Breathlessness

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonym: dyspnoea

Breathlessness is the distressing sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand. Breathlessness can be classified by its speed of onset as:[1] 

  • Acute breathlessness: develops over minutes, hours, or days.
  • Chronic breathlessness: develops over weeks or months.

Physiologically, we are all aware of breathlessness when we exercise beyond our normal tolerance but pathologically it can occur with little or no exertion. Afferent sources for the sensation of breathlessness arise from receptors in the upper airway, lungs and chest wall as well as autonomic centres in the brain stem and motor cortex. It is almost always associated with fear and, when chronic, can be disabling and severely diminish quality of life.[2]

Approximately two thirds of cases of dyspnoea in adults are due to a pulmonary or cardiac disorder. In about a third of cases, diagnosis will be multifactorial.[3]

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Acute causes of breathlessness[4]

Chronic causes of breathlessness[3]

Next to pain, breathlessness is the most common symptom for which patients seek help and relief from their doctor. Peak incidence of chronic dyspnoea occurs in the 55 to 69 year-old age bracket.[3] 

History

  • Duration of breathlessness and speed of onset, ie acute, chronic.
  • Timing of breathlessness - eg, diurnal variation with asthma.
  • Any known precipitating events - eg, trauma, palpitations, chest pain, exercise.
  • Past medical history: allergy, chest or cardiac disease, anxiety-related disorder.
  • Family history, especially heart disease.
  • Lifestyle/occupation: smoking history, occupation, pets, close contact with birds.
  • Drug exposure (beta-blockers, amiodarone, nitrofurantoin, methotrexate, heroin).

Assessment

Try to quantify exercise tolerance (eg, breathlessness at rest, with talking, dressing, distance walked or number of stairs climbed). There are a number of simple scales to assess the severity of breathlessness - eg, the modified Medical Research Council (MRC) dyspnoea score:[5] 

  • Grade 0: not troubled by breathlessness except on strenuous exertion.
  • Grade 1: short of breath when hurrying on level ground or walking up a slight incline.
  • Grade 2: walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
  • Grade 3: stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground.
  • Grade 4: too breathless to leave the house or breathless on dressing or undressing.

NB: there is no accepted gold standard for measuring breathlessness - unidimensional tools such as the above are recommended for assessing severity but multidimensional tools are required to capture the impact on quality of life.[6] 

Examination

Should include:

  • General:
    • Patient distress, colour of skin and lips, cyanosis, clubbing, lymphadenopathy, tremor, flap
    • Respiratory rate
    • Pulse - rate, rhythm
    • Height and weight (body mass index)
  • Chest:
    • Trachea - central, deviated to one side
    • Shape of chest - eg, kyphosis
    • Movement of chest - symmetrical, asymmetrical
    • Percussion note - eg, stony dull over a pleural effusion, hyper-resonant over a pneumothorax
  • Auscultation of chest
    • Wheezing/rhonchi - eg, asthma, COPD, heart failure, bronchiolitis
    • Crepitations - eg, pneumonia, bronchiectasis, fibrosis
    • Stridor - eg, foreign body, acute epiglottitis, anaphylaxis, trauma
    • No added sounds - eg, anaemia, pulmonary embolus, metabolic acidosis, neuromuscular causes

These will be dependent on the findings of the history and examination but may include:

  • Lung function tests - eg, peak flow measurement, spirometry
  • Pulse oximetry
  • CXR
  • Venous blood tests: FBC, brain natriuretic peptides (BNPs)
  • Arterial blood gases
  • ECG
  • Imaging:
    • Echocardiogram
    • High-resolution CT scan
    • V/Q scan
    • Radioallergosorbent test (RAST) measurement or skin prick testing to common aero-allergens

This is dependent on the underlying cause.

In an acute situation, breathless individuals should be assessed rapidly and treated with high-flow oxygen (>60%) unless there is a known history of COPD, in addition to any specific therapy for the underlying condition. If unstable, transfer to hospital should be arranged as an emergency.

In the chronic situation, the underlying cause should be addressed and treated. Frequently breathlessness is a common end point of non-reversible disease and symptomatic relief should be sought instead.

Strategies for relieving breathlessness (of respiratory origin)

Reassure and educate the patient and caregivers to increase confidence in their ability to control and interpret symptoms.

Controlled breathing technique counteracts the fast, shallow, inefficient breathing associated with dyspnoea:

  • Control respiratory rate
  • Use diaphragmatic breathing
  • Relax shoulders and upper chest.

Sit upright: leaning forward when standing or nursing a bed-bound patient as upright as possible can help to relieve breathlessness.

Modify activities of daily living, lifestyle and expectations in line with disability but avoid excessive restrictions on activity.

Cognitive behavioural therapy (CBT) seeks to modify the patient's response to the symptom. Anxiety and panic can be reduced often by using techniques such as distraction or relaxation.

Drugs for symptom control of dyspnoea[7] 

Drug treatment can be used to reduce the sensation of breathlessness. Opiates, such as morphine and codeine, are effective and used in palliative care settings but may further depress breathing so care is required.[8][9] Similarly, benzodiazepines such as diazepam are used to reduce anxiety associated with breathlessness but also carry the side-effect of respiratory depression. The use of nebulised furosemide is under investigation.[10] 

  • Oral morphine 2-2.5 mg prn if opioid naive. This dose can be repeated every four hours, although frequent dosing may not be required and may be used in anticipation of exercise (take 30 minutes prior to exercise for those with dyspnoea on exertion).
  • If already taking regular analgesic morphine, increase the regular dose by around 30% every two to three days until symptoms are controlled or adverse effects limit further increases.
  • Once stable, this can be converted to a modified-release preparation if needed regularly throughout the day. If only one or two doses are needed each day, continue as-required doses of standard-release morphine.
  • Benzodiazepines used when anxiety is an integral part of breathlessness, alone or alongside opiates - eg, lorazepam sublingual 0.5-1 mg prn or diazepam 2-5 mg tds, where there are persistent symptoms. Start at low doses in elderly or debilitated people.

Pulmonary rehabilitation

Individuals with severe breathlessness become less active and their general fitness levels diminish, causing a cycle of worsening breathlessness with less and less physical exertion.

Supervised pulmonary rehabilitation programmes of exercise training have been shown to be beneficial in COPD, improving both dyspnoea and fatigue levels.[11] Rehabilitation should not be neglected in a palliative setting.[12]

Nutrition

Patients with severe respiratory disease tend to be cachexic and have such generalised muscle weakness that the work of breathing is extremely demanding. Addressing nutritional support with a dietician may be helpful.

Oxygen therapy

Ongoing or intermittent oxygen therapy via a facemask or nasal prongs may be of benefit in some selected cases. In chronic heart and lung disease, benefit is only evident where there is confirmed hypoxia or pulmonary hypertension. Consistent benefit of oxygen therapy in advanced lung cancer or cardiac failure patients has not been shown.[13]

Partial ventilation support - continuous positive airway pressure (CPAP) can be used for several hours a day to rest chest muscles but is intrusive and of temporary benefit only.

Further reading & references

  1. Breathlessness; NICE CKS, August 2010
  2. Ries AL; Impact of chronic obstructive pulmonary disease on quality of life: the role of dyspnea. Am J Med. 2006 Oct;119(10 Suppl 1):12-20.
  3. Karnani NG, Reisfield GM, Wilson GR; Evaluation of chronic dyspnea. Am Fam Physician. 2005 Apr 15;71(8):1529-37.
  4. Zoorob RJ, Campbell JS; Acute dyspnea in the office. Am Fam Physician. 2003 Nov 1;68(9):1803-10.
  5. Launois C, Barbe C, Bertin E, et al; The modified Medical Research Council scale for the assessment of dyspnea in daily living in obesity: a pilot study. BMC Pulm Med. 2012 Oct 1;12:61. doi: 10.1186/1471-2466-12-61.
  6. Bausewein C, Booth S, Higginson IJ; Measurement of dyspnoea in the clinical rather than the research setting. Curr Opin Support Palliat Care. 2008 Jun;2(2):95-9.
  7. Paliative cancer care - dyspnoea; NICE CKS, November 2012
  8. Jennings AL, Davies AN, Higgins JP, et al; A systematic review of the use of opioids in the management of dyspnoea. Thorax. 2002 Nov;57(11):939-44.
  9. Abernethy AP, Currow DC, Frith P, et al; Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003 Sep 6;327(7414):523-8.
  10. Currow DC, Ward AM, Abernethy AP; Advances in the pharmacological management of breathlessness. Curr Opin Support Palliat Care. 2009 Jun;3(2):103-6.
  11. Lacasse Y, Goldstein R, Lasserson TJ, et al; Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003793.
  12. Sachs S, Weinberg RL; Pulmonary rehabilitation for dyspnea in the palliative-care setting. Curr Opin Support Palliat Care. 2009 Jun;3(2):112-9.
  13. Cranston JM, Crockett A, Currow D; Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004769.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Chloe Borton
Current Version:
Peer Reviewer:
Dr John Cox
Last Checked:
12/03/2014
Document ID:
1886 (v24)
© EMIS