Chronic Dyspnea

CARDIAC Heart Failure Anemia Myocardial Ischemia Pericardial disease Pulmonary emboli (chronic)

RESPIRATORY Asthma COPD Interstitial Lung Disease and Pulmonary Hypertension Pleural effusion Skeletal or Upper Airway deformities Neuromuscular Disease

 bold = common

SUMMARY APPROACH

1.  Address Myocardial Ischemia (Risk Factors; associated Anginal Equivalents)

• If possible, order EKG & Stress Testing

2.  If Ischemia unlikely, base Dx on Lung Exam

• Wheezes, Rhonchi, Long Expiratory Phase suggest Asthma
  • Give therapeutic trial
• Bibasilar Rales suggest CHF

3.  If NOT asthma, or if therapeutic trial no help, order initial W/U:

• CXR
• CBC
• BNP
• Chemistries & TSH if can’t distinguish dyspnea from fatigue

4.  Still no diagnosis?  Order:

• Echocardiogram
• Pulmonary Function Testing

5.  Progressive deconditioning (i.e. being out of shape) is a diagnosis of exclusion.