Private breathlessness clinic in London, same-day respiratory.

What the pattern tells you

• Worse lying flat, better sitting up, or waking you at night gasping — points to the heart.
• With wheeze, worse at night or with exercise, cold air or allergens — points to asthma.
• Gradual over months to years, in a smoker, with a productive cough — points to COPD.
• Sudden, sharp, one-sided — points to a collapsed lung or clot.
• With pallor and fatigue, worse on stairs — points to anaemia.
• At rest but not on exertion, with tingling around the mouth and hands — points to hyperventilation and anxiety.
• Only on exertion, with chest tightness relieved by rest — may be angina presenting as breathlessness.

The common causes

• Asthma and COPD
• Heart failure, and angina or heart attack
• Anaemia — particularly iron deficiency, very common and easily missed
• Chest infection, and pulmonary embolism
• Anxiety and hyperventilation — a genuine cause, and a diagnosis of exclusion rather than assumption
• Obesity and deconditioning, which are common and improvable
• Thyroid disease, sleep apnoea, and long COVID
• less commonly: interstitial lung disease, pulmonary hypertension, and pleural effusion

What assessment involves

• Oxygen saturation, pulse, blood pressure and respiratory rate
• Examination of heart, lungs and legs
• ECG, and echocardiography where the heart is in question
• Blood tests — full blood count, ferritin, kidney function, thyroid, and NT-proBNP for heart failure
• Spirometry for suspected asthma or COPD
• Chest X-ray, and CT where indicated
• D-dimer where a clot is being considered

Breathing pattern disorder

Some people develop an inefficient breathing pattern — upper chest rather than diaphragm, frequent sighing, breath-holding — often after an illness, anxiety or long COVID. It causes real breathlessness, dizziness and tingling despite normal lungs and heart. It is diagnosed after excluding other causes and responds well to breathing retraining with a physiotherapist, which is a specific treatment rather than a dismissal.