Persistent Shortness of Breath: Seeking the Right Specialist for Relief

Q: Persistent Shortness of Breath: Seeking the Right Specialist for Relief

Hello Jason： Your friend has been experiencing shortness of breath related to fluid accumulation, and the fluid extracted is clear pleural effusion. <br>Relevant tests have ruled out infections (including tuberculosis) and malignancies, suggesting that the issue may be related to

Persistent wheezing

Hello, the patient is currently 77 years old, with a height of 160 cm and a weight of around 65 kg.
He has a history of smoking but has significantly reduced his intake, averaging about one and a half packs per week.
He previously had a coronary stent placed.
Since May, he has been experiencing severe shortness of breath, to the extent that he needs to stop and rest after walking just 30 meters.
He first visited the emergency department at Shin Kong Hospital, where the doctor administered diuretics, which helped significantly.
However, after a week, the shortness of breath returned.
He was then hospitalized and initially evaluated by a cardiologist, who examined his blood vessels and stent, as well as his heart, and reported no issues, stating that the heart is healthy.
However, the patient occasionally experiences slight irregularities in heart rhythm.
He was then referred to a pulmonologist, who diagnosed pleural effusion and performed a thoracentesis to drain the fluid, which also resulted in significant improvement.
A week later, laboratory tests on the fluid indicated that it was clear and healthy, with no lung issues.
The doctor suggested that the problem might be related to the heart, so he was re-evaluated by the cardiologist, who again found no issues and suggested it might be a thoracic problem.
Initially, after the fluid was drained, there were no concerns since the doctors could not identify any problems, all stating that there were no issues.
Today, the patient has started experiencing shortness of breath again.
Which specialty should we consult for further assistance? Thank you.

jason, 20~29 year old female. Ask Date: 2015/06/11

Dr. Yang Wenda reply Pulmonology

Hello Jason: Your friend has been experiencing shortness of breath related to fluid accumulation, and the fluid extracted is clear pleural effusion.
Relevant tests have ruled out infections (including tuberculosis) and malignancies, suggesting that the issue may be related to the heart or albumin deficiency (assuming there are no liver or kidney problems).
However, since the patient has had a stent placed in the heart, there should be an improvement compared to before the stent was inserted.
Long-term smokers may experience right heart failure (cor pulmonale) due to chronic obstructive pulmonary disease (COPD).
The left ventricular contraction and cardiac output may be normal, but managing cor pulmonale can be more challenging.
There are several points the patient needs to adhere to: (1) complete smoking cessation, (2) control salt and fluid intake (especially from soups), (3) monitor daily weight, ensuring it does not exceed a gain of two kilograms (compared to a more comfortable state with less fluid accumulation), (4) comply with the use of diuretics prescribed by the physician, and (5) consider using low-flow oxygen at home (less than 2 liters per minute), and if possible, purchase a pulse oximeter (costing a few thousand dollars) to ensure blood oxygen saturation remains above 90%.
Best wishes!

Reply Date: 2015/06/11

More Info

Persistent shortness of breath, especially in an elderly patient with a history of smoking and heart issues, can be a complex problem that requires a multidisciplinary approach. Given the patient's age (77 years), history of smoking, and previous cardiac interventions (such as stent placement), it is essential to consider both pulmonary and cardiac factors that may contribute to the ongoing symptoms.

From the information provided, it seems that the patient has undergone evaluations by both cardiology and pulmonology, with findings indicating that the heart is functioning well and that there was a transient issue with pleural effusion (fluid accumulation in the chest cavity) that has since been resolved. However, the recurrent shortness of breath suggests that there may be underlying issues that have not yet been fully addressed.

Recommendations for Next Steps:
1. Pulmonary Rehabilitation: Since the patient has a history of smoking and has experienced significant shortness of breath, a referral to a pulmonary rehabilitation program may be beneficial. These programs are designed to help patients with chronic respiratory issues improve their lung function and overall quality of life through exercise, education, and support.

2. Further Pulmonary Evaluation: If the patient has not yet undergone a comprehensive pulmonary function test (PFT), this should be considered. PFTs can help assess the patient's lung capacity, airflow, and gas exchange efficiency. Conditions such as chronic obstructive pulmonary disease (COPD) or restrictive lung disease could be contributing to the symptoms.

3. Consideration of Other Specialists: Given the complexity of the case, it may be worthwhile to consult with a specialist in geriatric medicine. Geriatricians are trained to manage the unique health issues faced by older adults and can provide a holistic approach to the patient's care, considering both physical and cognitive aspects.

4. Cardiology Follow-Up: Since the patient has experienced episodes of irregular heart rhythms (palpitations), it may be prudent to have a follow-up with a cardiologist. An echocardiogram or Holter monitor could provide additional insights into the heart's function and rhythm, especially if the shortness of breath is related to cardiac output or arrhythmias.

5. Assessment for Anxiety or Panic Disorders: Given the patient's age and the stress of dealing with chronic health issues, it may also be beneficial to assess for anxiety or panic disorders, which can manifest as shortness of breath. A referral to a mental health professional may be warranted if anxiety is suspected.

6. Lifestyle Modifications: Encourage the patient to engage in lifestyle modifications, such as smoking cessation (if not already achieved), a heart-healthy diet, and regular physical activity as tolerated. These changes can significantly impact overall health and respiratory function.

Conclusion:
In summary, the persistent shortness of breath in this 77-year-old patient requires a comprehensive evaluation that includes both pulmonary and cardiac assessments. A multidisciplinary approach involving pulmonologists, cardiologists, geriatricians, and possibly mental health professionals will provide the best chance for identifying the underlying causes and developing an effective management plan. It is crucial to maintain open communication with the healthcare team and advocate for further evaluations as needed.

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