“SHORTNESS OF BREATH”
Shortness of breath is a very common symptom that affects many patients at some point in their lives. We will address the symptom of shortness of breath, often termed dyspnea, focusing first on the more ominous diseases, and ending with the less ominous and less frequent diseases. Certainly, we will not cover every cause, but we will cover many. Again, we cannot replace your physician, nor do we intend to.
Shortness of breath can occur with exertion, which might be normal if you are not accustomed to exerting yourself. Shortness of breath can occur with minimal exertion, or even at rest. Resting shortness of breath is very concerning if it is a new symptom or not. Shortness of breath can even occur in the middle of the night while you are sleeping that might wake you up. Do not take that symptom lightly. Our advice is to call 911 or get to a hospital fast.
If you have a common condition, such as chronic obstructive pulmonary disease or emphysema (COPD), and you are a smoker and you wheeze, then the shortness of breath is probably related to the condition of your lungs. If you do not have underlying lung disease, the shortness of breath can needs to be explored in detail.
Recent onset of shortness of breath with exertion out of proportion to what is normal for you should be explored. If lung disease, in the form of emphysema, COPD, or tobacco dependence, is not involved, then a secondary issue should be searched for. The most common secondary issue could be undiagnosed heart disease.
Heart disease can present in the form of blocked arteries feeding the heart muscle. These arteries are critical to the normal functioning and performance of the heart, and they are called coronary arteries. A blockage in one or more of these arteries is particularly more common in older patients and those with risk factors for heart disease. Partial blockages in these vital arteries can result in shortness of breath or chest pain. If the shortness of breath with exertion is accompanied by chest heaviness, pressure, or tightness, then blocked arteries feeding the heart might be the culprit. In that setting, a stress test, stress echocardiogram, or nuclear stress test is likely to reveal the problem.
Valvular heart disease, such as a leaky or narrowed aortic valve, or a leaky or narrowed mitral valve might cause gradual or sudden onset of shortness of breath. This is usually associated, however, with swelling in the legs, but not always.
A recent or previous heart attack that was not recognized by the patient can cause shortness of breath, either acutely or over time. You will be interested to know that approximately one third of all heart attacks occur without usual or conventional symptoms such as chest pain. Many people have symptoms, but some live in denial and justify the symptoms as being indigestion rather than heart disease. Diabetics with impaired nervous systems may not feel any chest discomfort at all during a heart attack. This information will be revealed on a stress test or another test.
Some anti-platelet medications given to patients who recently had a stent put in an artery of their heart can cause shortness of breath. These symptoms usually improve quickly after starting the new medication. If you had a recent heart stent and are on one of these medications, do not stop them without consulting your cardiologist first.
Congestive heart failure, whether systolic (which affects the contraction phase of heart function) or diastolic (which affects the relaxation phase of heart function), can result in shortness of breath with exertion and shortness of breath at rest. This can be discriminated through the use of an echocardiogram, which is an ultrasound of the heart. This is generally done at a cardiologist’s office. Your primary care physician will point you in the appropriate direction in that regard.
Shortness of breath associated with sudden onset of chest pain could be one of several things, the most ominous being a heart attack that is happening right now. The second most worrisome disease would be a clot in the leg called a DVT, or a deep vein thrombosis, that might have flown to the lungs and lodged in the lungs creating sharp chest pain and sudden shortness of breath. This can be associated with dizzy spells or nearly passing out or really passing out. If you suspect you have had a DVT resulting in flying clots, called Pulmonary Emboli, then you should call 911 or go immediately to the emergency room. This is particularly true if your husband, wife, or living associate notes that you are panting for breath and your lips are blue. If you have a history of a DVT, you need to be on the lookout for the development of a pulmonary embolus. Pulmonary emboli are more common in smokers, after long rides in the car or airplane, in those with a history of the same, those who take hormones, and those who have been sedentary due to an injury, or recent surgery on the knee, back or hip, and in those with hidden or known cancers. Blood clots can also run in families as a genetic defect in the clotting cascade, and people with inflammatory issues like Lupus.
Diabetics tend to develop kidney disease over time. This is particularly true when diabetes is not under good control. Diabetic kidney failure causes retention of too much fluid in the body. Anyone with kidney failure will swell up and retain fluid. When the fluid builds up to the point that it fills up the lungs, it results in shortness of breath with exertion first. If it progresses, the shortness of breath will occur at rest, particularly at night when the swelling in the feet is reabsorbed and gets back in the vascular system. This overwhelms the vascular system and fills the lungs with fluid. In that circumstance, the patient commonly sits bolt-upright in the bed to let gravity pull the fluid out of the lungs. This symptom is called orthopnea. Kidney disease can easily be diagnosed by a simple blood test to look at the BUN and Creatinine.
Shortness of breath can be brought on by Constrictive Pericarditis. The heart sits in a sac that minimizes friction as it moves. If the sac becomes stiff due to recurrent pericarditis, which is inflammation of the pericardium, it can become encased like concrete. This makes the heart difficult to fill and generates shortness of breath with exertion and sometimes at rest.
A cousin to pericarditis is a Pericardial Effusion, which is fluid in the sac around the heart. When the fluid reaches a volume that impedes the heart’s ability to fill, shortness of breath will surely follow, either at rest or with exertion. This fluid can be removed if causing a problem through a procedure called a Pericardiocentesis.
Restrictive heart disease is an infiltrative disease of the heart that affects its ability to fill and empty, and it is quite rare. There are many types. If interested, look at talks on types of congestive heart failure.
Underlying lung disease, in the form of emphysema or COPD, almost always causes shortness of breath.
A Spontaneous Pneumothorax, where a part of your lung drops away from the chest wall, can cause sudden onset of shortness of breath. A chest x-ray will help make this diagnosis.
Heart arrhythmias (particularly Atrial Fibrillation and Atrial Flutter, where there is electrical instability in the upper chambers of your heart) can cause your heart to beat too fast and irregularly, making it inefficient and resulting in shortness of breath. This cause can be either with exertion or at rest, depending on how fast your heart rate is going. Ventricular arrhythmias (such as sustained or nonsustained ventricular tachycardia, which is an irregular rhythm in the bottom half of your heart) can result in shortness of breath. Most heart rhythm causes of shortness of breath are associated with some sort of palpitations.
Anemia where your red blood cell count is low is a common cause of shortness of breath. Anemia can result from lack of production of red blood cells, increased destruction of red blood cells, or a loss of red blood cells, usually through the urinary or gastrointestinal systems. If the gastrointestinal system is implicated, as in a bleeding ulcer, usually the stools are black appearing in nature and will test heme positive on a Hemoccult test done on your feces to look for the presence of blood that shouldn’t be there. A bleeding colon polyp over time can result in iron deficiency anemia. Note that anemia is defined as a hemoglobin level less than a certain number. The normal ranges vary from lab to lab, but generally 12 is the lower limit of normal. If you develop anemia gradually, you might well become short of breath with exertion. If the anemia worsens, your shortness of breath will occur at rest. Blood loss in the lower end of the intestines tends not to be black, but rather dark red. This can also come from diverticulosis, which are out-pouches of the colon that tend to bleed, or it could come from bleeding polyps as well. We cannot forget cancers that can occur in and around the colon area, as well as Ulcerative Colitis and Crohn’s disease, which are also prone to bleeding. We have already mentioned peptic ulcer disease, defined as ulcers in the stomach or the duodenum, which can cause oozing of blood over time and result in iron deficiency anemia.
Anemia is easy to diagnose by a blood test to look at iron stores and the hemoglobin and hematocrit levels. Oftentimes chronic anemia is associated with lower extremity swelling. Anemia can creep up on you. It is interesting to note that many patients with chronic anemia tend to crave ice, eat clay, or boxed cooking starch. This is called the symptom of Pica. We had a patient that looked as white as a doctor’s coat and had feet so big he had to be in a wheelchair. Worse yet, he was a famous golf coach. His hemoglobin was two! That’s the lowest we have ever seen in an alive individual. He did great after getting five units of blood, and the swelling went away.
We mentioned valvular heart disease earlier. This is usually heralded by the presence of a heart murmur that a physician may have heard. Congenital heart disease, including holes in the atrial septum and the ventricular septum that were not detected in childhood, can result in shortness of breath. These are called ASDs and VSDs respectively. A Bicuspid aortic valve that has become narrowed can result in exertional shortness of breath. If ignored, the narrowing of the valve can get so severe that it causes shortness of breath at rest. Again, this situation can be diagnosed easily by an ultrasound of the heart called an echocardiogram. Leaky or narrowed Mitral Valves can do the same thing. Again, an echocardiogram of the heart and a good physical exam with a stethoscope will usually bring these issues to light. Rheumatic fever as a child from strep throat can rear its ugly head at any time later in life, revealing damage to any of the heart valves.
Obesity is a cause of shortness of breath. Obesity requires patients to ambulate with extra weight. This extra weight results in increased energy expenditure while walking which results in shortness of breath with exertion. Rarely does the shortness of breath associated with obesity occur while at rest.
Pulmonary hypertension, which is high blood pressure in the right side of the heart secondary to lung disease, or resistance of blood flow through the lungs, can result in shortness of breath with exertion and even shortness of breath at rest. It would be unusual to have this condition and it not be diagnosed at some point in your life prior to the development of full-blown symptoms of shortness of breath at rest. Oftentimes this is associated with expiratory wheezing while breathing. Pulmonary function studies can be done in many physicians’ offices to get a baseline of your lung function. Some patients have Primary Pulmonary Hypertension which requires a pulmonologist to diagnose and treat in most cases.
There is a rarer condition of the heart rhythm called Syndrome of Inappropriate Sinus Tachycardia, or SIST, for short where the pacemaker function of the heart drives it too fast that can result in the sensation of shortness of breath. These patients tend to have an awkward sensitivity to the presence of adrenaline in the blood stream.
Anxiety can cause shortness of breath. Panic attacks can also cause shortness of breath. You might not have anxiety or panic attacks, but for those who do, it is a real and scary phenomenon.
Lack of regular and routine exercise over time can lead to shortness of breath with exertion called dyspnea on exertion. If that is the sole problem you have, then the treatment is a regular aerobic and muscle strengthening routine to increase your functional capacity over time. This will require effort and commitment, however. We do suggest that if you don’t regularly exercise and are over 40, you might want to get a professional evaluation by a physician before you begin your marathon training routine.
Pneumonia and bronchitis can both contribute to shortness of breath. This can be diagnosed symptomatically by the presence of a fever and a cough. Pneumonia is usually associated with abnormalities on a chest x-ray that can be easily obtained at your physician’s office. Pneumonia is often accompanied by elevation of white blood cell count along with the fever.
Bronchitis is a symptomatic diagnosis that often causes shortness of breath and wheezing that might not show up on a chest x-ray. It is marked by the presence of a chronic cough that can but doesn’t have to be productive of yellow, green, or brown phlegm. If you have these symptoms, you need to see your physician to get a chest x-ray and blood work. This is much more common in smokers.
Less common causes of shortness of breath would include connections between the arterial side of your vascular system and the venous side called AV fistulas. They are rare, but they do occur. They can occur anywhere throughout the body, but tend to occur in the pelvis. We had one patient who had an AV fistula in the uterus that was unapproachable and resulted in profound shortness of breath with exertion and progressing to shortness of breath at rest. Again, this is a rare cause of shortness of breath, but it should not be overlooked if all other causes are excluded.
Excess thyroid hormone can cause your heart to beat too fast and inefficiently, resulting in shortness of breath. Excess thyroid hormone, called hyperthyroidism, is not a rare condition. The shortness of breath is due to fatigue of the heart muscle over time from beating too fast. Low thyroid hormone levels, called hypothyroidism can rob you of your energy and result in shortness of breath. These two issues can be tested for by a simple blood test.
A not-so-rare disease, but rarely thought of to cause shortness of breath is widely-spread Psoriasis. This is because much of your blood flow is shunted to the psoriatic skin lesions.
There are odd diseases such as Hemochromatosis, an iron storage disease, which deposits iron within the heart muscle itself making it stiff and inefficient. Less common causes of shortness of breath that affect the heart include Amyloidosis, which is the process of deposits of amyloid within the heart muscle itself. This makes the heart muscle stiff and over time not contract properly. This can easily be diagnosed on an echocardiogram by seeing a speckled pattern and thickened walls of the heart that are out of proportion to what they should be. This diagnosis is also associated with a low anion gap on routine blood work. It might require a fat pad or gingival biopsy with Congo-red stain. This will show the presence of amyloidosis. There are other storage diseases like, Hunter’s disease and Hurler’s disease, but these are rare. Multiple Myeloma can mimic amyloid. These and others like them are referred to as Restrictive Heart Disease.
Any shortness of breath associated with chest discomfort is cardiac until proven otherwise in older patients. That could mean the presence of systolic or diastolic congestive heart failure, valvular heart disease or, more importantly, blocked arteries of your heart that could result in a heart attack.
We hope you find this information useful as you have conversations with your personal physician about your complaints of shortness of breath. Please be advised that some topics were omitted, and this list is not completely covered, but broadly covered.