We are grateful for the helpful and important comments. Undoubtedly, continued diagnostics should only be performed upon considering the patient. In this respect, we thank Dr. Thöns for emphasizing that, especially at the end of life, overdiagnoses can be a burden rather than a meaningful explanation of cause that leads to therapy. Assessing whether diagnostics and the corresponding therapy, including inpatient care, are meaningful is one of the primary tasks of medical practice. This ethical question must be, and should be, asked on a daily basis and precedes any diagnostic activity. Our CME article aims to transmit the various diagnostic possibilities within a framework of acute or chronic dyspnea symptoms, with the assumption that a diagnosis is either desired by the patient or appears to be medically necessary under the circumstances.
Dr. Thöns also points out that CME articles are responsible for conveying the current state of knowledge to younger colleagues. Indeed, the use of the CRB-65 score, an internationally recognized and applied tool, can also be viewed in this context. Notably, younger colleagues frequently work in emergency departments, where they have to make rapid decisions about further diagnoses and therapies. Valid scores have the task of supporting such decision-making processes and providing assistance; they do not, of course, release the physicians from medical responsibilities that should be based on ethical considerations.
The other two authors likewise highlight an important point: the causes of dyspnea symptoms are manifold and require a collective observation. Thus, chronic dyspnea in pediatric patients is not likely to be caused by chronic obstructive pulmonary disease (COPD). Unfortunately, not all differential diagnoses can be broadly discussed in the limited scope of a journal article. In order to take this point into account, we provided a comprehensive description of the causes of dyspnea in eTable 2. Ketoacidosis and other metabolic causes are also listed here. A nephrogenic cause of dyspnea is not one of the most common causes according to the currently available literature—but it should always be taken into account for geriatric patients. However, renal failure is often only a secondary expression of an underlying disease, such as cardiac decompensation. Unfortunately, this detailed table could not be included in the printed version of the article. Finally, due to the expertise of the authors, the article focuses on the daily routine of patients in the adult age group. A similar article on dyspnea in children and adolescents could certainly be a useful supplement.
On behalf of the authors:
Dr. med. Dominik Berliner
Prof. Dr. med. Johann Bauersachs
Klinik für Kardiologie und Angiologie
Medizinische Hochschule Hannover, Germany
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
|1.||Berliner D, Schneider N, Welte T, Bauersachs J: The differential diagnosis of dyspnoea. Dtsch Arztebl Int 2016; 113: 834–45. VOLLTEXT|