The sensation of breathlessness is common and causes range from physiological to psychological and physical pathology. It is frequently regarded with grave foreboding by patients but is also a vital symptom for doctors.

Sudden Acute Causes of Breathlessness

While these are usually the most serious, they are the most straightforward to disentangle. They can be broken down into those more likely to present in younger or older ages.

Acute Breathing Difficulties at Younger Ages

• Pneumothorax: sharp unilateral pain and no history of respiratory problems (except in those with previous pneumothorax who will probably recognise their problem), typically tall thin young men (including the rare Marfan’s syndrome).
  
• Asthma: usually a history of episodic breathlessness and/or nocturnal cough and waking, and past history of childhood ‘chest troubles’ (frequently wrongly or vaguely diagnosed as: ‘wheezy bronchitis’ or similar colloquialism) (see Chapter 40).
  
• Pulmonary embolism: actually more common in older patients but is one of relatively few common acute causes of breathlessness in younger people. History of immobilisation (e.g. inpatient, long haul flight, plaster cast), smoking and combined oral contraceptive pill users (risk from both increases with age). Associated with pain and haemoptysis.
  
• Panic attacks: common and debilitating. Unlike the above where urgent admission is essential, avoiding admission and de-medicalising are more helpful here. First episodes are more likely to be associated with psychological stressors, later episodes less so. Episodes often come out of a background of emotional stress with acute provocation (e.g. an argument, or agoraphobic or claustrophobic situations). Symptoms and anxiety are disproportionate to physical findings, which may be of erratic or deep sighing breathing. Oxygen saturation levels will be normal, peak flow is usually unrecordable (due to inability to cooperate). A past history of panic attacks is helpful in diagnosing the current episode, but do not assume the current attack is panic just because of the past history.

Acute Breathing Difficulties at Older Ages

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