Shortness of breath

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MRC breathlessness scale
)
Shortness of breath
Other namesDyspnea, dyspnoea, breathlessness, difficulty (in/of) breathing; respiratory distress
Pronunciation
SpecialtyPulmonology

Shortness of breath (SOB), also medically known as dyspnea (in

BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity", and recommends evaluating dyspnea by assessing the intensity of its distinct sensations, the degree of distress and discomfort involved, and its burden or impact on the patient's activities of daily living. Distinct sensations include effort/work to breathe, chest tightness or pain, and "air hunger" (the feeling of not enough oxygen).[1] The tripod position
is often assumed to be a sign.

Dyspnea is a normal

congestive heart failure, chronic obstructive pulmonary disease, or psychogenic causes,[2][3] such as panic disorder and anxiety.[4] The best treatment to relieve or even remove shortness of breath[5] typically depends on the underlying cause.[6]

Definition

Dyspnea, in medical terms, is "shortness of breath". The American Thoracic Society defines dyspnea as: "A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity."[7] Other definitions also describe it as "difficulty in breathing",[8] "disordered or inadequate breathing",[9] "uncomfortable awareness of breathing",[3] and as the experience of "breathlessness" (which may be either acute or chronic).[2][6][10]

Differential diagnosis

While shortness of breath is generally caused by disorders of the

congestive heart failure while common pulmonary causes include chronic obstructive pulmonary disease, asthma, pneumothorax, pulmonary edema and pneumonia.[2] On a pathophysiological basis the causes can be divided into: (1) an increased awareness of normal breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3) an abnormality in the ventilatory or respiratory system.[11]
Ischemic strokes, hemorrhages, tumors, infections, seizures, and traumas at the brain stem can also cause shortness of breath, making them the only neurological causes of shortness of breath.

The tempo of onset and the duration of dyspnea are useful in knowing the etiology of dyspnea. Acute shortness of breath is usually connected with sudden physiological changes, such as

laryngeal edema, bronchospasm, myocardial infarction, pulmonary embolism, or pneumothorax. Patients with COPD and idiopathic pulmonary fibrosis (IPF) have a mild onset and gradual progression of dyspnea on exertion, punctuated by acute exacerbations of shortness of breath. In contrast, most asthmatics do not have daily symptoms, but have intermittent episodes of dyspnea, cough, and chest tightness that are usually associated with specific triggers, such as an upper respiratory tract infection or exposure to allergens.[14]

Acute coronary syndrome

cardiac enzymes are important both for diagnosis and directing treatment.[15] Treatment involves measures to decrease the oxygen requirement of the heart and efforts to increase blood flow.[2]

COVID-19

People that have been infected by

COVID-19 may have symptoms such as a fever, dry cough, loss of smell and taste, and in moderate to severe cases, shortness of breath.[citation needed
]

Congestive heart failure

abnormal heart rhythms, kidney failure, pulmonary emboli, hypertension, and infections.[15] Treatment efforts are directed towards decreasing lung congestion.[2]

Chronic obstructive pulmonary disease

People with

Asthma

wheezing, tightness in the chest, and a non productive cough.[2]
Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate.[16] Acute symptoms are treated with short-acting bronchodilators.[citation needed]

Pneumothorax

jugular venous distension, and tracheal deviation.[2]

Pneumonia

The symptoms of

antibiotics are typically used for treatment.[2]

Pulmonary embolism

anticoagulants; the presence of ominous signs (low blood pressure) may warrant the use of thrombolytic drugs.[2]

Anemia

Anemia that develops gradually usually presents with exertional dyspnea, fatigue, weakness, and tachycardia.[17] It may lead to heart failure.[17] Anaemia is often a cause of dyspnea. Menstruation, particularly if excessive, can contribute to anaemia and to consequential dyspnea in women. Headaches are also a symptom of dyspnea in patients with anaemia. Some patients report a numb sensation in their head, and others have reported blurred vision caused by hypotension behind the eye due to a lack of oxygen and pressure; these patients have also reported severe head pains, many of which lead to permanent brain damage. Symptoms can include loss of concentration, focus, fatigue, language faculty impairment and memory loss.[18][citation needed]

Cancer

Shortness of breath is common in people with cancer and may be caused by numerous different factors. In people with advanced cancer, periods of time with severe shortness of breath may occur, along with a more continuous feeling of breathlessness.[19] Treatments include both nonpharmacological and pharmacological interventions. Nonpharmacological interventions that showed improvement in breathlessness include fans, behavioral and pyschoeducational approaches, exercise and pulmonary rehabilitation. Integrative medicine options including acupuncture/acupressure/reflexology, meditation and music therapy were also used, with acupuncture/reflexology found to have a beneficial effect.[20]

Other

Other important or common causes of shortness of breath include cardiac tamponade, anaphylaxis, interstitial lung disease, panic attacks,[6][12][17] and pulmonary hypertension. Also, around 2/3 of women experience shortness of breath as a part of a normal pregnancy.[9]

Cardiac tamponade presents with dyspnea, tachycardia, elevated jugular venous pressure, and pulsus paradoxus.[17] The gold standard for diagnosis is ultrasound.[17]

Anaphylaxis typically begins over a few minutes in a person with a previous history of the same.

urticaria, throat swelling, and gastrointestinal upset.[6] The primary treatment is epinephrine.[6]

Interstitial lung disease presents with gradual onset of shortness of breath typically with a history of a predisposing environmental exposure.

Panic attacks typically present with hyperventilation, sweating, and numbness.[6] They are however a diagnosis of exclusion.[12]

Neurological conditions such as spinal cord injury, phrenic nerve injuries,

amyotrophic lateral sclerosis, multiple sclerosis and muscular dystrophy can all cause an individual to experience shortness of breath.[11] Shortness of breath can also occur as a result of vocal cord dysfunction (VCD).[21]

Sarcoidosis is an inflammatory disease of unknown etiology that generally presents with dry cough, fatigue, and shortness of breath, although multiple organ systems may be affected, with involvement of sites such as the eyes, the skin and the joints.[22]

Pathophysiology

Different physiological pathways may lead to shortness of breath including via ASIC chemoreceptors, mechanoreceptors, and lung receptors.[15]

It is thought that three main components contribute to dyspnea: afferent signals, efferent signals, and central information processing. It is believed the central processing in the brain compares the afferent and efferent signals; and dyspnea results when a "mismatch" occurs between the two: such as when the need for ventilation (afferent signaling) is not being met by physical breathing (efferent signaling).[23]

Afferent signals are sensory neuronal signals that ascend to the brain. Afferent neurons significant in dyspnea arise from a large number of sources including the

Muscle spindles in the chest wall signal the stretch and tension of the respiratory muscles. Thus, poor ventilation leading to hypercapnia, left heart failure leading to interstitial edema (impairing gas exchange), asthma causing bronchoconstriction (limiting airflow) and muscle fatigue leading to ineffective respiratory muscle action could all contribute to a feeling of dyspnea.[23]

Efferent signals are the motor neuronal signals descending to the respiratory muscles. The most important respiratory muscle is the diaphragm. Other respiratory muscles include the external and internal intercostal muscles, the abdominal muscles and the accessory breathing muscles.[25]

As the brain receives its plentiful supply of afferent information relating to ventilation, it is able to compare it to the current level of respiration as determined by the efferent signals. If the level of respiration is inappropriate for the body's status then dyspnea might occur. There is also a psychological component to dyspnea, as some people may become aware of their breathing in such circumstances but not experience the typical distress of dyspnea.[23]

Diagnosis

MRC breathlessness scale
Grade Degree of dyspnea
1 no dyspnea except with strenuous exercise
2 dyspnea when walking up an incline or hurrying on the level
3 walks slower than most on the level, or stops after 15 minutes of walking on the level
4 stops after a few minutes of walking on the level
5 with minimal activity such as getting dressed, too dyspneic to leave the house

The initial approach to evaluation begins by assessment of the

sternocleidomastoid, scalenes) and absent breath sounds.[12]

A number of scales may be used to quantify the degree of shortness of breath.

Borg Scale).[26] The MRC breathlessness scale suggests five grades of dyspnea based on the circumstances and severity in which it arises.[27]

Blood tests

A number of labs may be helpful in determining the cause of shortness of breath.

brain natriuretic peptide is useful in ruling out congestive heart failure; however, a high level, while supportive of the diagnosis, could also be due to advanced age, kidney failure, acute coronary syndrome, or a large pulmonary embolism.[15]

Imaging

A

radiocontrast is the imaging study of choice to evaluate for pulmonary embolism.[15]

Treatment

The primary treatment of shortness of breath is directed at its underlying cause.

hypoxia; however, this has no effect in those with normal blood oxygen saturations.[3][28]

Physiotherapy

Individuals can benefit from a variety of

ventilation.[30] Some physical therapy interventions for this population include active assisted cough techniques,[31] volume augmentation such as breath stacking,[32] education about body position and ventilation patterns[33] and movement strategies to facilitate breathing.[32] Pulmonary rehabilitation may alleviate symptoms in some people, such as those with COPD, but will not cure the underlying disease.[34][35] Fan therapy to the face has been shown to relieve shortness of breath in patients with a variety of advanced illnesses including cancer.[36]
The mechanism of action is thought to be stimulation of the trigeminal nerve.

Palliative medicine

Systemic immediate release

Non-pharmacological techniques

Pharmacological treatment

For people with severe, chronic, or uncontrollable breathlessness, non-pharmacological approaches to treating breathlessness may be combined with medication. For people who have cancer that is causing the breathlessness, medications that have been suggested include opioids, benzodiazepines, oxygen, and steroids.[19] Results of recent systematic reviews and meta-analyses found opioids were not necessarily associated with more effectiveness in treatment for patients with advanced cancer.[39][40]

Ensuring that the balance between side effects and adverse effects from medications and potential improvements from medications needs to be carefully considered before prescribing medication.[19] The use of systematic corticosteriods in palliative care for people with cancer is common, however the effectiveness and potential adverse effects of this approach in adults with cancer has not been well studied.[19]

Epidemiology

Shortness of breath is the primary reason 3.5% of people present to the

palliative care visit an emergency department.[3] Up to 70% of adults with advanced cancer also experience dyspnoea.[19]

Etymology and pronunciation

English dyspnea comes from

combining forms (dys- + -pnea) are familiar from other medical words, such as dysfunction (dys- + function) and apnea (a- + -pnea). The most common pronunciation in medical English is /dɪspˈnə/ disp-NEE, with the p expressed and the stress on the /niː/ syllable. But pronunciations with a silent p in pn (as also in pneumo-) are common (/dɪsˈnə/ or /ˈdɪsniə/),[44] as are those with the stress on the first syllable[44] (/ˈdɪspniə/ or /ˈdɪsniə/
).

In English, the various -pnea-suffixed words commonly used in medicine do not follow one clear pattern as to whether the /niː/ syllable or the one preceding it is stressed; the p is usually expressed but is sometimes silent depending on the word. The following collation or list shows the preponderance of how major dictionaries pronounce and transcribe them (less-used variants are omitted):

Group Term Combining forms Preponderance of transcriptions (major dictionaries)
good eupnea eu- + -pnea /jpˈnə/ yoop-NEE[45][46][44][47]
bad
dyspnea
dys- + -pnea /dɪspˈnə/ disp-NEE,[46][47][48] /ˈdɪspniə/ DISP-nee-ə[45][44]
fast tachypnea tachy- + -pnea /ˌtækɪpˈnə/ TAK-ip-NEE[45][46][44][47][48]
slow bradypnea brady- + -pnea /ˌbrdɪpˈnə/ BRAY-dip-NEE[46][44][47]
upright orthopnea ortho- + -pnea /ɔːrˈθɒpniə/ or-THOP-nee-ə,[46][44][48][45]: audio  /ɔːrθəpˈnə/ or-thəp-NEE[44][45]: print 
supine platypnea platy- + -pnea /pləˈtɪpniə/ plə-TIP-nee-ə[45][46]
bent over bendopnea bend + -o- + -pnea /bɛndˈɒpniə/ bend-OP-nee-ə
excessive hyperpnea hyper- + -pnea /ˌhpərpˈnə/ HY-pərp-NEE[45][46][44][47]
insufficient hypopnea hypo- + -pnea /hˈpɒpniə/ hy-POP-nee-ə,[45][46][47][48] /ˌhpəpˈnə/ high-pəp-NEE[44][47]
absent apnea a- + -pnea /ˈæpniə/ AP-nee-ə,[45][46][44][47][48]: US  /æpˈnə/ ap-NEE[44][47][48]: UK 

See also

References

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External links

Shortness Of Breath (Dyspnea)StatPearls