Relaxation exercises

Anxiety increases when dyspnea increases. Previously this has been primarily a clinical observation with anxiety increasing with increasing shortness of breath in a synergistic spiral resulting in severe shortness of breath and panic. Recently anxiety has been associated with increasing or high dyspnea in a controlled trial of asthma patients in an emergency room,63 in COPD patients during treadmill exercise64 and in cancer patients.8 Since they are related, strategies that decrease this...

Biofeedback

Today e-Health technological advances in monitoring body systems is a rapidly growing area of research with findings being translated into clinical practice.78,79 Patients are monitoring physiological data, such as peak flow rates and heart rate, that are often rapidly transferred to the provider. Therefore, it is conceivable that in the near future it will be much easier for a patient to use his her own respiratory pattern as feedback to change his her breathing pattern. Over the last decades...

Disease of nerve and muscle

Respiratory muscle weakness is a feature of a number of neuromuscular conditions. Acute respiratory muscle weakness occurs in a range of conditions including Guillain-Barre Syndrome,24 envenomation25 and organophsophate poisoning26 and was of course a common feature in poliomyelitis. In these conditions management of respiratory failure using endotracheal ventilation is of critical importance. For more slowly progressive conditions respiratory muscle weakness may significantly precede the need...

Neurodegenerative diseases

MND ALS is the most common degenerative disorder of the motor-neuronal system occurring in adults. It is a progressive disease with no curative treatment, and the average prognosis is 3-4 years. The estimated incidence is 1.5-2 per 100,000 per year and increasing.15 The clinical picture is characterized by fasiculations and progressive paresis of voluntary muscles, plus hyper- reflexia and spasticity caused by concomitant involvement of upper and lower motor neurones.16 Dyspnoea is a very...

Respiratory muscles in health

In health, inspiration is an active process whereas expiration at rest is a passive process driven by lung and chest wall recoil. However expiration can, in the absence of flow limitation, be augmented by expiratory muscle activity and this is observed during exercise1 and postural change.2 Of the inspiratory muscles the most important is the diaphragm accounting for 70 per cent of ventilation in man3 but additional contributions are made by the scalenes and intercostals.4 Histologically the...

Box 102 Causes of dyspnoea due to intrathoracic malignancy

Pulmonary sepsis (including empyema) disease can also give rise to this complication. Symptoms are usually caused by loss of functioning lung, often accompanied by significant shunting of blood through non-aerated lung. Abscess formation, empyema and haemoptysis can all occur as an end result of the obstruction, with potentially fatal consequences. There are several ways of clearing the obstructed lung. The first essential element is bronchoscopy (flexible or rigid) to evaluate the extent of...

Box 104 Nonmalignant causes of chronic dyspnoea

Emphysema and severe bullous disease Tracheal compression (e.g. thyroid) Idiopathic tracheal stenosis Thromboembloic pulmonary hypertension Although there was no overall increase in survival this demonstrated an improved increase in exercise capacity compared with best medical therapy. There were also other improvements for specific groups depending on the distribution of the emphysema. Main indications for LVRS heterogenous, mainly upper lobe disease, with no improvement on maximal therapy and...

Pharmacological management

Opioids A recent systematic review examined the effectiveness of oral or parenteral opioids for the management of dyspnea.67 The authors identified 18 randomized double-blind, controlled trials comparing the use of any opioid drug against placebo for the treatment of breathlessness in patients with any illness (only two studies conducted with cancer patients met the inclusion criteria for review (1 parenteral, 1 nebulized). In the studies68-75 involving the non-nebulized route of administration...

Understanding the mechanisms of breathlessness Why should we care

A 72-year-old former smoker with end stage obstructive lung disease comes to see her physician for a routine visit. She says she feels much worse as of late. Her last spirometry testing revealed her one second forced expiratory volume to be 600 milliliters, a decline in her lung function brought on by her smoking three packs of cigarettes per day for 50 years. She now must wear oxygen even at rest. Even when she feels her best, she is only able to walk up one flight of stairs before she must...

Dementia

Although included here under vascular disorders, dementia may also be neuro-degenerative. Pneumonia is markedly more common among those dying of advanced dementia that among those dying from cancer.32 Despite this, the prevalence of breathlessness among those dying from dementia is low (8.2 per cent compared to 27.6 per cent in cancer patients in the same study). This maybe because of the subjective nature of breathlessness as a symptom, and associated difficulties in detecting it in the...

Changes in pulmonary function

The administration of a diuretic, even to healthy subjects, suggests that pulmonary function is influenced to a considerable degree by the water content of the lung.12 In patients with radiological evidence of pulmonary venous hypertension, the mechanical and gas exchanging properties of the lung are both limited. In a study of ten non-smoking patients with asymptomatic left ventricular dysfunction, volume loading with saline provoked airflow obstruction and a decrease in the alveolar capillary...

Unexpected or sudden deterioration

If the palliative care team is called to someone they have not met before and the patient is in extreme respiratory distress they are likely to walk in to a highly charged situation where history and examination of the patient will be minimal and treatment has to be speedily effective. In this case the team needs to do their homework with the referring team and the clinical notes extensively before seeing the patient to satisfy themselves of the diagnosis and what needs to be done. They need to...

Factors associated with dyspnea

Few studies have examined the factors associated with dyspnea in patients with cancer.11'13'17'19-24 Some of these have found that dyspnea in cancer patients has diverse etiologies, commonly with more than one factor contributing to the breathlessness.17,20 In one study the prevalence of dyspnea was strongly related to the number of risk factors a patient had.11 Most studies have found that lung or pleural involvement with cancer is associated with the presence of dyspnea.11'13'17'19'20...

Measurement of the affective responses to dyspnea

Both normal subjects50 and patients with COPD who are exercising54 or completing daily self-reports43 can distinguish the intensity of their shortness of breath from the anxiety and or distress it causes them. After treatment, patients have stated that the intensity of shortness of breath with exercise may be at the same level, but because they feel more in control of the symptom, they are less anxious about the symptom, and therefore, the same intensity of shortness of breath is less...

Laboratory evaluation

There are a number of tests that can be done to help determine the etiology of a person's dyspnea but the choice of the appropriate diagnostic tests should be guided by the stage of disease, the prognosis, the risk benefit ratios of any proposed tests or interventions and the desires of the patient and family. Oxygen saturation can be measured non-invasively using a pulse oximeter. It should be remembered that pulse oximeters are reasonably accurate (+ -3 ) at high saturations, but less...

Methylxantines theophylline

Theophylline is noted for its very narrow therapeutic index so that even with close monitoring and apparent therapeutic levels, people can experience significant toxicity. There are theoretical benefits for dyspnoea beyond any effect on airway constriction. These include the ability to improve the strength and efficiency of the muscles of respiration, especially the diaphragm, and to stimulate the respiratory centre.43 There are studies that focus on symptomatic benefit in people with...

Clinical definition of heart failure

The traditional definition of heart failure has emphasized the clinical signs and symptoms that arise when the pump cannot satisfy the needs of the body, such as the dyspnoea and fatigue, although these do not relate to the heart itself. An alternative is that heart failure is a clinical syndrome in which heart disease reduces cardiac output and results in volume expansion, increased venous pressure and molecular abnormalities that cause progressive deterioration of the failing heart and...

The failing heart and the lungs

In health, there is a linear increase in pulmonary blood flow from the apex to the base of the lung. An increase in left atrial pressure results in pulmonary venous hypertension, and a more uniform distribution of blood flow in the lungs,8 via capillary distension and recruitment.9 A modest elevation in pulmonary capillary wedge pressure can therefore be accommodated, without the development of pulmonary oedema. As left ventricular end-diastolic pressure increases, the rise in capillary...

References

Mechanisms, assessment, and management a consensus statement. American Journal of Respiratory and Critical Care Medicine 1999 159(1) 321-40. 2. Comroe JH. Some theories of the mechanisms of dyspnea. In Howell JBL, Campbell EJM, eds Breathlessness, pp. 1-7. Oxford Blackwell Scientific, 1966. 3. Pennebaker JW. The Psychology of Physical Symptoms. New York Springer-Verlag, 1982. 4. Larson P, Carrieri-Kohlman V, Dodd MJ, Douglas M, Faucett J, Froelicher ES, et...

Noninvasive ventilation

Non-invasive ventilatory support in the form of a fitted facial or nasal mask is especially useful in neuromuscular disorders where respiratory failure and dyspnoea are associated with decreased muscular ability to breathe over long periods of time. In adolescents with Duchenne's muscular dystrophy, for example, many years of stable overall function and good quality of life maybe possible with the addition of non-invasive mechanical ventilatory support. In these young men the use of a fitted...

Lower airway receptors

The major receptors that reside in the lung parenchyma are characterized as stretch receptors and C-fibers (unmeyelinated nerve endings). These receptors are responsible for detecting a wide variety of pathophysiologic derangements in the lung and transmit information to the CNS via the vagus nerve. Several studies have explored the importance of these receptors in the production of breathlessness. Stretch receptors are thought to modulate breathlessness by altering effer-ent-reafferent...

Managing dyspnea in COPD

Recent national guidelines have recommended a dyspnea disability driven paradigm for managing COPD.81-83 Thus, therapy is escalated on an individual basis with the goal being maximum possible symptom relief. Education and smoking cessation are the first steps in symptom management (Figure 4.6) and are regarded as one of the best strategies to reduce mortality in COPD patients. Treatment with bronchodilators is another initial approach to therapy as they provide symptomatic relief by improving...

Language of breathlessness

Patients who present to their physician complaining of chest pain are routinely asked to describe the quality of the pain. Is it a burning sensation, a pressure, or a sharp pain Clinicians quickly learn to use these qualitative descriptions of pain to gain insight into the pathophysiologic mechanisms underlying the discomfort. For example, burning chest pain may indicate acid reflux into the esophagus, while pressure-like pain is in suggestive of ischemia of the myocardium, and sharp, stabbing...

Hypnosis

Hypnosis is a trance state that combines a heightened inner awareness with a diminished awareness of one's surroundings. It is suggested that hypnosis may modify the cortical centers and the perception of dyspnea, however, the available studies are primarily with asthma patients. Dyspnea decreased in one patient with severe COPD who received hypnotically-induced relaxation and biofeedback in an effort to decrease his dyspnea during periods of anxiety.83 Another 16 patients with asthma had a...

Affective dimension of dyspnea

The theoretical perspectives of symptom perception outlined above inform the non-pharmacological strategies for breathlessness discussed in this chapter. The prescription and use of non-pharmacological strategies also assumes that the dyspnea experience is similar to other symptoms, such as pain, and includes sensory and affective dimensions, both of which influence each other.22-24 Evidence for an 'unpleasant' or 'distressing' dimension of dyspnea is derived from clinical and research...

Increased ventilatory demand

An increase in ventilatory demand can occur when there is interruption of perfusion of the lung secondary to thrombo- or tumor emboli, vascular obstruction, or chemo- or radiation therapy. Other conditions that increase ventilatory demand are severe deconditioning with subsequent early and Table 5.1 Pathophysiological and clinical mechanisms of dyspnea in the cancer patient (a) Restrictive ventilatory deficit (i) Pleural or parenchymal disease (ii) Reduced movement of diaphragm (iii) Reduced...

Causes of dyspnea in advanced disease in children

There are myriad causes of dyspnea in a child which involve many of the branches of general paediatric medicine and paediatric respiratory medicine in particular. It is not within the scope of this chapter to address the aetiology and management of all causes of dyspnea with which a child with advanced disease might present. For example a child may have asthma in addition to the diagnosis of a brain tumour. At the end of life for this child it is possible that his asthma may be a significant...

Exercise as a strategy for changing central perception of dyspnea

One of the most powerful strategies for improving dyspnea with activity is exercise. The major benefits of exercise are attributed to the physiological effects of 'conditioning' or other physiological factors, including improvement in respiratory and peripheral muscle strength and changes in the pattern of breathing resulting in less dynamic hyperinflation with exer-cise.50,101 Others have found decreases in dyspnea despite little change in outcomes that reflect physiological effects.102-104...

Acupuncture and acupressure

Acupuncture and acupressure have shown early positive findings for their use in the management of dyspnea. Jobst compared the effects of 'traditional' and 'placebo' acupuncture in 24 COPD patients with 'disabling breathlessness'.71 During 13 treatment sessions administered over three weeks acupuncture needles were inserted according to 'traditional acupuncture points', while in the other group the placebo needles were inserted in non-acupuncture 'dead points'. Both groups did improve their...

Azopirones buspirone

As with most medications in the therapy of dyspnoea, there are limited data to inform the use of buspirone in clinical practice. Buspirone is a non-sedating anxiolytic with a gradual onset of action after it is commenced. There are two double-blind, RCTs that explore the effect of buspirone in people with COPD. The first of these explored in a placebo-controlled study the use of 10-20mg of buspirone three times daily on dyspnoea measured on Borg scale and physiological parameters of exercise....