| Dyspnea is the term for the sensation of abnormal or uncomfortable breathing in the context of what is normal for an individual. It manifests as breathlessness or increased respiratory effort. Dyspnea is experienced when the need for oxygen exceeds the actual or perceived capacity of the lungs to respond. This need results in an increased respiratory rate, thus increasing the physical effort needed for the individual to breathe.
The four general categories of dyspnea are cardiac, pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary. Dyspnea can result from weakness or injury to the chest wall or chest muscles, decreased lung elasticity, obstruction of the airway, increased oxygen demand, or unrelated factors such as obesity.
Sudden onset of dyspnea (acute dyspnea) is most typically associated with narrowing of the airways or airflow obstruction (bronchospasm), blockage of one of the arteries of the lung (pulmonary embolism), acute heart failure or heart attack, pneumonia, or anxiety. Long-standing dyspnea (chronic dyspnea) is most often a manifestation of chronic or progressive diseases of the lung and/or heart such as chronic obstructive pulmonary disease (COPD). These diseases include chronic asthma, chronic bronchitis, emphysema, or congestive heart failure (CHF) where poor pumping action of the heart results in increased pressure and fluid in the lungs.
Dyspnea is a hallmark finding in asthma, a lung condition characterized by periodic inflammation and narrowing of the airways following exposure to airway irritants. Asthma may disappear spontaneously or become progressively worse and develop into a chronic condition.
Another cause of dyspnea is occupational lung disease. Dyspnea appears early in this disease process and becomes worse as the disease progresses.
Anxiety or panic disorders can cause dyspnea due to asthma.
Dyspnea is also experienced by individuals encountering high-altitude sickness (high-altitude pulmonary edema, [HAPE]). This is associated with rapid rate of mountain ascent, and normally occurs during the first 1 to 3 days of achieving a high altitude. Dyspnea resolves with use of supplemental oxygen, rapid descent, and occasionally hypobaric therapy.Risk: Asthma occurs with equal frequency among men and women. There is a bimodal distribution of incidence, with the first peak occurring in childhood/adolescence, and the second peak beginning from middle age onwards, usually in response to exposure to various workplace and environmental pollutants.
Cigarette smokers have a greater risk of developing both COPD and occupational lung disease (OLD). Other risk factors for OLD include inhaling organic and inorganic dusts, irritant gases, and toxic fumes that adversely affect both the upper and lower tracts.
Congestive heart failure (CHF) is more common in blacks than whites, and slightly more common in men than in women.
Anxiety and panic disorders are more common in women than men by 2:1 (Plewa). Incidence and Prevalence: Asthma is a common condition occurring in about 5% of the population. Panic disorders are present in 5% to 40% of individuals suffering from asthma, and occur with a prevalence of 1% to 5% of individuals in the US (Plewa).
COPD affects about 16 million Americans, and CHF affects more than 3 million Americans. Incidence of exposure to environmental tobacco smoke is 37% to 63% (Eisner).
Occupational lung disease is one of the ten leading causes of work-related health problems in the US.
Incidence of HAPE is 0.01% to 0.1% in the general population and 1% to 2% in trekkers, climbers, and soldiers (Gallagher). Incidence of HAPE is as high as 20% to 33% in climbers of Alaska's Mount McKinley (Anholm). |
Source: Medical Disability Advisor
| History: Individual may complain of shortness of breath or "getting winded" when involved in their usual activities or at rest. Individuals may report shortness of breath occurring most commonly at night while lying flat in bed (orthopnea). Individuals may report the need to limit activities due to shortness of breath. They may describe other factors associated with the onset of dyspnea such as chest pain, anxiety, or exposure to smoke or other irritants. Individuals may have a history of heart or lung diseases, alcohol abuse, or smoking. They may report a recent respiratory infection, chest injury, surgery, or travel that required prolonged sitting. Physical exam: The exam may reveal poor coloring or skin that is blue in color (cyanosis) and rapid respirations. Individuals may have a fever, wheeze, or cough. They may require a longer time than normal to exhale air (prolonged expiratory phase). The lungs may sound bubbly or crackling (rhonchi or rales) if they contain fluid. Lung sounds may be absent in cases of collapsed lung (pneumothorax) or pneumonia. Examination should be done for the presence of nasal polyps, septal deviation, postnasal discharge, jugular vein distention, decreased pulse, increased chest diameter, rapid heart rate (tachycardia), heart murmur, changes in the fingertips and toes (clubbing) that indicate severe hypoxia (reduced oxygen to the tissues), enlarged liver (hepatomegaly), or tissue swelling (edema). Tests: Lab tests may include complete blood count (CBC), measure of arterial blood oxygen (arterial blood gases [ABG]), blood carbon monoxide levels, and renal function studies. Blood oxygen saturation may be measured using an infrared light sensor device on the finger (pulse oximeter). A chest x-ray and electrocardiogram (ECG) are typically done to determine the presence of any obvious lung or heart disorder. A radionuclide study of oxygen uptake and circulation in the lungs (ventilation-perfusion lung scan) may help rule out pulmonary embolus. Directly examining the small bronchial airways using a lighted scope (bronchoscopy) may be done in severe cases. Pulmonary function tests (PFT's) measure the degree to which an airway obstruction affects lung volumes and capacity. Other tests include an echocardiogram to detect heart valve abnormality, and cardiopulmonary exercise testing to quantify cardiac function and pulmonary ventilation. |
Source: Medical Disability Advisor
| Initial efforts are aimed at ensuring and maintaining an open airway and providing assistive ventilation, if necessary. Supplemental oxygen therapy is usually given, at least initially, to all individuals suffering from dyspnea. Those unable to independently maintain an open airway (due to decreased level of alertness) may need an artificial airway established by inserting a tube through the mouth or nose and into the trachea (intubation).
Once the airway is open and breathing and oxygenation are stabilized, the main objective is to diagnose and treat the underlying cause. Asthma is managed by avoiding conditions that trigger the attacks and using a combination of oral and inhaled medications that open the airways (bronchodilators). COPD is treated with supplemental oxygen (as needed), bronchodilators, and antibiotics (if infection is present). OLD is managed with supplemental oxygen (as needed) and bronchodilators. For all the above conditions, avoidance of airway irritants such as cigarette smoke, wood smoke, toxic fumes and gases, air pollution, and workplace irritants is essential. Severe cases of asthma, COPD, and OLD can result in inadequate oxygenation (respiratory failure) that may require emergency respiratory support with intubation and initiation of mechanical breathing (ventilator). |
Source: Medical Disability Advisor
| Acute dyspnea often resolves with treatment of the underlying condition. This is not the case, however, in dyspnea associated with chronic conditions such as COPD or CHF. These conditions usually result in progressive dysfunction, severe disability, and eventual death. |
Source: Medical Disability Advisor
| Pulmonary rehabilitation may be recommended for those with dyspnea. The rehabilitation program usually consists of an aerobic exercise program approximately 3 times a week. By building individuals' endurance through rehabilitation, they increase their ability to work and their resistance to fatigue. A physical therapist experienced in cardiac and pulmonary rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. As endurance increases without shortness of breath, the individual begins active upper and lower extremity exercises using very light resistance in addition to light aerobic activities that include brisk walking and low-resistance biking.
The principles of aerobic conditioning in physical therapy are commonly used to develop a program for individuals with pulmonary disorders. Rehabilitation is planned in four phases that follow the same progression as for cardiopulmonary diseases.
Phase 1 begins with low-demand aerobic activities using large muscle groups such as the lower extremities. Initial exercises include self-care activities such as sitting up in bed and moving from the bed to a chair. Calisthenics are instructed of varying intensity like marching in place and raising both arms overhead.
Phase 2 includes progression of activities such as walking (ambulating) with continuous monitoring for an initial 2 to 5 minutes then increasing to 15 to 20 minutes. The use of a stationary bicycle is useful when performed under supervision. This form of aerobic exercise progresses with time and intensity and varies from individual to individual.
Phase 3 continues to be supervised by the rehabilitation professional with progress recorded in a daily log containing the individual's blood pressure, heart rate, and cardiac rhythm. In some cases, individuals are attached to an electrocardiograph (ECG) monitor, a device used to record the continuous electrical activity of the heart muscle. Higher levels of exercises comprise this phase with the addition of recreational activities such as swimming and hiking. Light jogging at approximately 5 miles per hour (mph) and cycling at approximately 12 mph is appropriate as long as the individual tolerates the rehabilitation program well.
Phase 4 of cardiac rehabilitation involves aerobic exercises that increase cardiovascular fitness. The individual with dyspnea is instructed in walking briskly, running, jogging, swimming, climbing stairs, or bicycling. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week to help keep high blood pressure under control. Throughout all phases, it is important to allow the heart rate to gradually return to normal by cooling down slowly after exercise.
Smoking cessation programs are recommended for all individuals who smoke. Such programs may consist of group meetings or individual meetings with health professionals. |
Source: Medical Disability Advisor
| Complications of dyspnea secondary to lung or heart conditions include respiratory failure, heart failure, or spontaneous collapsed lung (pneumothorax). |
Source: Medical Disability Advisor
| Those who require continuous oxygen therapy must work in areas where there is no danger of igniting this gas. Job responsibilities should not involve strenuous activity such as frequent stair climbing or heavy lifting. Frequent rest periods or shorter workdays may be needed if the individual is symptomatic. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have weakness or injury to the chest wall or chest muscles, decreased lung elasticity, obstruction of the airway, increased oxygen demand, or unrelated factors such as obesity?
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Does individual have occupational lung disease (OLD)?
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Does individual complain of shortness of breath when involved in usual activities or at rest? Is it worse at night or when lying flat?
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Has individual experienced chest pain, anxiety, or exposure to smoke or other irritants? Does individual have a history of heart or lung diseases, alcohol abuse, or smoking? Does individual report a recent respiratory infection, chest injury, surgery, or travel that required prolonged sitting?
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On exam, is individual cyanotic and breathing rapidly?
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Does individual have a fever, wheeze, or cough? Abnormal lung sounds?
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Does individual have nasal polyps, septal deviation, postnasal discharge, jugular vein distention, decreased pulse, increased chest diameter, tachycardia, heart murmur, clubbing of the fingertips and toes, hepatomegaly, or edema?
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Has individual had a CBC, arterial blood gases, blood carbon monoxide levels, and renal function studies? Were chest x-ray, ECG, ventilation-perfusion lung scan, bronchoscopy, pulmonary function tests, echocardiogram, and cardiopulmonary exercise testing performed?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Did individual receive supplemental oxygen therapy? Was intubation necessary?
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What is the underlying cause of individual's dyspnea? Is it being treated?
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Does individual require a pulmonary rehabilitation program?
Regarding prognosis:
- Is individual active in rehabilitation? Does individual have a home exercise program?
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Has individual addressed smoking cessation?
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Can individual's employer accommodate any necessary restrictions?
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Does individual have any conditions that may affect ability to recover?
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Did any complications arise such as respiratory failure, heart failure, or pneumothorax?
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Source: Medical Disability Advisor
| Anholm, James D. "Altitude-Related Disorders." eMedicine. Eds. Gregory Tino, et al. 7 Oct. 2004. Medscape. 25 Oct. 2004 <http://emedicine.com/med/topic3225.htm>.Eisner, M. D. "Environmental Tobacco Smoke and Adult Asthma." Clinics in Chest Medicine 23 4 (2002): 749-761. MD Consult. Elsevier, Inc. 29 Jul. 2004 <http://home.mdconsult.com/das/journal/view/39491503-2/N/12604665?sid=287381140&source=MI>. Gallagher, S. A. "High Altitude Illness." Emergency Medicine Clinics of North America 22 2 (2004): 329-355. MD Consult. Elsevier, Inc. 29 Jul. 2004 <http://home.mdconsult.com/das/journal/view/39491503-2/N/14881323?sid=287381140&source=MI>. Plewa, Michael C. "Panic Disorders." eMedicine. Eds. Samuel M. Keim, et al. 2 Jul. 2004. Medscape. 25 Oct. 2004 <http://emedicine.com/emerg/topic766.htm>. |
Source: Medical Disability Advisor
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