Chronic Dyspnea Unexplained by History, Physical Examination, Chest Roentgenogram, and Spirometry: Analysis of a Seven-year Experience

doi:10.1378/chest.100.5.1293

Chest

Volume 100, Issue 5, November 1991, Pages 1293-1299

https://doi.org/10.1378/chest.100.5.1293 Get rights and content

The purpose of this article is to describe the spectrum and frequency of diseases presenting as unexplained dyspnea and to develop a logical diagnostic approach to such patients. Seventy-two consecutive physician-referred patients had dyspnea greater than one-month duration unexplained by the initial history, physical examination, chest roentgenogram, and spirometry. Patients underwent a standard diagnostic evaluation. A definite cause for dyspnea was recognized in 58 patients, and no answer was found in 14. Twenty-two diseases were recognized in the patient group. Dyspnea was due to pulmonary disease in 26 (36 percent) patients, cardiac disease in ten (14 percent) patients, hyperventilation in 14 (19 percent) patients, and only 3 patients had extrathoracic disease causing dyspnea. Age younger than 40 years, intermittent dyspnea, and normal alveolar-arterial oxygen pressure difference (P[A-a]O₂) at rest breathing room air was strongly predictive of bronchial hyperreactivity or hyperventilation. No patient diagnosed as having disease of the lung parenchyma or vasculature had a P(A-a)O₂ ≤20 mm Hg. The differential diagnosis to explain dyspnea in patients with nondirective histories, normal findings from physical examinations, normal chest roentgenograms, and normal spirograms is extensive. The patient's age and measurement of gas exchange at rest help to formulate a diagnostic approach.

Section snippets

Patient Population

All physician-referred patients who presented to the section of Pulmonary and Critical Care Medicine of the Virginia Mason Clinic (Seattle, WA) between 1981 and 1988 with unexplained dyspnea of greater than one-month duration were prospectively enrolled in the study. Entry criteria included the following: (1) an unrevealing history and physical exmaination by the referring physician; (2) a nondiagnostic chest roentgenogram; and (3) absence of spirometric evidence for either restrictive (FVC ≥80

Results

Seventy-seven patients were entered in the study. A repeat history and physical examination revealed previously unrecognized clinical findings that directed the diagnostic sequence in five patients. The presence of stridor led to the diagnosis of upper airway obstruction due to vocal cord paralysis in two patients. A patient with a chronic lower respiratory tract infection was recognized through a history of productive cough. One patient had typical angina pectoris and an endobronchial

Discussion

To our knowledge, this is the first reported experience of chronic dyspnea in patients whose conditions remain undiagnosed following a history and physical examination, chest roentgenogram, and spirometry. The present group of 72 such patients seen in a referral pulmonary practice over a seven-year period suggests that dyspnea of unknown origin is not uncommon. However, this is a highly selected group and the true incidence of this clinical presentation is unknown.

There is little in the medical

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Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O₂ uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate (“anaerobic”) threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO₂ output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea “quantity” and “quality”. Based on a conceptual framework that links exertional dyspnoea to “excessive” and/or “restrained” breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.
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Cardiopulmonary exercise testing for the diagnosis of unexplained dyspnea: a review of 194 cases
2019, Revue des Maladies Respiratoires
Les dyspnées inexpliquées après des épreuves fonctionnelles respiratoires de repos (EFR) et un bilan cardiovasculaire représentent une situation fréquente en pratique clinique. Le but de ce travail était de préciser l’intérêt de l’épreuve fonctionnelle à l’exercice (EFX) pour le diagnostic de ces dyspnées inexpliquées.
Cette étude monocentrique rétrospective incluait des patients successifs ayant des examens de repos normaux (examen clinique, hémoglobine, radiographie thoracique, ECG, EFR, échographie cardiaque). L’EFX était réalisée avec analyse des gaz du sang. L’analyse descriptive et la synthèse étaient réalisées par consensus entre au moins 3 des auteurs et permettait d’évoquer les étiologies suivantes : déconditionnement, hyperventilation inappropriée à l’exercice (HV), anomalies échanges gazeux (AEG), EFX sous-maximale, anomalies cardiovasculaires (ACV) et EFX normale.
Au total, 194 patients étaient inclus, (âge médian 53 ans ; sex-ratio (H/F) 0,83 ; IMC moyen 27,3 kg/m² ± 5,36). On retrouvait 32 % de profils compatibles avec un déconditionnement, 20 % HV, 18 % AEG, 13 % d’épreuves sous-maximales, 9 % ACV, 8 % d’épreuves maximales et normales.
Cette étude illustre l’intérêt de réaliser l’EFX précocement dans les dyspnées inexpliquées car dans plus de 50 % des cas, celles-ci correspondent soit à un déconditionnement soit à un syndrome d’hyperventilation, redevables d’une prise en charge simple en réhabilitation respiratoire.
Chronic dyspnoea that remains unexplained after resting pulmonary function and cardiovascular testing is a common problem in clinical practice. The aim of this study was to determine the utility of cardiopulmonary exercise testing (CPET) in the diagnosis of unexplained dyspnoea.
This retrospective single-centre study included consecutive patients with dyspnoea who had normal resting cardiopulmonary examinations (including chest X-ray, electrocardiography, pulmonary function tests [PFTs], and cardiac ultrasound). CPET was performed using a cycle ergometer with analysis of blood gases. The results were interpreted as being most likely due to one of the six pathophysiological mechanisms shown below. Consensus required agreement between at least three of the authors.
Of the 194 patients included (median age 53 years, sex-ratio (M:F) 0.83, mean body mass index 27.3 ± 5.36 kg/m²), 32% of the test profiles were compatible with deconditioning, 20% with inappropriate hyperventilation (without gas exchange abnormalities), 18% with disorders of gas exchange, 13% with sub-maximal CPET, 9% with cardiovascular anomalies, and 8% with normal CPET. Of the patients with gas exchange abnormalities, the most common causes were bronchiectasis (6), emphysema (6), recent pneumonia (2), and diffuse interstitial pneumonitis (2). Ten of the patients with cardiovascular abnormalities had chronotropic insufficiencies, 5 had excessive tension responses, and 3 had disorders of rhythm or repolarisation.
CPET may greatly facilitate the diagnosis of unexplained dyspnoea. More than 50% of the dyspnoea cases examined here were due to deconditioning or hyperventilation syndrome and would benefit from a simple pulmonary rehabilitation program.
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Citation Excerpt :
This is the first population-based study of which we are aware to evaluate the utility of a battery of cardiac and pulmonary tests for self-reported dyspnea in a community setting. Prior literature has examined the diagnostic yield of various tests among patients referred to specialty clinics for evaluation of shortness of breath.5-11 These studies have shown spirometry to have the highest diagnostic yield, consistent with our results, as well as substantial benefit in chest imaging via x-ray or CT.
Dyspnea on exertion is a common and debilitating symptom, yet evidence for the relative value of cardiac and pulmonary tests for the evaluation of chronic dyspnea among adults without known cardiac or pulmonary disease is limited.
The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants aged 45 to 84 years who were free of clinical cardiovascular disease from 6 communities; participants with clinical pulmonary disease were excluded from this report. Dyspnea on exertion was assessed via structured interview. Tests included electrocardiograms, cardiac computed tomography (CT) for coronary artery calcium, cardiac magnetic resonance imaging, spirometry, percent emphysema (percent of lung regions <−950 HU) on CT, inflammatory biomarkers, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Logistic regression was used to identify independent correlates of dyspnea after adjustment for age, sex, body mass index, physical activity, anxiety, and leg pain.
Among 1969 participants without known cardiopulmonary disease, 9% had dyspnea. The forced expiratory volume in 1 second (FEV₁) (P < .001), NT-proBNP (P = .004), and percent emphysema on CT (P = .004) provided independent information on the probability of self-reported dyspnea. Associations with the FEV₁ were stronger among smokers and participants with other recent respiratory symptoms or seasonal allergies; associations with NT-proBNP were present only among participants with coexisting symptoms of lower-extremity edema. Only the FEV₁ provided a significant improvement in the receiver operating curve.
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Reprint requests: Dr. Winterbauer, 1100 Ninth Avenue, Seattle, 98101

Manuscript received August 27; revision accepted March 8.

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Chest

Clinical InvestigationsChronic Dyspnea Unexplained by History, Physical Examination, Chest Roentgenogram, and Spirometry: Analysis of a Seven-year Experience

Section snippets

Patient Population

Results

Discussion

Respir Physiol

J Allergy Clin Immunol

J Allergy Clin Immunol

Am J Med

J Am Coll Cardiol

Am J Cardiol

Cause and evaluation of chronic dyspnea in a pulmonary disease clinic.

Arch Intern Med

A standardized breath holding technique for the clinical measurement of the diffusing capacity of the lung for carbon monoxide.

J Clin Invest

Arterial oxygen tension in relation to age in healthy subjects.

Respiration

Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress.

Medicine

Practical assessment of obstruction in the larynx and trachea.

J Laryngol Otol

Methotrexate pneumonitis in rheumatoid arthritis: potential risk factors: four case reports and a review of the literature.

J Rheumatol

Clinical Investigations
Chronic Dyspnea Unexplained by History, Physical Examination, Chest Roentgenogram, and Spirometry: Analysis of a Seven-year Experience