Managing Patients With Dyspnea: Effective Strategies and Care Guidelines

Introduction

Dyspnea is a medical term used for unpleasant respiratory sensations such as difficult and labored breathing, breathlessness, or shortness of breath. This respiratory symptom can range from mild to severe. If the dyspnea is chronic (persistent over a long duration), it can reduce the quality of life and limit activity. Shortness of breath can occur due to underlying medical conditions of the heart, lung, neuromuscular, vascular, and metabolic issues. Many patients (third most common) calling for emergency medical services complain of shortness of breath, as it is an important symptom of a wide range of health emergencies. Sometimes, identifying the underlying cause can be difficult. Special diagnostic tests are used in such scenarios. Treatment depends on the underlying cause of the dyspnea.

What Are the Causes of Dyspnea?

Several medical conditions cause shortness of breath. The most common causes of dyspnea include:

1. Chest or lung infection.

2. Asthma.

3. Obesity.

4. Habits such as smoking.

5. Panic attack.

6. Pregnancy.

Sometimes shortness of breath can indicate a severe underlying medical problem such as:

• Lung conditions such as chronic obstructive pulmonary disease, pneumonia, pneumothorax, pulmonary embolism, and pleural effusion.

• Scarring (fibrosis) in the lungs.

• Pulmonary edema with left ventricular (heart failure).

• Heart problems such as heart failure.

• Lung cancer.

• Neuromuscular conditions.

• Rarely, metabolic acidosis, aspirin poisoning, and renal failure can cause dyspnea.

The pathophysiology of dyspnea involves the following due to the underlying heart or lung disease:

1. Heightened ventilatory demand.

2. Abnormal breathing patterns.

3. Respiratory muscle abnormalities.

4. Airflow limitations.

5. Abnormal ventilatory impedance.

6. Blood-gas abnormalities (oxygen, carbon dioxide).

When Should a Person Visit the Doctor for Dyspnea?

If a person has shortness of breath, it is essential to seek medical advice to rule out any underlying critical health issues. It is vital to go for a check-up if the shortness of breath has:

• Lasts for more than a month.

• Gets worse with exercise or activity.

• Worsens on lying down.

• A cough accompanies it for more than three weeks.

• Occurs along with swollen ankles.

When Should We Call for Emergency Help?

Dyspnea or shortness of breath may be nothing to worry about. However, it could be caused by serious underlying medical issues (such as heart attack or problems with the lungs or airway) requiring immediate treatment. We should call for emergency medical help or rush to the nearest hospital emergency department in case of the following:

1. If the patient is struggling to breathe.

2. Sudden severe dyspnea.

3. Feeling chest tightness or heavy chest.

4. Dyspnea with pain radiating to arms, neck, back, or jaw.

5. If the patient appears critically sick along with dyspnea.

How Is Dyspnea Diagnosed?

• History and Physical Examination: The patient with dyspnea is evaluated for severity and cause. In most cases, the initial evaluation is emphasized by identifying the underlying pathophysiology (mechanism of dyspnea). History and physical examination are vital to identify the patient's heart, neuromuscular, and lung problems. Diagnostic testing is done following a thorough history and physical examination, which helps to identify the specific nature of the underlying medical problem. The increased work of breathing is identified through the following signs and symptoms:

• Stridor (associated with other key findings).

• Use of accessory muscles during breathing.

• Need to sit upright.

• Tracheal tug.

• Intercostal recession.

• Wheeze (expiratory).

• Unable to speak in whole sentences.

The signs of inadequate respiration (systemic effects) include:

• Respiratory rate less than ten or greater than 29.

• Weak respiratory effort.

• Breath sounds are absent.

• Decreased and asymmetrical breath sounds.

• Oxygen saturation of less than 92 percent on air (or less than 95 percent on high-concentration oxygen)

• Peak expiratory flow rate (PEFR) less than 33 % of normal.

• Hypercapnia (increased carbon dioxide levels).

• Increased heart rate or tachycardia (more than 120 beats per minute).

• Low heart rate or bradycardia (late and ominous finding).

• Arrhythmias (irregular heart rate).

• Pallor.

• Cyanosis (bluish discoloration of skin and nails)

• Cool, clammy skin.

• Falling blood pressure (late and ominous finding)

• Altered mental status—confusion, the feeling of impending doom, and combativeness.

• Loss of consciousness

• Exhaustion with muscular chest pain.

• Diagnostic Tests: As dyspnea has several possible causes, diagnosis becomes difficult. Some cases require specific tests, echocardiogram, and imaging of the chest. The standard diagnostic tests used to diagnose shortness of breath include

  • Non-invasive cardiopulmonary tests.

  • Electrocardiogram (EKG).

  • Computed tomography (CT).

  • Pulmonary function test (PFT).

  • Advanced cardiopulmonary exercise testing.

  • Standard spirometry.

  • Lung volume measurements (plethysmography or gas dilution method).

In patients who experience unexplained shortness of breath, advanced cardiopulmonary testing can help in the diagnosis. This test assesses how the body utilizes oxygen during exercise (cycling or treadmill). Catheters are used during exercise to assess and measure lung and heart function.

How Are Dyspneic Patients Managed?

Patients with life-threatening conditions such as respiratory failure or distress present with dyspnea. Those with respiratory distress can compensate for their illness, and further deterioration of their condition is prevented by urgent medical care and treatment. They present with increased work of breathing, but oxygen and carbon dioxide levels in their body will be normal. However, patients with respiratory failure may show limited evidence of increased work breathing as they are too tired to compensate. The oxygen levels are too low for these patients and show high or abnormal carbon dioxide levels. Immediate medical treatment is essential to save their lives.

Treatment Before Transportation:

• The airway is secured with manual methods, simple adjuncts, intubation, and cricothyroidotomy until the airway is secured.

• High-concentration oxygen is administered through a non-rebreathing mask.

• Assisted ventilations are initiated if the respiratory rate is low.

• Nebulized beta-2 agonist is administered in the presence of wheeze (for example, Salbutamol 5 mg initially)

• Nebulized anticholinergic is administered in the presence of asthma or COPD (such as Ipratropium bromide 0.5 mg, mixed with Salbutamol)

• Intramuscular Adrenaline is administered in the presence of anaphylaxis.

• Decompression is performed in case of tension pneumothorax.

• The chance of heart attack or acute coronary syndrome is considered. If present medications such as nitrates, Aspirin, and Morphine are administered, thrombolysis and heparinization are also considered depending on the need.

Treatment During Transportation: In addition to the above immediate medical interventions, the following are considered:

• Nebulized beta-2 bronchodilators (Salbutamol).

• Intravenous fluids ( for asthma and anaphylaxis).

• Intravenous or oral corticosteroids (for asthma and anaphylaxis).

• Antihistamines (for anaphylaxis).

• Pain relieving medications if needed.

A definitive diagnosis is made once the patient reaches the hospital. Treatment for shortness of breath (dyspnea) depends on the underlying cause or condition. For example, fluid in the chest is drained in case of pleural effusion. Depending on the cause of dyspnea, it is treated with medical interventions, medications, and surgery.

Conclusion

Dyspnea is shortness of breath or increased work of breathing that is commonly seen in patients with underlying lung or heart conditions. About a third of patients calling for emergency medical help have shortness of breath as a symptom of their underlying disease. Patients who experience sudden severe dyspnea (struggling to breathe) along with chest pain and signs of other heart or lung diseases must seek emergency care as they might have a heart attack, respiratory failure, or other life-threatening conditions.