Shortness of Breath

Also known as “Dyspnoea”

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credit: Sourced from the MSD Manual, Consumer Version; authored by Dr Noah Lechtzin (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Shortness of breath—what doctors call dyspnoea—is the unpleasant sensation of having difficulty breathing. People experience and describe shortness of breath differently depending on the cause.

The rate and depth of breathing normally increase during exercise and at high altitudes, but the increase seldom causes discomfort. Breathing rate is also increased at rest in people with many disorders, whether of the lungs or other parts of the body. For example, people with a fever generally breathe faster.

With dyspnoea, faster breathing is accompanied by the sensation of running out of air. People feel as if they cannot breathe fast enough or deeply enough. They may notice that more effort is needed to expand the chest when breathing in or to expel air when breathing out. They may also have the uncomfortable sensation that inhaling (inspiration) is urgently needed before exhaling (expiration) is completed and have various sensations often described as tightness in the chest.

Other symptoms, such as cough or chest pain, may be present depending on the cause of dyspnoea.

Causes

Dyspnoea can be caused by disorders of both the LUNGS or HEART.

Overall, the most common causes include:

• Asthma (lungs)
• Pneumonia (lungs)
• Chronic obstructive pulmonary disease (COPD) (lungs)
• A heart attack or angina (chest pain due to inadequate blood flow and oxygen to the heart—called myocardial ischemia) (heart)
• Physical deconditioning (weakening of muscles and the heart due to inactivity) (heart)
• Pulmonary embolism (sudden blockage of an artery of the lung, usually by a blood clot) is a less common, but serious cause. (heart and lungs)

The most common cause in people with a chronic lung or heart disorder is:

• Worsening of their disease

However, such people may also develop another disorder. For example, people with long-standing asthma may have a heart attack, or people with chronic heart failure may develop pneumonia.

Lung disorders causing dyspnoea

People who have lung disorders often experience dyspnoea when they physically exert themselves. During exercise, the body makes more carbon dioxide and uses more oxygen. The respiratory centre in the brain speeds up breathing when blood levels of oxygen are low, or blood levels of carbon dioxide are high. If the heart or lungs are not functioning normally, even a little exertion can dramatically increase the breathing rate and dyspnoea. Dyspnoea is so unpleasant that people avoid exertion. As the lung disorder becomes more severe, dyspnoea may occur even at rest.

Dyspnoea may result from:

• Restrictive lung disorders
• Obstructive lung disorders

In restrictive lung disorders (such as idiopathic pulmonary fibrosis), lungs become stiff and require more effort to expand during inhalation. Severe curvature of the spine (scoliosis) can also restrict breathing because it reduces movement of the rib cage.

In obstructive disorders (such as COPD or asthma), resistance to airflow is increased because the airways are narrowed. Because airways widen during inhalation, air can usually be pulled in. However, because airways narrow during exhalation, air cannot be exhaled from the lungs as fast as normal, and people wheeze, and breathing is laboured. Dyspnoea results when too much air is left in the lungs after exhaling.

People with asthma have dyspnoea when they have an attack. Doctors typically advise people to keep an inhaler on hand to use during an attack. The drug in the inhaler helps open the airways.

Heart disorders causing dyspnoea

The heart pumps blood through the lungs. If the heart is pumping inadequately (called heart failure), fluid may accumulate in the lungs—a disorder called pulmonary oedema. This disorder causes dyspnoea that is often accompanied by a feeling of smothering or heaviness in the chest. The fluid accumulation in the lungs may also narrow the airways and cause wheezing—a disorder called cardiac asthma.

Some people with heart failure have orthopnoea, paroxysmal nocturnal dyspnoea, or both. Orthopnoea is shortness of breath that occurs when people lie down and is relieved by sitting up. Paroxysmal nocturnal dyspnoea is a sudden, often terrifying attack of dyspnoea during sleep. People awaken gasping and must sit or stand to catch their breath. This disorder is an extreme form of orthopnoea and a sign of severe heart failure.

Anaemia

When people have anaemia or have lost a large amount of blood because of an injury, they have fewer red blood cells. Red blood cells carry oxygen to the tissues, so in these people, the amount of oxygen that blood can deliver is decreased. Most people with anaemia are comfortable sitting still. However, they often feel dyspnoea during physical activity because the blood cannot deliver the increased oxygen the body requires. Thus, they breathe rapidly and deeply in a reflex effort to try to increase the amount of oxygen in the blood.

Other causes

If a large amount of acid accumulates in the blood (called metabolic acidosis), people may feel out of breath and begin to pant quickly. Severe kidney failure, sudden worsening of diabetes mellitus, and ingestion of certain drugs or poisons can cause metabolic acidosis. Anaemia and heart failure may contribute to dyspnoea in people with kidney failure.

In hyperventilation syndrome, people feel that they cannot get enough air, and they breathe heavily and rapidly. This syndrome is commonly caused by anxiety rather than a physical problem. Many people who experience it are frightened, may have chest pain, and may believe they are having a heart attack. They may have a change in consciousness, usually described as feeling that events occurring around them are far away, and they may feel tingling in their hands and feet and around their mouth.

Evaluation

The following information can help people decide whether a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with dyspnoea, the following symptoms are of particular concern:

• Shortness of breath at rest
• A decreased level of consciousness, agitation, or confusion
• Chest discomfort or the feeling the heart is pounding or racing or has skipped a beat (palpitations)
• Weight loss
• Night sweats

When to see a doctor

People who have shortness of breath at rest, chest pain, palpitations, a decreased level of consciousness, agitation, or confusion or have difficulty moving air in or out of their lungs should go to the hospital right away. Such people may need immediate testing, treatment, and sometimes admission to the hospital. Other people should call a doctor. The doctor can determine how rapidly they need to be evaluated based on the nature and severity of their symptoms, their age, and any underlying medical conditions. Typically, they should be evaluated within a few days.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What doctors find during the history and physical examination often suggests a cause and the tests that may need to be done (see Table: Some Causes and Features of Shortness of Breath).

Doctors ask questions to determine:

• When shortness of breath started
• Whether it started abruptly or gradually
• How long the person has felt short of breath
• Whether any conditions (such as cold, exertion, exposure to allergens, or lying down) trigger it or make it worse

The person is also asked questions about past medical history (including any lung or heart disorders), a history of smoking, any family members who have had high blood pressure or high cholesterol levels, and risk factors for pulmonary embolism (such as recent hospitalization, surgery, or long-distance travel).

The physical examination focuses on the heart and lungs. Doctors listen to the lungs for congestion, wheezing, and abnormal sounds called crackles. They listen to the heart for murmurs (suggesting a heart valve disorder). Swelling of both legs suggests heart failure but swelling of only one leg is more likely to result from a blood clot in the leg. A blood clot in the leg may break off and travel to the blood vessels in the lungs, causing pulmonary embolism.

Some Causes and Features of Shortness of Breath

Please note: Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Acute causes (in other words, develops within minute or hours)

Anxiety disorder—hyperventilation

• Shortness of breath related to a specific situation, often accompanied by agitation and tingling or numbness in the fingers and/or around the mouth
• Normal results on the heart and lung examination

Asthma

• Wheezing that starts spontaneously or after exposure to specific stimuli (such as pollen or another allergen, an upper respiratory infection, cold air, or exercise)
• Usually a history of asthma
• A foreign object that has been inhaled
• A cough or high-pitched wheezing that starts suddenly in people (typically infants or young children) without any symptoms of an upper respiratory infection or other illness

Heart attack or acute myocardial ischemia

• Caused by inadequate blood flow and oxygen supply to the heart
• Deep chest pressure that may or may not radiate to the arm or jaw, particularly in people with risk factors for coronary artery disease

Heart failure

• Often swelling (oedema) of the legs
• Shortness of breath that worsens while lying flat (orthopnoea) or that appears 1–2 hours after falling asleep (paroxysmal nocturnal dyspnoea)
• Sounds suggesting fluid in the lungs, heard through a stethoscope
• Frothy, pink sputum, sometimes with blood streaks

Pneumothorax (a collapsed lung)

• Sharp chest pain and rapid breathing that start suddenly
• May follow an injury or occur spontaneously, especially in tall, thin people and in people with COPD

Pulmonary embolism (sudden blockage of an artery in a lung, usually by a blood clot)

• Sudden appearance of sharp chest pain that usually worsens when inhaling
• A rapid heart rate and a rapid breathing rate
• Often risk factors for pulmonary embolism, such as cancer, immobility (as results from being bedbound), blood clots in the legs, pregnancy, use of birth control pills (oral contraceptives) or other drugs that contain oestrogen, recent surgery or hospitalization, or a family history of the disorder

Subacute causes (develops over hours or days)

Angina or coronary artery disease

• Deep chest pressure that may or may not radiate to the arm or jaw, often triggered by physical exertion
• Often in people with risk factors for coronary artery disease

A chronic obstructive pulmonary disease (COPD) flare-up

• Often a cough that may or may not produce sputum (productive or non-productive)
• Wheezing and breathing through pursed lips
• In people who already have COPD

Pneumonia

• Fever, a feeling of illness, and a productive cough
• Sudden appearance of sharp chest pain when taking deep breaths
• Certain abnormal breath sounds, heard through a stethoscope

Chronic causes (present for many weeks to years)

Anaemia

• Shortness of breath during exertion, progressing to shortness of breath at rest
• Normal lung examination results and oxygen levels in the blood

Interstitial lung disease

• Abnormal lung sounds called crackles, heard through a stethoscope

Obstructive lung disease

• A history of extensive smoking, a barrel-shaped chest, and difficulty moving air in and out of the lungs
• Usually in people who already have COPD
• Physical deconditioning
• Shortness of breath only during exertion
• In older people with a sedentary lifestyle

Pleural effusion (fluid in the chest cavity)

• Sometimes a history of cancer, heart failure, rheumatoid arthritis, systemic lupus erythematosus (lupus), or acute pneumonia

Restrictive lung disease

• Progressive shortness of breath in people known to have been exposed to inhaled irritants at work (occupational exposure) or to have a disorder of the nervous system

Stable angina or coronary artery disease

• Deep chest pressure that may or may not radiate to the arm or jaw, often triggered by physical exertion
• Often in people with risk factors for coronary artery disease

Tests that can be done by the doctor to determine the cause

To help determine the severity of the problem, doctors measure oxygen levels in the blood with a sensor placed on a finger (pulse oximetry). Typically, they also take a chest x-ray unless the person clearly appears to be having a mild flare-up of an already diagnosed chronic disorder such as asthma or heart failure. The chest x-ray can show evidence of a collapsed lung, pneumonia, and many other lung and heart abnormalities. For most adults, electrocardiography (ECG) is done to check for inadequate blood flow to the heart.

Other tests are done based on results of the examination. Tests to evaluate how well the lungs are functioning (pulmonary function testing) are done when the doctor's examination suggests a lung disorder, but the chest x-ray does not provide a diagnosis. Pulmonary function tests can measure the degree of restriction or obstruction and the ability of the lungs to transport oxygen from the air to the blood. A lung problem may include restrictive and obstructive abnormalities as well as abnormal oxygen transport.

For people at moderate or high risk of pulmonary embolism, specialized imaging tests, such as computed tomography angiography or ventilation/perfusion scanning, are done. For people at low risk of pulmonary embolism, a D-dimer test may be done. This blood test helps identify or rule out a blood clot. Other tests may be necessary to diagnose and further evaluate anaemia, heart problems, and certain specific lung problems.

Treatment

Treatment of shortness of breath (dyspnoea) is directed at the cause. People with a low blood oxygen level are given supplemental oxygen using plastic nasal prongs or a plastic mask worn over the face. In severe cases, particularly if people cannot breathe deeply or rapidly enough, breathing may be assisted by mechanical ventilation using a breathing tube inserted in the windpipe or a tight-fitting face mask.

Morphine may be given intravenously to reduce anxiety and the discomfort of dyspnoea in people with various disorders, including a heart attack, pulmonary embolism, and a terminal illness.

KEY POINTS

• Shortness of breath (dyspnoea) is usually caused by lung or heart disorders.
• In people with a chronic lung disorder (such as chronic obstructive pulmonary disease) or heart disorder (such as heart failure), the most common cause of dyspnoea is a flare-up of the chronic disorder, but these people can also develop a new problem (such as a heart attack) that contributes to or causes dyspnoea.
• People who have dyspnoea at rest, a decreased level of consciousness, or confusion should go to the hospital immediately for emergency evaluation.
• To determine the severity of the problem, doctors measure oxygen levels in the blood with a sensor placed on a finger (pulse oximetry).
• Doctors evaluate people for inadequate delivery of blood and oxygen to the heart (myocardial ischemia) and for pulmonary embolism, but sometimes symptoms of these disorders are vague.

About the author

Dr Noah Lechtzin

MD, MHS

Dr Noah Lechtzin is an Associate Professor of Medicine and Director of the Adult Cystic Fibrosis Program at the Johns Hopkins University School of Medicine.

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