1. Out of Breath? Know When to See a Physician
Stuart Rich, M.D.
Professor of Medicine
Director, Pulmonary Vascular Disease Program
Bluhm Cardiovascular Institute
Northwestern Memorial Hospital

3. How we normally breathe

4. Breathlessness a.k.a. Dyspnea
It is normal to be aware of breathlessness when we exercise beyond our normal tolerance.
It is not normal if it occurs with little or no exertion.
Next to pain, breathlessness is the most common symptom for which patients seek help from their doctor.
It is often associated with fear and can be disabling and severely diminish quality of life.

7. What causes breathlessness?
Breathlessness is the sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand.
Breathlessness can be classified by its speed of onset as: 
Acute breathlessness:
develops over minutes, hours, or days.
Chronic breathlessness:
develops over weeks or months.

9. Acute causes of breathlessness
Cardiac causes:
Pulmonary edema (fluid build-up in the lung from heart disease)
Heart attack
Arrhythmia (abnormal heart rhythm)
Pericarditis (inflammation around the heart)

10. Acute causes of breathlessness
Pulmonary causes
Pneumonia
Pneumothorax (collapsed lung)
Pulmonary embolism (blood clot)
Asthma
Chronic lung disease (COPD)
Large airway obstruction (foreign body, compression)

11. Other causes of acute breathlessness
Pain
Drugs
Trauma
Altitude sickness
Hyperventilation and panic attack

12. Chronic causes of breathlessness
Cardiac causes:
Congestive heart failure
Heart valve disease
Arrhythmias
Pulmonary hypertension (high blood pressure in the lungs)

15. Chronic causes of breathlessness
Pulmonary causes:
Asthma
COPD
Pulmonary fibrosis
Pleural effusion (fluid in the chest)
Lung cancer

17. Chronic causes of breathlessness
Other causes:
Severe anemia
Psychogenic - eg, anxiety
Neuromuscular causes
Thromboembolic disease
Thyroid disease
Obesity

18. The Goddess Ondine and The Curse
Ondine was a beautiful goddess who married the handsome young Palemon.
Palemon vowed "My every waking breath shall be my pledge of love and faithfulness to you."
After Ondine gave birth to their son, her beauty began to fade.
Palemon's eye began to wander to the younger women he met at court.
When Ondine became aware, she gave him the following curse:
For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you."

19. How Severe Is It? Grade 0: not troubled except on strenuous exertion.
Grade 1: short of breath when hurrying on level ground or walking up a slight incline.
Grade 2: walks slower than contemporaries because of breathlessness.
Grade 3: stops for breath after walking about 100 yards or stops after a few minutes of walking on level ground.
Grade 4: too breathless to leave the house or breathless on dressing or undressing

20. The downward spiral

21. Breathlessness and Denial
Patients will often become aware that they are getting more out of breath with activity, but will choose not to seek help because:
“I’m getting older”
“I put on weight”
“I’m out of shape”
“It’s not so bad”

22. Contact your physician if the following occur with breathing difficulties
Chest discomfort, pain, or pressure - these are symptoms of angina
Fever
Shortness of breath after only slight activity or while at rest
Shortness of breath that wakes you up at night or requires you to sleep propped up to breathe
Tightness in the throat or a barking, croupy cough
You have breathed in or choked on an object (foreign object aspiration or ingestion)
Wheezing

23. Examining the patient General:
Patient distress, color of skin and lips, cyanosis,
Respiratory rate
Pulse - rate, rhythm
Height and weight

24. A good history and physical exam may often reveal the source of breathlessness.

25. Helpful medical tests Lung function tests Pulse oximetry Chest X-ray
Arterial blood gases
Electrocardiogram
Imaging:
Echocardiogram
Chest CT scan
V/Q scan

27. How do doctors treat dyspnea?
The primary goal is to identify the underlying cause:
It may arise from one specific cause
It may arise from the combination of causes
Initiate treatment to rectify the immediate problem if possible (e.g.):
Supplemental oxygen
Diuretics
Analgesics
Address correction of any underlying condition

28. "Life is not measured by the number of breaths we take, but by the moments that take our breath away." -- Hillary Cooper