1. Dyspnea: Differential Diagnosis
Cyril Štěchovský
Dept. of Cardiology 2.LF UK a FNM

2. Dyspnea Symptom – shortness of breath
Sign – abnormal respiratory effort

3. Dyspnea is a symptom of disorder at different levels
Central nervous system
Ventilation
Diffusion
Pulmonary perfusion
Oxygen transportation
Cellular oxygenation

4. Central disorders Hypoxemia Hypercapnia Stroke Encephalitis Tumor
Intoxication
Anxiety

5. Disorders of ventilation and diffusion
Neuromuscular disorders
Trauma
Exhaustion
Airway obstruction
Laryngospasm
COPD
Bronchial asthma
Tumor
Foreign body
Restrictive pulmonary disorders - fibrosis
Atelectasis
Pneumonia
Pulmonary congestion / edema
Fluidothorax
Pneumothorax
Esophageal hernia
Pulmonary resection
Chest deformity
High diaphragm

6. Disorders of pulmonary perfusion
Pulmonary embolism
Pulmonary hypertension

7. Disorders of oxygen transportation and utilization
Anemia
Methemoglobinemia
Carboxyhemoglobinemia
Cyanide intoxication

8. Others
Pain
Decondition
Hyperthyreosis
Fever

9. Pulmonary edema
Fluid excess in pulmonary interstitium and alveoli

10. Pulmonary edema Cardiac – increased LVEDP (PCWP)
Noncardiac (ARDS) – inflammation, „leaky“ alveolocapillary membrane
Inhaled toxins, aspiration, sepsis, oxygen toxicity, pancreatits, traumatic shock

11. DDx Pulse oximetry Chest x-ray History Physical examination
Paleness (anemia), cyanosis
Respiratory rate, heart rate, BP, body temperature
Respiratory effort
Lungs and heart auscultation
Peripheral edema
Pulse oximetry
Chest x-ray

12. DDx Complete blood count ECG Arterial blood gases ECHO Spirometry
Chest CT scan
Spiroergometry

13. Arterial blood gases analysispH
Saturation
pO2
pCO2
Bicarbonate
Lactate
Anion gap
Base excess
Hemoglobin

14. Case 1 76-yo male w. dyspnea and chest pain BP 95/72mmHg Hgb 138g/l
SpO2 7,9 kPa
SpCO2 3,1 kPa
Lactate acidosis
TnI 6800 ng/l

15. Case 1 – acute left heart failure with cardiogenic shock

16. Case 2 - COPD 62-yo male w. dyspnea and cough and expectoration
BP 155/75mmHg
T 37,2C
Hgb 168g/l
SpO2 8,2 kPa
SpCO2 7,1 kPa
CRP 75 mg/l
NT-proBNP 1050 ng/l
Hypertension, LV hypertrophy, LV diastolic dysfunction, mild pulmonary hypertension, biatrial dilatation.

17. Case 3 – pulmonary embolism
52-yo female w. dyspnea and chest pain
BP 115/85 mmHg
tachypnea
SpO2 8,1 kPa
SpCO2 2,4 kPa
pH 7,49 – respiratory alcalosis
D-dimer 2800µg/l

18. Case 3 – pulmonary embolism
Max. Gradient on TR 48mmHg
PASP ≈ 60mmHg

19. Case 4 – decompensed chronic heart failure
58-yo male w. dyspnea nad large periferal oedema
BP 142/89mmHg
Hgb 106g/l
SpO2 10,8 kPa
SpCO2 5,4 kPa
TnI 870 ng/l
INR 4,8
Elevated liver enzymes, bilirubin
eGFR 45ml/m2/min

20. Case 4 – decompensed chronic heart failure

21. Case 5 – sepsis with acidosis
75-yo female w. dyspnea, fewer, altered mental status and back pain
BP 98/66mmHg
T 38,4C
Hgb 88g/l
SpO2 7,5 kPa
SpCO2 3,0 kPa
pH 7,18, lactate 6,5mmol/l
WBC , left shift
CRP 345 mg/l
eGFR 25ml/m2/min

22. Case 6 – aortic stenosis 82-yo female w. dyspnea and syncope
BP 178/96mmHg
SpO2 11,5 kPa
SpCO2 5,2 kPa

23. Case 6 – aortic stenosis Vmax. 4,29m/s
Graient on aortic valve 74/44mmHg

24. Take home message Dyspnea is a common symptom.
Physical examination, ECG, chest x-ray and echocardiography make most of the ddx.
Always test arterial blood gases in acute patients.