Shortness of Breath

1. Overview

Shortness of breath, also called dyspnoea, is the subjective sensation of difficult, uncomfortable or inadequate breathing. In an OSCE, the first priority is to determine whether the patient is acutely unwell, hypoxic or unable to speak in full sentences.

The differential diagnosis is broad and includes respiratory, cardiac, metabolic, haematological and psychological causes. A structured approach helps separate immediately life-threatening causes from chronic or stable causes.

Key OSCE priorities

• Assess severity immediately.
• Check whether the patient can speak in full sentences.
• Ask about onset, duration and progression.
• Ask about chest pain, wheeze, cough, fever, haemoptysis and collapse.
• Screen for asthma, COPD, pneumonia, pulmonary embolism, pneumothorax and heart failure.
• Ask about smoking, occupational exposure and previous respiratory disease.
• Check observations and oxygen saturation early.
• Perform a structured respiratory and cardiovascular examination.
• State that acute severe breathlessness requires ABCDE assessment and urgent senior help.

Important causes

• Asthma exacerbation.
• COPD exacerbation.
• Pneumonia.
• Pulmonary embolism.
• Pneumothorax.
• Pleural effusion.
• Acute pulmonary oedema.
• Heart failure.
• Acute coronary syndrome.
• Anaemia.
• Metabolic acidosis.
• Anxiety or panic attack.
• Interstitial lung disease.
• Lung cancer.
• Anaphylaxis.

Red flag features

• Severe breathlessness at rest.
• Unable to complete sentences.
• Cyanosis.
• Low oxygen saturation.
• Chest pain.
• Syncope or collapse.
• Haemoptysis.
• Confusion or reduced consciousness.
• Silent chest in asthma.
• Hypotension.
• Unilateral leg swelling suggesting DVT.
• Tracheal deviation or absent breath sounds suggesting tension pneumothorax.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their breathing.
• Gain consent.
• Check whether the patient is too breathless to speak.
• If the patient is acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask when the breathlessness started.
• Ask whether onset was sudden or gradual.
• Ask whether it is constant or intermittent.
• Ask whether it is worsening, improving or stable.
• Ask whether it occurs at rest, on exertion or both.
• Ask how far the patient can walk now compared with baseline.
• Ask whether this has happened before.
• Ask what the patient was doing when it started.

Severity assessment

• Ask whether the patient can speak in full sentences.
• Ask whether they are breathless at rest.
• Ask about exercise tolerance.
• Ask how many stairs they can climb.
• Ask whether breathlessness affects sleep.
• Ask whether they need to sit upright to breathe.
• Ask whether symptoms limit washing, dressing or eating.
• Ask whether they have needed emergency treatment before.

Character and triggers

• Ask whether breathing feels tight, heavy, painful or restricted.
• Ask about wheeze.
• Ask about cough.
• Ask about sputum production.
• Ask about pleuritic chest pain.
• Ask whether symptoms are triggered by exercise, cold air, allergens, infection or emotion.
• Ask whether symptoms are worse at night or early morning.
• Ask whether symptoms are worse when lying flat.
• Ask whether inhalers or rest improve symptoms.

Associated respiratory symptoms

• Cough.
• Sputum.
• Haemoptysis.
• Wheeze.
• Chest tightness.
• Pleuritic chest pain.
• Fever or rigors.
• Night sweats.
• Weight loss.
• Hoarseness.
• Recurrent chest infections.

Asthma screen

• Episodic wheeze.
• Cough, especially at night or early morning.
• Chest tightness.
• Symptoms triggered by exercise, cold air, pollen, dust or animals.
• Personal or family history of atopy.
• Previous hospital admissions or ICU admission for asthma.
• Current inhalers and adherence.
• Recent increase in reliever inhaler use.

COPD screen

• Smoking history.
• Chronic cough.
• Chronic sputum production.
• Progressive exertional dyspnoea.
• Frequent winter bronchitis.
• Previous COPD diagnosis.
• Previous exacerbations or hospital admissions.
• Home oxygen or nebuliser use.

Pneumonia and infection screen

• Fever.
• Rigors.
• Productive cough.
• Purulent sputum.
• Pleuritic chest pain.
• Confusion, especially in older patients.
• Recent viral illness.
• Sick contacts.
• Recent hospital admission.
• Immunosuppression.

Pulmonary embolism screen

• Sudden onset breathlessness.
• Pleuritic chest pain.
• Haemoptysis.
• Syncope or collapse.
• Unilateral leg swelling or calf pain.
• Recent surgery.
• Recent immobility or long-haul travel.
• Pregnancy or postpartum period.
• Combined oral contraceptive pill or oestrogen therapy.
• Active cancer.
• Previous DVT or PE.
• Known thrombophilia.

Pneumothorax screen

• Sudden onset unilateral pleuritic chest pain.
• Sudden breathlessness.
• Tall thin body habitus.
• Smoking.
• Known lung disease.
• Recent trauma.
• Recent procedure such as central line insertion or lung biopsy.
• Previous pneumothorax.

Heart failure screen

• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Ankle swelling.
• Rapid weight gain.
• Nocturnal cough.
• Reduced exercise tolerance.
• Chest pain.
• Palpitations.
• Known ischaemic heart disease, hypertension, valve disease or cardiomyopathy.

Acute coronary syndrome screen

• Central chest pain or pressure.
• Pain radiating to arm, jaw, neck or back.
• Sweating.
• Nausea or vomiting.
• Breathlessness with chest discomfort.
• Diabetes, hypertension, hyperlipidaemia or smoking history.
• Previous myocardial infarction or coronary stent.

Anaemia and systemic screen

• Fatigue.
• Dizziness.
• Palpitations.
• Pallor.
• Heavy menstrual bleeding.
• PR bleeding or melaena.
• Poor diet.
• Weight loss.
• Chronic kidney disease.
• Known malignancy or chronic inflammatory disease.

Past medical history

• Asthma.
• COPD.
• Bronchiectasis.
• Pneumonia.
• Tuberculosis.
• Pulmonary embolism or DVT.
• Pneumothorax.
• Interstitial lung disease.
• Lung cancer.
• Heart failure.
• Ischaemic heart disease.
• Atrial fibrillation.
• Valvular heart disease.
• Anaemia.
• Chronic kidney disease.
• Anxiety or panic disorder.

Drug history and allergies

• Current regular medications.
• Inhalers and inhaler technique.
• Recent increase in reliever inhaler use.
• Steroid use.
• Antibiotics.
• Anticoagulants.
• Diuretics.
• Beta-blockers.
• ACE inhibitors.
• Oestrogen therapy or combined oral contraceptive pill.
• Chemotherapy or immunosuppressants.
• Drug allergies and reaction.

Family history

• Asthma or atopy.
• COPD.
• Thrombophilia.
• Pulmonary embolism or DVT.
• Early ischaemic heart disease.
• Heart failure or cardiomyopathy.
• Inherited lung disease if relevant.

Social history

• Smoking status and pack-year history.
• Vaping.
• Alcohol intake.
• Recreational drug use.
• Occupation and exposure to dust, fumes, chemicals or asbestos.
• Pets, birds or mould exposure.
• Recent travel.
• Baseline exercise tolerance.
• Living situation and support.
• Impact on work and daily activities.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the breathlessness.
• Ask what they are most worried about.
• Ask whether they are worried about asthma, infection, blood clot, heart disease or cancer.
• Ask what they were hoping would happen today.
• Acknowledge that breathlessness can be frightening.

Red flags

• Breathlessness at rest.
• Unable to speak in full sentences.
• Chest pain.
• Haemoptysis.
• Syncope or collapse.
• Cyanosis.
• Confusion or drowsiness.
• Unilateral leg swelling.
• Severe wheeze or silent chest.
• Tracheal deviation.
• Fever with sepsis features.
• Weight loss or night sweats.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would check observations, oxygen saturation, examine the respiratory and cardiovascular systems, and arrange investigations according to severity.

3. Physical Examination

The examination should start with severity assessment. If the patient is acutely breathless, perform an ABCDE assessment before a routine respiratory examination.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask whether the patient is comfortable to proceed.
• Position the patient sitting upright or at 45 degrees.
• Expose the chest appropriately while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is alert, confused, cyanosed, pale or sweaty.
• Assess whether the patient can speak in full sentences.
• Look for use of accessory muscles.
• Look for tripod position.
• Look for intercostal or subcostal recession.
• Look for oxygen therapy, nebulisers, inhalers, sputum pot, chest drain or monitoring.
• If acutely unwell, perform ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether the airway is patent.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing, chest expansion and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level and capillary blood glucose.
• Exposure: check temperature, look for rash, leg swelling, infection, trauma and medication patches while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Peak expiratory flow if asthma is suspected and the patient can perform it safely.
• Pain score if chest pain is present.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for finger clubbing.
• Look for nicotine staining.
• Look for tremor suggesting beta-agonist use or anxiety.
• Look for asterixis suggesting carbon dioxide retention.
• Look for palmar pallor suggesting anaemia.
• Assess peripheral temperature.

Pulse and blood pressure

• Assess pulse rate.
• Assess pulse rhythm.
• Tachycardia may suggest hypoxia, infection, PE, arrhythmia or anxiety.
• Irregularly irregular pulse suggests atrial fibrillation.
• Measure blood pressure.
• Hypotension suggests severe illness, sepsis, PE, anaphylaxis or shock.

Face, mouth and neck

• Look for central cyanosis.
• Look for conjunctival pallor.
• Look for pursed-lip breathing.
• Look for cachexia or weight loss.
• Inspect for angioedema or facial swelling if anaphylaxis is suspected.
• Assess cervical and supraclavicular lymph nodes.
• Check tracheal position.
• Assess jugular venous pressure.

Chest inspection

• Inspect chest shape.
• Look for hyperinflation or barrel chest.
• Look for asymmetrical chest movement.
• Look for scars.
• Look for chest wall deformity.
• Look for respiratory distress.
• Observe respiratory pattern.
• Look for chest drain or surgical emphysema if relevant.

Palpation

• Confirm tracheal position.
• Assess chest expansion.
• Compare expansion on both sides.
• Assess tactile vocal fremitus if consolidation or effusion is suspected.
• Palpate for chest wall tenderness.
• Palpate for subcutaneous emphysema if pneumothorax or trauma is suspected.

Percussion

• Percuss symmetrical areas of the chest.
• Dullness may suggest consolidation, collapse or pleural effusion.
• Stony dullness suggests pleural effusion.
• Hyperresonance may suggest pneumothorax or hyperinflation.
• Compare side to side.

Auscultation

• Auscultate symmetrical areas of the chest.
• Assess air entry.
• Listen for wheeze.
• Listen for crackles.
• Listen for bronchial breathing.
• Listen for pleural rub.
• Assess vocal resonance if consolidation or effusion is suspected.
• A silent chest in severe asthma is a medical emergency.

Respiratory findings to interpret

• Wheeze suggests asthma, COPD or sometimes pulmonary oedema.
• Fine inspiratory crackles may suggest pulmonary oedema or interstitial lung disease.
• Coarse crackles may suggest infection or bronchiectasis.
• Bronchial breathing with dullness suggests consolidation.
• Reduced breath sounds with stony dullness suggests pleural effusion.
• Reduced breath sounds with hyperresonance suggests pneumothorax.
• Pleural rub suggests pleurisy or pulmonary embolism.

Cardiovascular examination

• Assess JVP.
• Palpate the apex beat.
• Auscultate heart sounds.
• Listen for murmurs.
• Assess for peripheral oedema.
• Look for signs of heart failure.
• Check for irregular pulse suggesting atrial fibrillation.

Peripheral and abdominal examination

• Inspect legs for unilateral swelling or calf tenderness suggesting DVT.
• Check for peripheral oedema.
• Assess for hepatomegaly if right heart failure is suspected.
• Look for signs of chronic liver disease or anaemia if relevant.
• Assess temperature and rash if infection or anaphylaxis is suspected.

Specific findings to mention in OSCE

• Severe respiratory distress requires ABCDE assessment.
• Low oxygen saturation is a red flag.
• Wheeze suggests obstructive airway disease but can also occur in heart failure.
• Unilateral absent breath sounds may suggest pneumothorax.
• Focal crackles and bronchial breathing suggest pneumonia.
• Raised JVP, bibasal crackles and oedema suggest heart failure.
• Unilateral leg swelling with breathlessness suggests possible PE.
• Normal examination does not exclude PE, early asthma, anaemia or metabolic acidosis.

To complete the examination

To complete my examination, I would review observations, check oxygen saturation, perform peak flow if asthma is suspected, arrange ECG, chest X-ray and blood tests, and consider arterial or venous blood gas, D-dimer, CT pulmonary angiography, spirometry or echocardiography depending on the suspected diagnosis.

4. Differential Diagnosis

Respiratory causes

• Asthma exacerbation.
• COPD exacerbation.
• Pneumonia.
• Pulmonary embolism.
• Pneumothorax.
• Pleural effusion.
• Bronchiectasis.
• Interstitial lung disease.
• Lung cancer.
• Tuberculosis.
• Anaphylaxis.
• Aspiration.

Cardiac causes

• Acute pulmonary oedema.
• Chronic heart failure.
• Acute coronary syndrome.
• Arrhythmia.
• Valvular heart disease.
• Cardiac tamponade.
• Pulmonary hypertension.

Haematological and metabolic causes

• Anaemia.
• Metabolic acidosis.
• Diabetic ketoacidosis.
• Sepsis.
• Renal failure with acidosis or fluid overload.
• Thyrotoxicosis.

Psychological and functional causes

• Anxiety.
• Panic attack.
• Dysfunctional breathing.
• Deconditioning.
• Obesity-related breathlessness.

Important mimics and clues

• Sudden pleuritic pain suggests PE or pneumothorax.
• Wheeze and nocturnal symptoms suggest asthma.
• Smoking with chronic sputum suggests COPD.
• Fever and productive cough suggest pneumonia.
• Orthopnoea and ankle swelling suggest heart failure.
• Normal oxygen saturation does not exclude serious pathology.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• Peak expiratory flow if asthma is suspected.
• Capillary blood glucose if acutely unwell or diabetic.
• 12-lead ECG.
• Urine dip if infection, renal disease or pregnancy-related issue is suspected.
• Pregnancy test in women of reproductive age when appropriate.

Blood tests

• Full blood count to assess anaemia or infection.
• Urea and electrolytes.
• CRP.
• Liver function tests if systemic illness is suspected.
• Troponin if ACS is suspected.
• BNP or NT-proBNP if heart failure is suspected.
• D-dimer only if PE is possible and clinical probability supports testing.
• Arterial or venous blood gas if severe breathlessness, hypoxia, COPD exacerbation, acidosis or respiratory failure is suspected.
• Blood cultures if sepsis or severe pneumonia is suspected.

Imaging

• Chest X-ray.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• CT chest if malignancy, interstitial lung disease or complex pathology is suspected.
• Ultrasound chest if pleural effusion is suspected.
• Bedside lung ultrasound may help assess effusion, pneumothorax or pulmonary oedema where available.

Respiratory tests

• Spirometry when stable if asthma or COPD is suspected.
• Bronchodilator reversibility testing if obstructive airway disease is suspected.
• Peak flow diary if asthma variability is suspected.
• FeNO where available for suspected eosinophilic airway disease.
• Sputum culture if productive cough or pneumonia is suspected.
• Sputum AFB testing if TB is suspected.

Cardiac investigations

• ECG for arrhythmia, ischaemia or right heart strain.
• Echocardiography if heart failure, valvular disease or pulmonary hypertension is suspected.
• Troponin if acute coronary syndrome is suspected.
• BNP or NT-proBNP if heart failure is suspected.

Important investigation points

• Investigations depend on severity and suspected diagnosis.
• Chest X-ray is a high-yield first-line investigation in many patients with breathlessness.
• A normal chest X-ray does not exclude PE, asthma or early infection.
• Blood gas is useful when respiratory failure, CO2 retention or metabolic acidosis is suspected.
• PE investigation should follow clinical probability and local protocol.

6. Management

Management depends on severity and cause. In an OSCE, always begin with ABCDE assessment for acute breathlessness, then treat the most likely life-threatening cause while arranging investigations.

Immediate approach if acutely unwell

1. Assess using ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, chest pain, confusion, hypotension or cyanosis is present.
3. Sit the patient upright.
4. Give oxygen if hypoxaemic according to local oxygen target protocol.
5. Attach monitoring if unstable.
6. Obtain IV access if clinically indicated.
7. Perform ECG and chest X-ray.
8. Send blood tests and blood gas if indicated.
9. Treat the likely emergency cause.

Oxygen principles

• Oxygen is a treatment for hypoxaemia, not for breathlessness alone.
• Use target oxygen saturation ranges according to local policy.
• Most acutely unwell patients are usually targeted to 94 to 98 percent.
• Patients at risk of hypercapnic respiratory failure, such as some COPD patients, usually require a lower target range such as 88 to 92 percent.
• Recheck oxygen saturation and clinical response after starting oxygen.
• Consider blood gas if COPD, CO2 retention or severe respiratory failure is suspected.

If asthma exacerbation is suspected

• Assess severity using symptoms, respiratory rate, oxygen saturation, pulse and peak flow.
• Give oxygen if hypoxaemic.
• Give inhaled or nebulised bronchodilator according to local protocol.
• Give systemic corticosteroids according to local protocol.
• Escalate urgently if poor response, exhaustion, silent chest, cyanosis or reduced consciousness.
• Review inhaler technique and provide an asthma action plan after stabilisation.

If COPD exacerbation is suspected

• Assess oxygen saturation and risk of CO2 retention.
• Use controlled oxygen if at risk of hypercapnic respiratory failure.
• Give bronchodilators according to local protocol.
• Consider steroids and antibiotics depending on features of exacerbation.
• Check blood gas if severe, drowsy, hypoxic or retaining CO2.
• Consider non-invasive ventilation if respiratory acidosis persists according to local protocol.
• Review smoking cessation, inhaler technique and pulmonary rehabilitation.

If pneumonia is suspected

• Assess severity and sepsis features.
• Give oxygen if hypoxaemic.
• Arrange chest X-ray and blood tests.
• Give antibiotics according to local antimicrobial guidance.
• Give IV fluids if clinically indicated, avoiding overload.
• Consider admission if hypoxic, confused, hypotensive, elderly, frail or high risk.

If pulmonary embolism is suspected

• Assess haemodynamic stability.
• Give oxygen if hypoxaemic.
• Assess PE probability using local protocol.
• Arrange D-dimer or imaging according to probability.
• Consider anticoagulation according to local protocol if PE is likely or imaging is delayed.
• Escalate urgently if hypotension, syncope, shock or severe hypoxia is present.

If pneumothorax is suspected

• Assess severity and oxygen saturation.
• Give oxygen if hypoxaemic.
• Request urgent chest X-ray if stable.
• If tension pneumothorax is suspected, call for immediate senior help and decompress according to emergency protocol.
• Definitive management may require aspiration or chest drain depending on size, symptoms and local guideline.

If heart failure or pulmonary oedema is suspected

• Sit the patient upright.
• Give oxygen if hypoxaemic.
• Perform ECG and chest X-ray.
• Check BNP or NT-proBNP where appropriate.
• Give diuretics according to local protocol if fluid overloaded.
• Consider nitrates if hypertensive pulmonary oedema and not contraindicated.
• Consider non-invasive ventilation if severe respiratory distress or hypoxaemia persists.
• Treat precipitating causes such as ACS, arrhythmia or infection.

If anxiety or panic is suspected

• First exclude dangerous causes based on history, examination and observations.
• Reassure calmly.
• Encourage slow breathing.
• Assess mental health and triggers.
• Provide follow-up and safety-net advice.
• Do not label breathlessness as anxiety without appropriate assessment.

Safety-net advice

• Seek urgent help for worsening breathlessness.
• Seek urgent help for chest pain.
• Seek urgent help for blue lips, confusion or collapse.
• Seek urgent help for coughing blood.
• Seek urgent help for severe wheeze or poor response to inhaler.
• Seek urgent help for unilateral leg swelling with breathlessness.
• Return for persistent fever, weight loss or night sweats.

7. Examiner Questions

1. What are the life-threatening causes of acute shortness of breath?
2. What red flags would you ask about?
3. How would you assess severity?
4. What features suggest asthma?
5. What features suggest COPD exacerbation?
6. What features suggest pneumonia?
7. What features suggest pulmonary embolism?
8. What features suggest pneumothorax?
9. What features suggest heart failure?
10. What bedside tests would you do first?
11. When would you request a blood gas?
12. What is the role of chest X-ray?
13. How would you manage acute severe breathlessness?
14. How should oxygen be prescribed?
15. Why should you be careful with oxygen in COPD?

Suggested short answers

8. OSCE Pearls

• Shortness of breath is assessed by severity first, diagnosis second.
• Check whether the patient can speak in full sentences.
• Respiratory rate is a vital sign; do not ignore it.
• Always check oxygen saturation.
• Ask about chest pain, haemoptysis, syncope and unilateral leg swelling.
• Sudden onset suggests PE, pneumothorax or ACS.
• Wheeze suggests asthma or COPD, but can occur in heart failure.
• Orthopnoea and ankle swelling suggest heart failure.
• Pleuritic chest pain suggests PE, pneumonia, pleurisy or pneumothorax.
• Normal chest examination does not exclude PE or metabolic causes.
• Oxygen is for hypoxaemia, not for breathlessness alone.
• Consider controlled oxygen and blood gas in COPD.
• Do not diagnose anxiety until serious causes are considered.
• Escalate early if the patient is hypoxic, confused, hypotensive or exhausted.

9. Example Presentation to Examiner

10. References

• NICE Clinical Knowledge Summary: Breathlessness.
• British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings.
• BTS/NICE/SIGN guideline on asthma diagnosis, monitoring and management.
• Local emergency medicine, respiratory and oxygen therapy protocols.
• Standard undergraduate respiratory examination and OSCE teaching resources.