BREATHLESSNESS

Definition
• Breathlessness is an unpleasant sensation of uncomfortable, rapid or
difficult breathing. People say they feel puffed, short of breath or winded.
The medical term is dyspnoea. Your chest may feel tight and breathing
may hurt. Everyone can experience breathlessness if they run for a bus or
exert themselves to an unusual extent. But it is important to seek medical
attention if you experience breathlessness, as it may be due to a serious
underlying problem

• Undue awareness of breathing and is normal with strenuous physical

exercise
• Sense of awareness of increased respiratoryeffort that is unpleasant and that
is recognizedby the patient as being inappropriate
• Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable
need to breathe..
• Patients use terms such as ‘shortness of breath’,difficulty getting enough air in’,
‘tiredness’,‘difficult, laboured, uncomfortable breathing;it is an unpleasant type of
breathing, though it isnot painful in the usual sense of the word’
MRC (medical research council)Dyspnoea Scale
Grade Degree of breathlessness related to activity

1 Not troubled by breathlessness except on strenuous exercise

Short of breath when hurrying on a level or when walking up a slight hill

2

Walks slower than most people on the level, stops after a mile (1.6 km) or so,
3 or stops after 15 minutes walking at own pace

Stops for breath after walking 100 yards (90 m), or after a few minutes
4 on level ground

Too breathless to leave the house, or breathless when

5 dressing/undressing
 New York Heart Association (NYHA)
Functional Classification
Grade Symptoms

Grade 1 ( Mild ) No limitation on physical activity. Ordinary physical activity doesn't cause undue
fatigue, palpitation, dyspnoea

Slight limitation of physical activity. Comfortable at rest but

Grade 2 ( Mild ) ordinary physical activity results in fatigue, palpitation,

dyspnoea.

Marked limitation of physical activity. Comfortable at rest. Less than

Grade 3 ( Moderate ) ordinary activity causes fatigue, palpitation, or dyspnea.

Unable to carry out any physical activity without discomfort. Dyspnoea present
Grade 4 ( Severe ) at rest, if any physical activity is undertaken the discomfort increases.
 Common Causes

System Acute dyspnoea

Cardiovascular Acute pulmonary oedema

Acute severe asthma

Acute exacerbation of COPD

Pneumothorax
Respiratory
Pneumonia

Pulmonary embolus

ARDS

Inhaled foreign body

Lobar collapse

Laryngeal oedema

Metabolic acidosis
Others
Psychogenic hyperventilation
 Common Causes
System Chronic exertional dyspnoea

Chronic heart failure

Cardiovascular
Myocardial ischaemia

COPD

Chronic asthma
Respiratory Bronchial carcinoma

Interstitial lung disease

Chronic pulmonary thromboembolism

Lymphatic carcinomatosis

Large pleural effusions

Severe anaemia
Others Obesity

Deconditioning
• Patient's details :
 Name
 Age
 Sex
 Occupation : paint sprayers, History taking
rubber industry workers are
prone to lung disease
 Address
 Date of Admission
History • Chief Complaints
oShortness of breath for how many days
taking / weeks

• History of Presenting Illness oOnset :

gradual/sudden
• oProgression : worsen/better
• oSeverity : NYCA/MRCA grading

oDiurnal variability : worsen at night /

morning- asthma

oPostural variability : orthopnoea ,

oAggravating factors : pollen, dust, cold

climate - asthma, sinusitis

oRelieving factors : rest, medication

 • Associated symptoms :
History a) Cough : yes/no
oIf yes , onset/duration/progression -
chronic cough - bronchiectasis
taking oFrequency, severity
oDiurnal variability - might indicate
asthma
oPostural variability - might indicate
bronchiectasis
oProductive/ dry cough

b) Sputum :
oHow much? Frequency? - Copious sputum
suggestive of bronchiectasis
oColour? – White (viral) , yellowish
(bacteria), rusty (pneumonia)

oConsistency

oFoul smell? - Suggestive of bronchiectasis,

suppurative lung disease
History
• Associated symptoms :
c) Haemoptysis :
oDuration, onset, progression

taking oAmount of blood?

oAssociated with melena or epistaxis?
oMight be due to malignancy

d) Chest pain :
oOnset, duration, progression
oSite? Bilateral/ unilateral
oType of pain
oRadiating - CVS pathology
oPain on deep inspiration, pain relief when lie
on same side- pleuritic chest pain
History
• Associated symptoms:
e) Fever :
oOnset, progression, duration
taking oAssociated with chills or rigor,
night sweats
oHigh / low grade
oEvening rise of temp - TB
f) Wheezing – asthma
g) Weight lost - TB, malignancy
h) Palpitation - CVS pathology
i) Sinusitis
j) Rhinitis
 • Past History :
History oHistory of TB, Measle/whopping cough, Asthma/
allergy, IHD, chest trauma/ surgery , similar
complains, DM/HTN

taking • Personal History :

oDiet, Addiction, Bowel/Bladder
movement, Sleep, Appetite
oSmoking- highly ass with Emphysema
oAlcoholism - Aspiration Pneumonia
oLost of appetite & weight - TB,
Malignancy
• Family History :
oAsthma, TB, Cystic Fibrosis,
Malignancy
oAnyone with similar complaints
Abnormalities on Physical
Examination
 General Physical Examination
• BMI –
• Normal : 18.5 – 22.9 ( Asian )
18.5 – 24.9 ( Non-Asian )
• Obesity might be the cause of the
breathlessness
oExtra weight in the chest and
abdomen

Increased work load on muscles that

control breathing
 Head to Toe Examination
1. Nails and Hands
 Pallor ( Left Heart Failure ,COPD)
 Cyanosis ( Cardiac Failure , COPD , Pulmonary oedema )
 Clubbing ( Carcinoma of Bronchus , Pulmonary Fibrosis
,Bronchiectasis , Lung Abscess , Pleural Empyema )
 Koilonychia ( Anaemia )

2 Neck :
 JVP increased ( Right Heart Failure caused by Chronic Pulmonary Hypertension in
severe lung disease such as COPD )

3. Face :
 Eyes – Pallor ( Anaemia )
 Lips and Tongue – Cyanosis ( Cardiac Failure , COPD )
oIndicate poor oxygenation of blood

4. Lower limb :
 Pitting Pedal Oedema
oUnilateral – DVT
oBilateral – Congestive Heart Failure
 Respiratory System Examination
 Auscultation
• Stridor ( Laryngeal Oedema ,
Foreign bodies )
• Diminished Vesicular Breath
Sounds ( Obesity , Pleural
Effusion , Pneumothorax , COPD , Lung
collapse )
• Bronchial Breath Sounds ( Lung
consolidation in pneumonia )
• Vocal Resonance ( over
consolidated lung , the spoken
numbers are clearly audible but
over an effusion or collapse they are
muffled )
• Rhonchi / Wheeze ( COPD ,
Bronchial Asthma )
• Pleural Rub ( Pneumonia , TB )
• Crackles
 Examination Sequence
1. Note the patient’s general muscles.
appearance and demeanour.
2. Look for central cyanosisof 10. Inspect the chest front and back
the for abnormalities of shape and
lips and tongue. scars.
3. Examine the skin for rashes and 11. Feel the trachea and cardiac apex
nodules. beat for evidence of mediastinal
4. Listen for hoarseness and stridor. shift.
5. Examine the hands for finger 12. Percuss the chest front and back
clubbing, peripheral cyanosis and for areas of dullness or
tremor. hyperresonance.
6. Measure the bloodpressure. 13. Listen to the chest front and back
7. Examine the neck for raised JVP for alteredbreath sounds and added
and cervical lymphadenopathy. sounds.
8. Record the respiratory rate. Certain groups of physical signs are
9. Observe the breathing pattern, typically associated with particular
and look for use of accessory
pathological changes in the lungs.
Differential diagnosis

Develop differential diagnosis in a patient with

breathlessness based on history and examination
Differential Diagnosis
 Bedside investigations
Pulse Oximetry Peak Flow Rate

•A spectrophotometric device that • Person's maximum speed of

measures arterial oxygen saturation expiration.
by determining the differential
• Normal test results depends on age
absorption of light by
oxyhaemoglobin and year gender and sometimes
deoxyhaemoglobin . occupation.
• This allows detection and ongoing • Helps to differentiate between
monitoring of hypoxaemia with pulmonary and cardiac causes of
initiation of oxygen supplementation dyspnoea. Low peak flow rates are
as necessary, while undertaking associated with obstructive lung
diagnostic work-up for its cause disease such as asthma, COPD, and
cystic fibrosis.
• Normal: 80-100 per cent of usual
flow
rate.
 Radiology
Chest X-Ray
• To determine the lobe / area in
which the lung is affected.
• Make out any cardiomegaly in the
PA view of the x-ray
• Check for any fluid / consolidation
of the lungs.
• Check for any structural damage
such as a broken rib
Chest fluoroscopy / Sniff test
• Determines how well lungs,
diaphragm, or other parts of your
chest are working.
• Uses more radiation than a
standard
chest X-ray.
• It detects the movement of the
diaphragm when the patient breathes.
• Hence able to detect any abnormal
diaphragmatic conditions.
Treatment

MANAGEMENT OF
BREATHLESSNESS
 Pharmacological
• The treatment of breathlessness is complex. It depends on the underlying
causes.
• Opioids-either oral or parenteral-are now considered to be the
gold standard in reducing ventilator demand. A slow release
preparation of morphine has been found to be beneficial
• Anxiolytics such as benzodiazepines may assist in the anxiety
component of breathlessness. However, these may be poorly
tolerated in some patients, especially in those with liver failure.
• Long acting beta agonists may be beneficial in breathlessness due to
COPD in reducing the work of breathing.
• Bronchodilators help in relaxing muscles and improving muscle tone
in the airways.
 Oxygen Treatment

• Evidence have shown oxygen treatment is of no use in a patient

with breathlessness WITHOUT hypoxia.
• Otherwise, high flow oxygen of >60 percent is used except
in COPD patients.
 Non-pharmacological

• There does seem to be a relationship between anxiety and

breathlessness, however, which one comes first is difficult to tell.
Strategies such as relaxation training and distraction do seem to help as
do cognitive behavioural therapies.
• Controlled breathing exercises and techniques such as an upright leaning
forward position and pursed lip breathing are also beneficial therapies.
• Chest wall vibration, neuro-electrical muscle stimulation, walking
aides, and breathing training.
 There are some breathing control techniques that can help to reduce
breathlessness. Examples include:
• Relaxed, slow, deep breathing: breathe in gently through your nose and
breathe out through your nose and mouth. Try to stay feeling relaxed and
calm.
• Paced breathing: this may help when you are walking or climbing stairs.
Try to breathe in rhythm with your steps at a speed you find comfortable.
• Controlled breathing. This involves using your diaphragm and lower chest
muscles to breathe instead of your upper chest and shoulder muscles.
Breathe gently and keep your shoulders and upper chest muscles relaxed.
 Use different comfortable seating and standing positions when you feel
breathless. Different positions suit different people but examples include:

• When standing up, lean from the hips with your forearms resting on
something at a comfortable height, such as a chair or kitchen work surface.
• When standing put your hands on your waist or in your back pockets.
• When sitting, lean forwards, resting your forearms on your knees, on the
arms of a chair, or on a table.

 Arrange the things you use every day to make sure they are easy to reach.
Try to stay active but take a rest when you feel breathless and then start
again.
 Avoidance/prevention
• Quit smoking, alcohol
• Weight loss
• Regular exercise
• Avoid going to areas with dust, smoke, air pollution
• Cholesterol management
• Bp management
• Diabetes control
• diet
Thank you