Dyspnoea

Original Editor -Safiya NazTop Contributors - Safiya Naz, Lucinda hampton and Kim Jackson

Introduction

Dyspnea 01.png

Dyspnoea (also is known as dyspnea, shortness of breath or breathlessness) is a subjective awareness of the sensation of uncomfortable breathing[1]

  • Dyspnoea represents one of the most frequent cardinal symptoms in general practice and interdisciplinary emergency care across all sectors[2]
  • It is a sensation of running out of the air and of not being able to breathe fast enough or deeply enough[3]
  • Is a subjective sensation which probably develops as a result of the integration of signals from the central nervous system and some peripheral receptors.
  • Known dyspnoeic stimuli include the sensation of an increased effort of the respiratory muscles; information from chemoreceptors on the inadequacy of ventilation; from pulmonary receptors on the compression of the airways; disharmony between information on the tension of the respiratory muscles and the corresponding shortening of the muscle.[4]

Mechanism

There is no universal theory that explains the mechanism of Dyspnoea in all clinical situations[5]

  • In the 1960s Campbell and Howell first introduced the theory of length-tension appropriateness to explain the sensation of Dyspnoea originating from the inappropriate response of the respiratory system to the outgoing motor command[5]
  • More recently this theory has been redefined and a mechanism based on a neuro-ventilatory dissociation has been proposed[6].[7][8]
  • The sensation of Dyspnoea seems to originate with the activation of sensory systems involved in respiration. Sensory information is, in turn, relayed to higher brain centres where central processing of respiratory-related signals and contextual, cognitive and behavioural influences shape the ultimate expression of the evoked sensation. The homeostatic systems involved in the regulation of respiration provide a framework for understanding the mechanisms of dyspnea[9]

The neural basis of dyspnea is likely to involve activation of both the cortex and the limbic system[10]

  • Dyspnoea is a heightened level of awareness of respiratory sensation and has a strong emotional component.
  • Healthy subjects can experience Dyspnoea in different situations, e.g. at high altitude, after breath-holding, during stressful situations that cause anxiety or panic, and more commonly during strenuous exercise.
  • Many factors play an important role in the mechanisms of dyspnea: functional status or respiratory muscles, mechanical and chemical afferents, central motor output.[6]

Types

  1. Orthopnea - it is the sensation of dyspnoea in the recumbent position, relieved by sitting or standing.
  2. Paroxysmal nocturnal dyspnea (PND) - it is a sensation of dyspnoea that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.
  3. Trepopnea - it is a sensation of dyspnoea that occurs in one lateral decubitus position as opposed to the other.
  4. Platypnea - it is a sensation of dyspnoea that occurs in the upright position and is relieved with recumbency.[11]

Clinical Presentation

Some characteristics of a sensation of Dyspnoea with different disorders; these are guidelines only, and patients vary Disorder.

COPD

Asthma

Interstitial lung disease

Pneumonia

Pneumothorax

Hyperventilation

Pulmonary oedema

Neuromuscular

Deconditioning

Obesity/pregnancy

Slow onset

Episodic, on exhalation

Progressive, exertional

Exertional

Moderate/severe

Air hunger, not relieved by rest

Positional, on inhalation

Exertional, on inhalation

Heavy

Exertional [12]

Diagnostic Procedures

History Examination

The history and physical exam should ascertain whether there are any ongoing cardiovascular, pulmonary, musculoskeletal, or psychiatric illnesses. Key components of the history to collect include onset, duration, and occurrence with rest or exertion.

  • A patient with dyspnoea may say: "I feel short of breath," "I"m having difficulty breathing," "I can"t catch my breath," "I feel like I"m suffocating." Because it is a subjective phenomenon, the perception of dyspnoea and its interpretation vary from patient to patient. Begin with a nonleading question:
  • Do you have any difficulty breathing? If the response is affirmative and dyspnoea is established as a problem, it should be characterized in detail. When did it begin? Has the onset been sudden or insidious? Inquire about the frequency and duration of attacks.
  • The conditions in which dyspnoea occurs should be ascertained. Response to activity, emotional state, and change of body position should be noted. Ask about associated symptoms: chest pain, palpitations, wheezing or coughing. Sometimes a nonproductive cough may be present as a " dyspnoea equivalent." What other significant medical problems does the patient have, and what medications has he been taking? How much has he smoked?
  • Additional questions should be aimed at ascertaining whether the patient has orthopnea or paroxysmal nocturnal dyspnoea.
  • Inquire about the number of pillows he uses under his head at night and whether he has ever had to sleep sitting up. Does he develop coughing or wheezing in the recumbent position? Did he ever wake up at night with shortness of breath? How long after lying down did the episode occur, and what did he do to relieve his distress?
  • Characteristically, the patient with left ventricular failure sits up at bedside, dangles his feet, and refrains from ambulation or other activity that is likely to worsen his symptoms[11]

Physical Examination

  • Physical exam should begin with a rapid assessment of the ABCs (airway, breathing, and circulation).
  • Once a patient is determined to be stable, a full physical exam can be done.
  • To determine the severity of dyspnoea, observe respiratory effort, use of accessory muscles, mental status, and speaking ability.
  • Distention of the neck veins implies cor pulmonale caused by severe COPD, congestive heart failure, or cardiac tamponade.
  • Thyromegaly may indicate hyperthyroidism or Hypothyroidism. The tracheal deviation may indicate possible anatomic abnormality or pneumothorax.
  • Auscultate for stridor in the upper airways indicates obstructed airway. Palpation of the chest can determine the presence of subcutaneous emphysema or crepitus. Percussion of the lung lobes for dullness can determine the presence or absence of consolidation and effusion.
  • Hyperresonance on percussion is a worrisome finding that indicates possible pneumothorax or severe bullous Emphysema.
  • Lung Auscultation may reveal absent breath sounds indicating the presence of pneumothorax or region occupying mass such as pleural effusion or malignancy.
  • The presence of wheezing is highly consistent with the diagnosis of obstructive lung diseases such as asthma or COPD.  However, wheezing may be associated with pulmonary oedema or pulmonary embolism. Pulmonary oedema and pneumonia may present with rales on auscultation.
  • Auscultation of the heart may reveal the presence of dysrhythmia, cardiac murmurs, or aberrant heart gallops. An S3 gallop indicates cardiac overfilling seen in left ventricular systolic dysfunction and congestive heart failure. An S4 gallop suggests left ventricular dysmotility and dysfunction. A loud P2 indicates possible pulmonary hypertension. Murmurs may indicate valvular dysfunction. Diminished heart sounds may indicate cardiac tamponade.
  • Pericarditis may present with a rubbing cardiac sound on auscultation. On abdominal examination, hepatomegaly, ascites, positive hepatojugular reflux may indicate the diagnosis of congestive heart failure.
  • Lower extremities oedema is associated with congestive heart failure, and extreme swelling of the extremities suggest possible deep venous thrombosis that can lead to a pulmonary embolism. Digits clubbing is present in some forms of lung malignancy or severe chronic hypoxia. Cyanosis of the extremities indicates hypoxia.[13]

Differential Diagnosis

  • Dyspnoea is a symptom of the disease, rather than a disease itself. As such, its aetiology can be designated as arising from four primary categories: respiratory, cardiac, neuromuscular, psychogenic, systemic illness, or a combination of these.
  • Respiratory causes may include asthma, acute exacerbation of or chronic congestive obstructive pulmonary disorder (COPD), pneumonia, pulmonary Embolism, lung malignancy, pneumothorax, or aspiration.
  • Cardiovascular causes may include congestive heart failure, pulmonary oedema, acute coronary syndrome, pericardial tamponade, valvular heart defect, pulmonary hypertension, cardiac arrhythmia, or intracardiac shunting.
  • Neuromuscular causes may include chest trauma with fracture or flail chest, massive Obesity, kyphoscoliosis, central nervous system (CNS) or spinal cord dysfunction, phrenic nerve paralysis, myopathy, and neuropathy.
  • Psychogenic causes may include hyperventilation syndrome, psychogenic dyspnea, vocal cord dysfunction syndrome, and foreign body aspiration.
  • Other systemic illnesses may include anaemia, acute renal failure, metabolic acidosis, thyrotoxicosis, cirrhosis of the liver, anaphylaxis, sepsis, angioedema, and epiglottitis[3]

Physiotherapy Management

  • Breathe.jpg
    Dyspnoea can be either acute or chronic with acute occurring over hours to days and chronic occurring for more than 4 to 8 weeks.[3]
  • Acute dyspnoea is usually a medical emergency and is best managed by an interprofessional team that includes the emergency department physician, internist, pulmonologist, intensivist, radiologist and nurse practitioner. The cause of dyspnoea must be identified and treated, otherwise, the patient may develop respiratory failure and/or death, [3]
  • Acute dyspnoea typically is due to a more life-threatening process and requires rapid intervention. All patients should be placed on supplemental oxygen, pulse oximetry, and a cardiac monitor. Then the appropriate therapy should be initiated based on the suspected or diagnosed aetiology. If Respiratory failure is imminent, there should be a low threshold for intubating patients. Diagnostic workup should be performed only once appropriate, and the patient is stable.[14].
  • Aerobic
  • walking
  • Cycling
  • Diaphragmatic breathing
  • Resistance exercise training[15][16] [17] [18] [19]
  • Breathing pattern retraining is frequently used for exertional dyspnea relief in adults with moderate to severe chronic obstructive pulmonary disease.
  • Many dyspnoeic people automatically assume a posture that eases their breathing, but others need the advice to find the position that best facilitates their inspiratory muscles. Patients with a flat diaphragm may benefit from positions that use pressure from the abdominal contents to dome the muscle and provide some stretch to its fibres so that it can work with greater efficiency. The arms are best supported, to optimize accessory muscle function, but without tension or active fixation.Positions to facilitate efficient breathing in dyspnoeic people include:
  1. High side-lying.
  2. Sitting upright in a chair with supporting arms; for many patients, it is easier to breathe in this position than in bed. Some like to lean back for support, others prefer to lean slightly forward to put some stretch on the diaphragm
  3. Sitting leaning forward from the waist, arms resting on pillows on a table, feet on the floor
  4. Sitting leaning forward from the waist, arms resting on pillows on a table, feet on the floor
  5. Standing relaxed, leaning forwards with arms resting on a support such as a window sill.
  6. Standing relaxed, leaning back against a wall with legs slightly apart.
  7. Standing relaxed leaning sideways against a wall, arms in pockets if support is needed for the accessory muscles.
  8. Occasionally, lying flat is beneficial because of pressure from the abdominal contents against the diaphragm. A few patients even find a slight head-down tip helpful. [12]
  • Pursed Lip Breathing relieve dyspnoea and increasing exercise tolerance, sustained improvement in exertional dyspnoea and physical function[16][20]
  • Evidence from this review indicates that some form of upper limb exercise training when compared to no upper limb training or a sham intervention improves dyspnoea[21]
    [19]

Outcome Measures

Dyspnoea is harmless. However, it is a symptom, not an illness. Therefore, the outcomes are highly variable depending on the exact aetiology and patient demographics[3]

Dyspnea Management Questionnaire (DMQ)[22][23],

Borg Rating Of Perceived Exertion

References

  1. Coccia CB, Palkowski GH, Schweitzer B, Motsohi T, Ntusi NA. Dyspnoea: Pathophysiology and a clinical approach. SAMJ: South African Medical Journal. 2016 Jan;106(1):32-6.
  2. Hauswaldt J, Blaschke S. Dyspnoe. Der Internist. 2017 Sep 1;58(9):925-36.
  3. 3.0 3.1 3.2 3.3 3.4 Sharma S, Hashmi MF, Badireddy M. Dyspnea on Exertion (DOE). StatPearls Publishing 2020 May 23. .
  4. Smejkal V. Dyspnea remains a complicated medical (clinical) problem. Casopis Lekaru Ceskych. 2000 Jan 1;139(1):9-12.
  5. 5.0 5.1 Campbell EJ, Howell JB. The sensation of breathlessness. British Medical Bulletin. 1963 Jan 1;19(1):36-40.
  6. 6.0 6.1 Gigliotti F. Mechanisms of dyspnea in healthy subjects. Multidisciplinary respiratory medicine. 2010 Dec;5(3):1-7.
  7. Gandevia SC. Neural mechanisms underlying the sensation of breathlessness: kinesthetic parallels between respiratory and limb muscles. Australian and New Zealand journal of medicine. 1988 Feb;18(1):83-91.
  8. O'Donnell DE. Breathlessness in patients with chronic airflow limitation: mechanisms and management. Chest. 1994 Sep 1;106(3):904-12.
  9. American Thoracic Society. Dyspnea: mechanisms, assessment, and management: a consensus statement. Am. J. Respir. Crit. Care Med.. 1999;159:321-40.
  10. Buchanan GF, Richerson GB. Role of chemoreceptors in mediating dyspnea. Respiratory physiology & neurobiology. 2009 May 30;167(1):9-19.
  11. 11.0 11.1 Bass JB. Dyspnea. clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition Butterworths 1990.
  12. 12.0 12.1 Alexandra Hough Physiotherapy in respiratory care: An evidence-based approach to respiratory and cardiac management (3rd edition) UK 2001.
  13. Sandeep Sharma, Muhammad F. Hashmi, Madhu Badireddy. Dyspnea on Exertion (DOE). StatPearls Publishing 2020 May 23
  14. Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine. 2012 Feb 15;185(4):435-52.
  15. Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. The Lancet. 1996 Oct 26;348(9035):1115-9.
  16. 16.0 16.1 Puente-Maestu L, Abad YM, Pedraza F, Sánchez G, Stringer WW. A controlled trial of the effects of leg training on breathing pattern and dynamic hyperinflation in severe COPD. Lung. 2006 Jun 1;184(3):159-67.
  17. Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. The Lancet. 1996 Oct 26;348(9035):1115-9.
  18. Puente-Maestu L, Abad YM, Pedraza F, Sánchez G, Stringer WW. A controlled trial of the effects of leg training on breathing pattern and dynamic hyperinflation in severe COPD. Lung. 2006 Jun 1;184(3):159-67.
  19. 19.0 19.1 Breathing Techniques to Manage Dyspnea https://www.youtube.com/watch?v=O4lcEKBMTMg
  20. Watchie J. Cardiovascular and Pulmonary Physical Therapy: A Clinical Manual. Elsevier Health Sciences; 2009 Sep 8.
  21. McKeough ZJ, Velloso M, Lima VP, Alison JA. Upper limb exercise training for COPD. Cochrane Database of Systematic Reviews. 2016(11).
  22. Norweg A, Jette AM, Ni P, Whiteson J, Kim M. Outcome measurement for COPD: reliability and validity of the Dyspnea Management Questionnaire. Respiratory medicine. 2011 Mar 1;105(3):442-53.
  23. Norweg AM, Whiteson J, Demetis S, Rey M. A new functional status outcome measure of dyspnea and anxiety for adults with lung disease: the dyspnea management questionnaire. Journal of Cardiopulmonary Rehabilitation and Prevention. 2006 Nov 1;26(6):395-404.