The patient with dyspnea. Rational diagnostic evaluation

Management of Refractory Breathlessness: a Review for General Internists

Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.

Diagnostic approach to chronic dyspnoea in adults

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.

Dyspnea: An underestimated symptom in Parkinson's disease

INTRODUCTION

Dyspnea is one of the least well-characterized non-motor symptoms (NMS) associated with Parkinson's disease (PD).

OBJECTIVE

To determine the frequency of dyspnea in a large, single-center cohort of consecutive PD patients with no history of lung or heart disease, and to compare clinical features in dyspneic vs. non-dyspneic patients.

METHODS

Patients with abnormal cardiovascular and pulmonary results in a clinical examination were excluded. A positive response to at least one question ("In the last month, have you suffered from breathlessness?" and "In the last month, have you had trouble breathing normally?") was considered to signify the experience of dyspnea. MDS-UPDRS, global cognitive performance, non-motor symptoms and quality of life were assessed.

RESULTS

In the cohort of 153 non-demented PD patients (mean age ± standard deviation: 63.9 ± 7.4; mean disease duration: 9.2 ± 6.1 years), the mean [95% confidence interval (CI)] frequency of dyspnea was 39.2% (31.5-47). After adjustment for disease severity, PD patients with dyspnea had a significantly higher Movement Disorders Society Unified Parkinson's Disease Rating Scale part I, II and IV scores, a higher HAD anxiety and depression scores and a significantly higher 8-item Parkinson's Disease Questionnaire.

CONCLUSION

Dyspnea is a frequent NMS in PD. Its pathophysiology and prognostic value need more investigation.

MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care

BACKGROUND

Detection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital.

DESIGN

A decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care.

METHODS

Data from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective.

RESULTS

The current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a "do nothing" strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses.

CONCLUSIONS

This represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.

From breathless to failure: symptom onset and diagnostic meaning in patients with heart failure-a qualitative study

OBJECTIVES

To explore 2 key points in the heart failure diagnostic pathway-symptom onset and diagnostic meaning-from the patient perspective.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from a secondary care clinic in central England following referral from primary care.

PARTICIPANTS

Over age 55 years with a recent (<1 year) diagnosis of heart failure confirmed by a cardiologist following initial presentation to primary care.

METHODS

Semistructured interviews were carried out with 16 participants (11 men and 5 women, median age 78.5 years) in their own homes. Data were audio-recorded and transcribed. Participants were asked to describe their diagnostic journey from when they first noticed something wrong up to and including the point of diagnosis. Data were analysed using the framework method.

RESULTS

Participants initially normalised symptoms and only sought medical help when daily activities were affected. Failure to realise that anything was wrong led to a delay in help-seeking. Participants' understanding of the term 'heart failure' was variable and 1 participant did not know he had the condition. The term itself caused great anxiety initially but participants learnt to cope with and accept their diagnosis over time.

CONCLUSIONS

Greater public awareness of symptoms and adequate explanation of 'heart failure' as a diagnostic label, or reconsideration of its use, are potential areas of service improvement.