[Dyspnea. From the concept up to diagnostics]

Tracheal atypical solitary carcinoid in a so called "difficult asthma": a diagnostic challenge

This report describes the case of a 46-year-old non-smoker housewife. She presented to our attention having a diagnosis of "difficult asthma" from another center in the previous two years. She had no allergies and had not been exposed to an excessive amount of noxious stimuli. Her chronic respiratory symptoms (dyspnea on exertion with wheezing) remained uncontrolled despite maximal anti-asthmatic inhaled therapy. An HRCT scan was performed to further investigate other pulmonary diseases that mimic asthma. It revealed a pedunculated endotracheal lesion with regular borders that obstructed 90% of the tracheal lumen. The lesion was removed via rigid bronchoscopy with laser endobronchial; histological examination revealed the presence of atypical carcinoid. Atypical carcinoids are a rare subtype of neuroendocrine lung tumor that accounts for 2% of all thoracic malignancies. They frequently arise from the central airways and cause obstructive symptoms such as coughing, wheezing, chest pain, or recurrent obstructing pneumonia, which is caused by central airway obstruction. Clinical onset is gradual and characterized by non-specific symptoms, which frequently result in misdiagnosis. As a result, in a young patient with progressive dyspnea, chronic cough, and wheezing that is not responding to anti-asthmatic treatment, second-level investigations are required and may lead to a definite diagnosis, allowing the appropriate course of treatment to begin.

Dyspnea: Common Side Effect

For dyspnea, standards of care are based on emerging evidence-based practice. Dyspnea, or shortness of breath, is a subjective experience of breathing discomfort marked by distinct sensations of varying intensity. Resulting from interactions among physiologic, psychological, social, and environmental factors, dyspnea may lead to secondary physiologic and behavioral responses. Dyspnea can be caused by cardiac and pulmonary disease (e.g., congestive heart failure, acute coronary syndrome, pneumonia, chronic obstructive pulmonary disease, pulmonary embolism), as well as other conditions (e.g., anemia, mental disorders, lung cancer).

[Dyspnea : A challenging symptom in the primary care setting]

Dyspnea is a very common symptom leading to visits to a general physician (GP). Correct differential diagnosis is the major challenge for the GP. There are no guidelines on dyspnea. This review provides an overview of the main causal diseases for dyspnea, presents methods for history taking and differential diagnosis, and specifies the role of GPs in the primary care setting in the case of dyspnea.

The Differential Diagnosis of Dyspnea

BACKGROUND

Dyspnea is a common symptom affecting as many as 25% of patients seen in the ambulatory setting. It can arise from many different underlying conditions and is sometimes a manifestation of a life-threatening disease.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines.

RESULTS

The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. A distinction is drawn between dyspnea of acute onset and chronic dyspnea: the latter, by definition, has been present for more than four weeks. The history, physical examination, and observation of the patient's breathing pattern often lead to the correct diagnosis, yet, in 30-50% of cases, more diagnostic studies are needed, including biomarker measurements and other ancillary tests. The diagnosis can be more difficult to establish when more than one underlying disease is present simultaneously. The causes of dyspnea include cardiac and pulmonary disease (congestive heart failure, acute coronary syndrome; pneumonia, chronic obstructive pulmonary disease) and many other conditions (anemia, mental disorders).

CONCLUSION

The many causes of dyspnea make it a diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of disease.

[Dyspnea]

Dyspnea represents one of the most frequent cardinal symptoms in general practice and interdisciplinary emergency care across all sectors. Due to its subjective character, dyspnea is described by patients in many different ways, including "shortness of breath, difficulty of breathing, feeling of chest tightness, etc". The spectrum of differential diagnoses is broad, including in particular pulmonary and cardiovascular diseases. In addition to an evaluation of severity and an assessment of temporal, situation-related, and causal classification criteria, a structured process of multiple diagnostic steps in both primary and emergency care is a prerequisite for fast and correct diagnosis. In this context, it is of crucial importance to identify life-threatening diseases according to defined criteria and thus initiate adequate emergency measures. Further treatment options at the interface between primary and clinical care can be based on the German Appropriate Evaluation Protocol (G-AEP) criteria.