Written by Dimitrios Vrachatis, Specialist Cardiologist, PhD, National and Kapodistrian University of Athens.
What is breathlessness?
Breathlessness, or dyspnoea, is the subjective feeling of difficulty breathing. People may feel that they cannot get enough air, cannot take a full breath, are short of breath or are suffocating. It can occur even with normal measured blood oxygen and a normal breathing rate, ordinarily up to 20 breaths per minute.
When does breathlessness occur?
Some breathlessness after very intense exercise is expected and settles when the effort stops.
It is not normal at rest, with mild activity or when it wakes you from sleep. It may be acute or chronic and disrupt everyday life. Persistent, continuous symptoms are more likely to have a medical cause.
Some breathlessness can be normal during pregnancy, particularly later on. Any concern should nevertheless be discussed with the treating doctor.
What conditions can cause it?
- Lung conditions, including:
- Bacterial or viral pneumonia, including COVID-19
- Chronic lung disease
- Allergic asthma
- Cancer
- Airway obstruction by a foreign body
- Heart disease, discussed below
- An allergic or anaphylactic reaction
- Diaphragm or chest wall disorders
- Anaemia
- Systemic infections, especially in older people
- Thyroid disorders
- Kidney dysfunction
- Psychological stress or panic attacks
- Obesity
- Certain medicines
What cardiovascular conditions can cause breathlessness?
Acute or chronic causes include:
- Pulmonary embolism
- Myocardial infarction
- Heart failure
- Valve disease
- Atrial fibrillation or other fast or slow arrhythmias
- Pericarditis
The feeling of not getting enough air may accompany or be confused with chest pain.
When do I need urgent medical assessment?
Breathlessness should not be underestimated. Its cause requires systematic assessment by a cardiologist and/or other specialists, such as a respiratory or internal medicine physician.
Urgent assessment is needed if it:
- Accompanies a marked, persistent rapid heartbeat
- Accompanies pain
- Accompanies rapid breathing
- Suddenly reduces exercise capacity, for example requiring repeated stops when walking was previously easy
- Occurs in someone with known valve disease, according to their cardiologist’s instructions
- Accompanies sudden leg swelling
When is breathlessness dangerous?
There is no universal answer. A serious underlying cause is less likely in younger people than in smokers, older people or those with known conditions. Self-diagnosis can nevertheless have serious consequences, so a specialist should assess the symptom.
Which investigations might I need?
Assessment starts with a detailed personal and family history and examination, including listening to the heart and lungs, checking the calves for inflammation and the legs for swelling.
Basic cardiac investigations include:
- Electrocardiogram
- Echocardiogram
- Chest X-ray
- Blood tests, such as blood count, troponin, BNP and D-dimer
Findings or assessment by another specialist may lead to further tests, such as an exercise test, stress echocardiogram, chest CT, coronary angiography, spirometry or other specialised investigations.
Could I need hospital admission?
The treating doctor decides after a thorough assessment. Even with negative initial tests, admission may be needed for observation and further investigation. Non-urgent cases are preferably investigated as outpatients.