Diagnostic approach to chronic dyspnoea in adults

Abstract

Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.

Keywords: Dyspnoea; algorithm; breathlessness; diagnosis.

Figure 1

Diagnostic pathway for chronic dyspnoea presentations in adults. Figure broadly based on (10,12,13,15) with modifications. Clinical judgement for selection of investigations is recommended. Cardiac and respiratory investigations may overlap. Physical examination should include clinical observations including pulse oximetry. BNP, B-type natriuretic peptide; FBC, full blood count; TFTs, thyroid function tests; ECG, electrocardiogram; RFTs, respiratory function testing; CPET, cardiopulmonary exercise testing; MPS, myocardial perfusion scan; V/Q, ventilation/perfusion.