Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Dyspnea


Related Terms

  • Breathlessness
  • Shortness of Breath

Differential Diagnosis

  • Altitude sickness (high altitude pulmonary edema)
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure (CHF)
  • Panic disorder
  • Pneumonia

Specialists

  • Cardiologist, Cardiovascular Physician
  • Emergency Medicine Physician
  • Internal Medicine Physician
  • Pulmonologist

Comorbid Conditions

Factors Influencing Duration

The severity of the underlying disease, age of the individual, compliance with treatment regimen, and any associated complications, will influence disability.

Medical Codes

ICD-9-CM:
786.05 - Shortness of Breath
786.09 - Dyspnea and Respiratory Abnormalities; Other: Respiratory: Distress, Insufficiency

Overview

Dyspnea is a sensation of difficult or uncomfortable breathing. 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 (tachypnea), thus increasing the physical effort needed for the individual get adequate oxygen. Dyspnea is believed to result from complex interactions between neurologic stimulation, the mechanics of breathing, and the related response of the central nervous system. A specific area has been identified in the mid-brain that may influence the perception of breathing difficulties.

The four general categories of dyspnea are based on its causes: cardiac, pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary. The most common heart and lung diseases that produce dyspnea are asthma, pneumonia, chronic obstructive pulmonary disease (COPD), and myocardial ischemia or heart attack (myocardial infarction). Foreign body inhalation, toxic damage to the airway, pulmonary embolism, congestive heart failure (CHF), anxiety with hyperventilation (panic disorder), anemia, and physical deconditioning because of sedentary lifestyle or obesity can produce dyspnea. In most cases, dyspnea occurs with exacerbation of the underlying disease. Dyspnea also can result from weakness or injury to the chest wall or chest muscles, decreased lung elasticity, obstruction of the airway, increased oxygen demand, or poor pumping action of the heart that results in increased pressure and fluid in the lungs, such as in CHF.

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 myocardial infarction, pneumonia, or panic disorder. Long-standing dyspnea (chronic dyspnea) is most often a manifestation of chronic or progressive diseases of the lung and/or heart, such as COPD, which includes chronic bronchitis and emphysema.
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 resolve spontaneously or become progressively worse and develop into a chronic condition. Anxiety or panic disorders may contribute to dyspnea in individuals with asthma.

Dyspnea appears early in occupational lung disease (OLD), which is caused by repeated exposure to toxic fumes, dust, or airborne particles in the workplace. Dyspnea becomes worse as the disease progresses.

Dyspnea also is 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 hyperbaric therapy.

Incidence and Prevalence: The exact incidence of dyspnea cannot be estimated because of the broad range of disease-related causes in which it may occur. Dyspnea is often recorded as a symptom of an underlying disease rather than as a separate disease. Incidence of common causes of dyspnea is shown below.

Asthma is a common condition that affects 22 million individuals in the US, occurring in about 5% to 10% of the population and accounting for more than 1.8 million emergency department visits annually (Morris). Panic disorders are present in 5% to 40% of individuals with asthma, and occur with a prevalence of 1% to 5% of all individuals in the US (Plewa).

About 12 million adults over age 25 have been diagnosed with COPD; of these approximately 9.2 million individuals have chronic bronchitis, 2 million have emphysema and 0.9 million have both conditions (Doherty). It is estimated that at least other 12 million individuals have undiagnosed COPD.
Occupational lung disease is a leading cause of work-related health problems in the US, but the actual incidence is difficult to determine because of lack of reporting, low recognition of signs and symptoms associated with substance exposure, and poor understanding of the disease and of the guidelines for diagnosis.

About 19.8% of US adults smoke tobacco; death from tobacco smoking occurs 13 to 14 years earlier than in non-smokers (CDC Tobacco Fact Sheet).

Heart disease, including CHF, CAD, and myocardial infarction, is the leading cause of death in men and women in Native American, Alaskan natives, blacks, whites, and Hispanic populations (CDC Heart Disease Fact Sheet).

Incidence of HAPE is 0.01% to 0.1% in the general population and as high as 20% to 33% in climbers (Kale).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for dyspnea are associated with the diseases and conditions in which dyspnea occurs. Clinical risk factors include having chronic asthma, COPD, cardiovascular disease (e.g., CHF, coronary artery disease [CAD]), and consistent exposure to toxic irritants such as tobacco smoke and certain industrial toxins. Individuals with anemia, anxiety and panic disorders, sedentary lifestyle, and obesity are at greater risk of developing dyspnea than those without these conditions.

Asthma occurs with equal frequency among men and women. There is a bimodal distribution of incidence, with the first peak occurring in childhood and adolescence. In childhood asthma, the male to female ratio is 2:1, and after puberty this reverses, with higher prevalence in females. The second peak occurs beginning from middle age onwards, usually in response to exposure to workplace and environmental pollutants. Adult-onset asthma in individuals older than age 40 is also predominately female (Morris).

Individuals at risk for pulmonary embolism include those with cancer, immobilization or prolonged bed rest, deep vein thrombosis (DVT), recent pregnancy, recent surgery, those taking estrogen-containing drugs, and those with a family history of the condition (Lechtzin).

Cigarette smokers have a greater risk of developing COPD and OLD than nonsmokers. Other risk factors for OLD include inhaling organic and inorganic dusts, irritant gases, and toxic fumes that adversely affect both the upper and lower airways.

Anxiety and panic disorders are more common in women than men by 2:1 (Plewa).

At high altitudes, individuals with CAD, asthma, anemia (especially sickle cell disease), and COPD are at greater risk of experiencing dyspnea as a symptom than those without these conditions (Kale).

Source: Medical Disability Advisor



Diagnosis

History: Individual may complain of shortness of breath or "getting winded" when involved in usual activities or at rest and may report the need to limit activities due to shortness of breath. Some individuals may report shortness of breath occurring most commonly at night while lying flat in bed (orthopnea). Individuals may describe other factors associated with the onset of dyspnea such as chest pain, weight loss, night sweats, anxiety, or exposure to smoke or other irritants. Medical history may include diseases known to cause dyspnea such as asthma, COPD, heart disease, alcoholism, or smoking. The individual may report a recent respiratory infection, chest injury, surgery, an extensive period of bed rest, 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. A complete lung exam is done including breath sounds during both inhalation and exhalation (auscultation). The individual may require a longer time than normal to exhale air (prolonged expiratory phase). An increased chest diameter may suggest emphysema. The lungs may sound bubbly or crackling (rhonchi or rales) if they contain fluid. Breath sounds may be absent in cases of collapsed lung (pneumothorax) or pneumonia. A thorough examination may reveal conditions such as nasal polyps, septal deviation, or postnasal discharge indicating upper respiratory causes; jugular vein distention, decreased pulse, tachycardia, heart murmur or extra heart sounds indicative of cardiovascular disorders; changes in the fingertips and toes (clubbing) that indicate severe reduction of oxygen supply to the tissues (hypoxia); or tissue swelling (edema) in legs and presacral area that may suggest heart failure. Lymph glands may be examined for enlargement (lymphadenopathy). The liver also may be enlarged (hepatomegaly). The individual may appear to be agitated or confused.

Tests: Laboratory tests may include complete blood count (CBC), measurement of arterial blood oxygen (arterial blood gases [ABG]), blood carbon monoxide levels, and renal function studies. Blood oxygen saturation is measured using an infrared light sensor device on the finger (pulse oximetry) and is considered a key diagnostic parameter for dyspnea (Lechtzin). A chest x-ray and electrocardiogram (ECG) typically are done to determine the presence of any lung or heart disorder if none has been previously diagnosed (e.g., asthma or CHF). A radionuclide study of oxygen uptake and circulation in the lungs (ventilation-perfusion lung scan) may help rule out pulmonary embolus. A D-dimer test may be done to detect clot formation if pulmonary embolism is suspected. Directly examining the small bronchial airways using a lighted scope (bronchoscopy) may be done in severe cases or to rule out airway obstruction. Pulmonary function tests (PFTs) measure the degree to which airway obstruction affects lung volumes and capacity. Other tests may include an echocardiogram to detect heart valve abnormality and cardiopulmonary exercise testing to quantify cardiac function and pulmonary ventilation. Computed tomography (CT) angiography is done in patients with no definitive diagnosis after chest x-ray and ECG.

Source: Medical Disability Advisor



Treatment

Initial efforts are aimed at ensuring and maintaining an open airway and providing assisted ventilation, if necessary. Supplemental oxygen therapy usually is given, at least initially, to relieve hypoxia in all individuals experiencing 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). Morphine may be given to reduce anxiety and extreme discomfort of dyspnea that may occur with myocardial infarction, pulmonary embolism, or terminal illness, but is contraindicated in patients with asthma or COPD because opioids may exacerbate these respiratory disorders.

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 drugs 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 respiratory failure that may require emergency respiratory support with intubation and initiation of mechanical breathing (ventilator).

Source: Medical Disability Advisor



Prognosis

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



Rehabilitation

Pulmonary rehabilitation may be recommended for those with dyspnea. The rehabilitation program usually consists of an aerobic exercise program approximately 3 times a week. Building an individual's endurance through rehabilitation can increase the ability to work and resistance to fatigue. The principles of aerobic conditioning in physical therapy are commonly used to develop a program for individuals with pulmonary disorders. A physical therapist experienced in cardiac and pulmonary rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. 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. Individuals are instructed in calisthenics of varying intensity, such as 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. A stationary bicycle may be used under supervision. Aerobic exercises progress in time and intensity, and vary from individual to individual.

Phase 3 continues to be supervised by a 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) or cycling at approximately 12 mph is appropriate as long as the rehabilitation program is tolerated by the individual.

Phase 4 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

Complications of dyspnea secondary to lung or heart conditions include respiratory failure, heart failure, and pneumothorax.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Reassignment to less strenuous duties is likely to be required. 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. Inhalation of airway irritants must be avoided. Those who require continuous oxygen therapy must work in areas where there is no danger of igniting this gas.

Source: Medical Disability Advisor



Failure to Recover

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 poor pumping action of the heart as in CHF?
  • Does individual have previously diagnosed asthma, COPD, CHF, myocardial ischemia, or pneumonia?
  • Has individual been exposed to industrial irritants or does individual have documented OLD?
  • Does individual complain of shortness of breath when involved in usual activities or at rest? Is it worse at night or when lying flat?
  • Has individual experienced chest pain, anxiety, or exposure to smoke or other irritants?
  • Does individual have a history of heart or lung diseases, alcoholism, or smoking?
  • Does individual report a recent respiratory infection, chest injury, surgery, or travel that required prolonged sitting?
  • Is individual sedentary? Obese?
  • On exam, was individual cyanotic and breathing rapidly?
  • Does individual have a fever, wheeze, or cough? Abnormal breath sounds?
  • Was pulse oximetry done?
  • 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?
  • Has individual had a CBC, ABG, 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?
  • Were additional tests such as CT angiography performed?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Did individual receive supplemental oxygen therapy? Was intubation necessary?
  • What is the underlying cause of individual's dyspnea? Is it being treated? Is treatment likely to be curative?
  • Does individual require a pulmonary rehabilitation program?

Regarding prognosis:

  • Is the primary diagnosis underlying dyspnea being managed effectively?
  • Is individual active in rehabilitation? Does individual have a home exercise program?
  • Has individual addressed smoking cessation?
  • Can individual's employer accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Did any complications arise such as respiratory failure, heart failure, or pneumothorax?

Source: Medical Disability Advisor



References

Cited

"Fast Facts." Tobacco & Smoking Use. 6 Oct. 2009. Centers for Disease Control and Prevention. 5 Nov. 2009 <http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm>.

"Heart Disease Fact Sheet." Heart Disease. 12 Feb. 2009. Centers for Disease Control and Prevention. 5 Nov. 2009 <http://www.cdc.gov/heartdisease/statistics.htm>.

Doherty, Dennis E., and Dick D. Briggs. "Chronic Obstructive Pulmonary Disease: Epidemiology, Pathogenesis, Disease Course, and Prognosis." Clinical Cornerstone 6 Suppl 2 (2004): S5-16. MD Consult. Elsevier, Inc. 23 Oct. 2009 <www.mdconsult.com/das/article/body/145796129-3/html>.

Kale, Rahul, and James D. Anholm. "Altitude-Related Disorders." eMedicine. Eds. Gregory Tino, et al. 3 Apr. 2009. Medscape. 23 Oct. 2009 <http://emedicine.medscape.com/article/303571-overview>.

Lechtzin, Noah. "Dyspnea: Approach to the Patient with Pulmonary Symptoms." The Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008. Merck Manual of Diagnosis and Therapy. Jul. 2009. Merck & Co., Inc. 22 Oct. 2009 <http://www.merck.com/mmpe/sec05/ch045/ch045d.html>.

Morris, Michael J. "Asthma." eMedicine. Eds. Helen M. Hollingsworth, et al. 9 Sep. 2009. Medscape. 22 Oct. 2009 <http://emedicine.medscape.com/article/296301-overview>.

Plewa, Michael C. "Panic Disorders." eMedicine. Eds. Samuel M. Keim, et al. 7 May. 2009. Medscape. 23 Oct. 2009 <http://emedicine.medscape.com/article/806402-overview>.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.