Chronic breathlessness (dyspnoea): causes, red flags and tests

Breathlessness is a symptom with many descriptions: an inability to get a deep breath, tightness, air hunger, effort that seems out of proportion, or needing to stop and rest. Chronic breathlessness is usually defined by duration, often more than a few weeks. The pattern of when it happens is the most valuable clue for a clinician.

Try to answer these before the appointment: how far can you walk on the flat before stopping, and has that changed; do stairs or hills trigger it; does it happen at rest or at night; is it worse lying flat; do you wheeze or cough; have you noticed swollen ankles or weight gain; and does it come with chest pain, palpitations or dizziness. The NHS says you are not wasting anyone's time by getting it checked.

Lung disease tends to produce breathlessness with a cough, wheeze or phlegm, and with a history of smoking or dust exposure. In asthma the symptoms vary from day to day and are worse at night or with triggers, whereas in COPD they are steadily progressive. The NHS notes that many people with COPD do not realise they have it and may dismiss the cough as a smoker's cough.

Heart failure tends to produce breathlessness that worsens when lying flat, forcing people to prop themselves on extra pillows, together with ankle swelling and fatigue. The NHS asks for an urgent GP appointment or NHS 111 contact if you feel breathless lying down or from everyday activity, are coughing up frothy pink phlegm, or have suddenly gained weight. The heart and lung causes can coexist, which is common in older smokers.

• Call 999 or go to A&E if you have severe difficulty breathing: gasping, choking or not able to get words out.

• Call 999 or go to A&E if your chest feels tight or heavy, or you have pain spreading to your arms, back, neck and jaw.

• Call 999 or go to A&E if your lips or skin are turning very pale, blue or grey; on brown or black skin this may be easier to see on the palms of the hands.

• Call 999 or go to A&E if you suddenly feel confused. Do not drive to A&E.

• Contact NHS 111 if you have difficulty breathing and are more short of breath than usual, are feeling or being sick, are coughing up blood, have pain or swelling in one leg, or heart palpitations.

• Ask for an urgent GP appointment or NHS 111 help if you feel breathless lying down or with everyday activity, are coughing up frothy pink phlegm or have suddenly gained weight, as the NHS heart failure page advises.

• See a GP if breathlessness gets worse with normal activities or lying down, if you also have swollen ankles, or you have been coughing for 3 weeks or more.

The history covers onset, tempo, triggers, cough, phlegm, wheeze, chest pain, palpitations, ankle swelling, weight change, smoking and occupational exposures such as dust, metal, wood or asbestos, which the NHS lists as linked with pulmonary fibrosis, and a family history of lung or heart disease. Medicines matter too, since some heart and cancer drugs affect the lungs.

The examination checks pulse, blood pressure, oxygen saturation and respiratory rate, listens to heart and lungs, looks for ankle swelling, raised neck veins, finger clubbing and pallor, and checks weight. A walking test may be used to see whether oxygen levels fall on exertion.

The NHS says the GP can organise a breathing test, spirometry, to help diagnose COPD and rule out other lung conditions such as asthma. For heart failure it lists blood and urine tests, an electrocardiogram, scans including chest X-ray, echocardiogram and MRI, and breathing tests such as a peak flow test and spirometry, with referral to a cardiologist. For idiopathic pulmonary fibrosis it lists spirometry and a chest X-ray followed by a CT scan, with bronchoscopy or lung biopsy if the cause is still unclear.

A full blood count looks for anaemia, and a natriuretic peptide blood test (BNP or NT-proBNP) is often used to decide whether heart failure is likely. Referral to a respiratory or cardiology clinic follows depending on the leading suspect.

Treatment follows the cause. For COPD the NHS lists stopping smoking as the most important step, inhalers and medicines, pulmonary rehabilitation (a specialised programme of exercise and education) and, rarely, surgery or lung transplant. For heart failure, treatment aims to ease symptoms and prevent the condition worsening. For idiopathic pulmonary fibrosis the NHS says two medicines, pirfenidone and nintedanib, may be prescribed to slow the scarring. For asthma the aims are control of symptoms with inhalers and avoiding triggers.

The NHS directs people to Asthma + Lung UK for living well with breathlessness. Practical measures that help many people include pacing activity, breathing techniques taught by a physiotherapist, a fan directed at the face, stopping smoking, weight management and flu and pneumonia vaccination if advised. Keep a note of how far you can walk before you need to stop; it helps measure change over time.