Chronic Shortness of Breath (SOB)

“True” Chronic SOB is always felt on exertion.  Patients feel well at rest, with normal vital signs and normal oxygen saturation tests (if not, see Life-Threatening Acute SOB).  For a patient without any clues in the medical history (like having had a heart attack in the past), clinicians think as follows:

Causes of Chronic Shortness of Breath

โ€ข Heart Failure (HF) **
โ€ข Anemia
โ€ข Angina **

xxxxxxxxxNormal SOB
โ€ข Deconditioning (out-of-shape) **

    ** SOB, with exertion, may come and go
โ€ข Asthma **
โ€ข COPD (esp. Emphysema)
โ€ข Interstitial Lung Disease      

xxxxxxxxxUncommon Causes
Click for List of Rare Causes

1.ย  Decide if Angina (Coronary Artery Disease) is a possibility, by factors below.ย  If so, work up with EKG & stress tests [see Diagnosing Coronary Artery Disease].

  • Duration: SOB on exertion, lasts approx. 1-5 min upon resting (never just seconds)
  • Risk Factors: Hypertension, Smoking, Diabetes, High Cholesterol, Cocaine / Meth, Family History of heart attack (at around patientโ€™s age)
  • Chest Pain occurring along with the SOB, described as โ€œpressure,โ€ โ€œheaviness,โ€ squeezing,โ€ or โ€œtightness,โ€ maybe in Left shoulder, upper arm, neck, or lower jaw.
  • Other Symptoms occurring along with the SOB  — a) Nausea/Vomit; b) Lightheadedness; c) Cold Sweat breaks out on forehead
  • Beware that a person who has waited out Angina may be on the verge of a full-fledged Heart Attack (M.I.) (see Acute SOB)

2.  But letโ€™s assume Angina is not a consideration.  We focus on the Exam by Stethoscope:

**ย  Bibasilar rales (crackles) at bottom of both Lungs, with normal inspiratory-to-expiratory phases, suggests Heart Failure (HF), especially in the older patient.ย  Swollen feet / neck veins clinches it. See Lung Sounds)

**  Abnormal Heart Exam —  may suggest Heart Failure due to heart disease (damaged valve, abnormal rhythm like Atrial Fibrillation, etc).

**  Wheezes in Lungs, or expiration longer than inspiration (see Lung Sounds) suggests Asthma or COPD

  • If non-smoker, itโ€™ll certainly be Asthma, especially if they also cough.
  • If long smoking history, bet on COPD (Chronic Bronchitis if also a cough, Emphysema if no cough).
  • If Asthma / Chronic Bronchitis seem likely, we give a trial of treatment.
  • Can also check Peak Flow, give an asthma treatment, & see if Peak flow improves. If so, we have a diagnosis.

3.  If none of above, or if symptoms remain unchanged after an Asthma treatment trial, we order:

4.  Everything Normal, No Diagnosis?  And weโ€™re convinced the patient experiences โ€œtrueโ€ SOB?  We order:

5. Heart or Lung abnormalities found by the above tests?  Next Steps:

  • For Heart: Cardiology referral, for maybe Cardiac Catheterization (right and/or left sides)
  • For Lung:  Chest CT Scan (regular, or high-resolution); maybe “V/Q Scan” for the rare case of Chronic Pulmonary Embolism; referral to Pulmonologist

6.  Still No Abnormalities (everything normal)?  We can certainly reassure the patient.  Might just be simple Deconditioning.

  • We keep following them to make sure nothing changes, & that they’re not losing weight.
  • If getting worse, repeat some of the above tests, maybe refer to a Pulmonologist

See Chronic Shortness of Breath โ€” Full Text for more in-depth explanations and discussions.

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