Updated
Shortness of breath history: questions to ask
Breathlessness can come from the airways, the lungs, the pulmonary circulation, the heart, or the blood. The single most useful question is how quickly it came on, because each tempo has its own short list of causes. If the patient cannot finish a sentence, assess and treat first and take the history afterwards.
How fast did it come on?
- Seconds to minutes
- Pulmonary embolism, pneumothorax, anaphylaxis, acute pulmonary edema, an inhaled foreign body.
- Hours to days
- Pneumonia, an exacerbation of asthma or COPD, worsening heart failure, a pleural effusion.
- Weeks to months
- Chronic heart failure, interstitial lung disease, COPD, anemia, lung cancer, a slowly growing effusion.
Associated symptoms
- Cough, and the color and amount of any sputum
- Coughing up blood
- Wheeze, or chest tightness
- Chest pain, and whether it is worse on breathing in
- Fever and night sweats
- Orthopnea: "How many pillows do you sleep on? Do you get breathless lying flat?"
- Paroxysmal nocturnal dyspnea: waking at night gasping for breath
- Ankle swelling, palpitations
- Weight loss
Orthopnea, waking breathless at night and ankle swelling point to heart failure. Wheeze, sputum and a smoking history point to the airways.
How limited is the patient?
Measure exercise tolerance in concrete terms: how far they can walk on the flat, how many flights of stairs they can climb, and what they could do six months ago. The mMRC dyspnea scale grades breathlessness from 0 (only with strenuous exercise) to 4 (too breathless to leave the house, or breathless when dressing).
Background
- Known asthma or COPD: inhalers and how they are used, previous exacerbations, steroid courses, hospital and ICU admissions
- Heart disease: heart attacks, heart failure, valve disease
- Smoking, in pack-years: packs per day multiplied by years smoked
- Occupational exposures: asbestos, silica, coal dust, farming, birds
- Clotting risk factors: recent surgery or immobility, travel, cancer, previous clots, estrogen-containing medication
- Medications that can cause breathlessness, such as beta-blockers in asthma, amiodarone and methotrexate
- Allergies, and any new exposure before an acute episode
Red flags
- Unable to speak in full sentences
- Sudden onset with pleuritic chest pain
- Coughing up blood, especially with weight loss in a smoker
- Stridor, or swelling of the lips and tongue
- A previous ICU admission or intubation for asthma
- Confusion or drowsiness
Frequently asked questions
- What questions should I ask a patient with shortness of breath?
- Ask how quickly it came on, whether it is getting worse, and what brings it on. Then ask about cough, sputum, coughing up blood, wheeze, chest pain, fever, breathlessness lying flat or at night, ankle swelling and weight loss, followed by smoking, occupation, clotting risk and known heart or lung disease.
- What causes sudden shortness of breath?
- Shortness of breath that comes on over seconds to minutes suggests pulmonary embolism, pneumothorax, anaphylaxis, acute pulmonary edema or an inhaled foreign body.
- What is orthopnea?
- Orthopnea is breathlessness when lying flat, relieved by sitting up. It is a feature of heart failure. Ask how many pillows the patient sleeps on and whether that has changed.
- How do you calculate pack-years?
- Multiply the number of packs (20 cigarettes) smoked per day by the number of years smoked. One pack a day for 30 years is 30 pack-years, and so is two packs a day for 15 years.