rales or rhonchi may be heard in the chest. The ECG often does not show P-Pulmonale and is normal. The fluoroscopy shows evidence of air trapping. A routine blood count will show Hb of more than 14 gms which is not common in Indian patients. Those doctors who are using pulse oximeter can make a spot diagnosis of advanced COPD where the SPO2 will be less than 97%.
6. Patients having ILD (Interstitial Lung Disease) are extremely easy to diagnose. A good clinical examination will show that a patient who has lost weight very rapidly, has presence of mild clubbing of the nails, mild cyanosis and the lungs are full of crepitations specially heard posteriorly.
The ECG and fluoroscopy of the chest may not help in this patient but the pulse oximeter will give an instant diagnosis because the SPO2 will be extremely low-often 80-85%. Again the blood count will show polycythaemia.
Coming to dyspnoea at rest, the textbooks mention that the doctors must have the facility of following tests to make a proper diagnosis:
1. X-ray Chest
2. Electrocardiogram
3. 2-D Echo Cardiography
4. ABG (Arterial blood gases)
5. B. Urea and Creatinine
All the six diseases discussed above can cause dyspnoea at rest and the patient can present in a doctor's clinic with severe breathlessness. Remember that the X-ray chest will not help more than fluoroscopy examination. 2-D Echo will not help more than a good auscultation done with a stethoscope and palpation of the heart with your hand, if a proper positioning of the chest is done.
ABG is not required at all for all those doctors who use pulse oximeter in the clinic. ABG is an extremely tedious test. The patient has to be sent to a big hospital (and not a private pathology laboratory). He has to suffer the pain of an intra-arterial prick and the relations have to suffer the expenses and waste time commuting to the hospital two times to bring the reports.
Blood Urea and Creatinine will often be found to be high in patients, who have got severe anaemia and presence of good amount of albumin in the urine, specially when associated with hypertension and sometimes even retinal changes.
In addition to the diseases discussed above, a patient who has developed dyspnoea at rest can have a lung pathology, e.g. a patch of pneumonia, pulmonary infarction, pneumothorax, massive pleural effusion, silent cancer or lymphoma of the lungs or chest, etc. All these conditions can be spotted easily on X-ray chest, which I pick up in my dark room fluoroscopy examination, which has been given up by most of the Indian doctors, just because of the cost of the machine and so-called radiation hazard to the doctor.
The only condition, which is most difficult to diagnose in a patient having dyspnoea at rest, is an attack of pulmonary embolism. In fact, in this condition even when the patient has dyspnoea, the X-ray chest, 2-D Echocardiogram, blood urea and creatinine may all be normal. The diagnosis may be picked up if the report of ABG shows a fall in oxygen levels. But the patient will have to be sent for a lung scanning to look out for a mismatched ventilation perfusion scan.
In private practice, I find it extremely easy to diagnose this very difficult condition, by eliciting the history of the patient who has developed either chest pain which increase on deep breathing, with or without sudden dyspnoea in the form of fast breathing (tachypnoea). On examination, the pulse may be fast but the pulse oximeter helps you by showing the abnormal SPO2. Even a slight fall in SPO2 is enough to confirm your diagnosis, specially in a patient who is known to have DVT or any other risk factor known in patients prone to VTE (Venous Thrombo-Embolism). Of course the D-Dimer blood test, if available, will confirm the diagnosis.
It is worth remembering that if the above findings in the doctor's clinic are all normal and the patient is a female patient with a background of neurotic and hysterical personality, then the diagnosis of hysterical asthma can be made confidently, otherwise, it will be missed even if all the above five investigations being carried out in the best hospital!!
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