At a glance......
- 1 Pathophysiology
- 2 Causes of Dyspnea
- 3 Symptoms of Dyspnea
- 4 Diagnosis of Dyspnea
- 5 Treatment of Dyspnea
- 5.1 Initial Stage
- 5.2 Pharmacological Treatment
- 5.3 Symptom-Based Medications
- 5.4 Non-Pharmacologic Therapies
- 5.5 Diet and exercise
- 5.6 Pulmonary rehabilitation
- 5.7 Cardiac rehabilitation
- 5.8 Physiotherapy and Pulmonary Rehabilitation
- 5.9 Palliative Medicine
- 5.10 Try a Humidifier
- 5.11 Practice Helpful Breathing Techniques
- 5.12 Reduce Stress and Relax Daily
- 5.13 Change Your Angle or Outlook
- 5.14 Try Acupressure and/or Acupuncture
- 5.15 Dyspnea Precautions
- 5.16 References
- 5.17 People Also Reading
Dyspnea has been defined as shortness of breath or perceived difficulty breathing or an uncomfortable breathing sensation. In general, dyspnea is distressful or unpleasant in nature [rx–rx]. This is in contrast to the athlete who might not perceive dyspnea despite exercising at a very high-intensity since a degree of respiratory difficulty is expected and not distressful or upsetting.
The word “dyspnea” is derived from the Greek roots dys, meaning difficult, and pneuma meaning breath. Dyspnea, or breathlessness, is a common and oppressive symptom experienced by many patients throughout the trajectory of life-limiting illness. Dyspnea may be related to the illness, its comorbidities, therapy for either, or hypoxia. Often it is the result of a combination of all these.
Shortness of breath, also known as dyspnea, is the feeling that one cannot breathe well enough. The American Thoracic Society defines it as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity”, and recommends evaluating dyspnea by assessing the intensity of the distinct sensations, the degree of distress involved, and its burden or impact on activities of daily living. Distinct sensations include effort/work, chest tightness, and air hunger (the feeling of not enough oxygen).[RX]
Dyspnea is a sensation of running out of the air and of not being able to breathe fast enough or deeply enough. It results from multiple interactions of signals and receptors in the CNS, peripheral receptors chemoreceptors, and mechanoreceptors in the upper airway, lungs, and chest wall.
The respiratory center of the brain is comprised of 3 neuron groupings in the brain: the dorsal and ventral medullary groups and the pontine grouping. The pontine grouping further classifies into the pneumatic and apneustic centers. The dorsal medulla is responsible for inhalation; the ventral medulla is responsible for exhalation; the pontine groupings are responsible for modulating the intensity and frequency of the medullary signals where the pneumatic groups limit inhalation and the apneustic centers prolong and encourage inhalation. Each of these groups communicates the another to work together for the pacemaking potential of respiration.
Mechanoreceptors located in the airways, trachea, lung, and pulmonary vessels exist to provide sensory information to the respiratory center of the brain regarding the volume of the lung space. There are 2 primary types of thoracic sensors: slow adapting stretch spindles and rapid adapting irritant receptors. Slow-acting spindle sensors convey only volume information. However, the rapid-acting receptors respond to both volumes of the lung information and chemical irritation triggers such as harmful foreign agents that may be present. Both types of mechanoreceptors signal via cranial nerve X (the vagus nerve) to the brain to increase the rate of breathing, the volume of breathing, or to stimulate errant coughing patterns of breathing secondary to irritants in the airway.
Peripheral chemoreceptors consist of the carotid and aortic bodies. Both sites function to monitor the partial pressure of arterial oxygen in the blood. However, hypercapnia and acidosis increase the sensitivity of these sensors, thus playing a partial role in the receptor’s function. The carotid bodies are located at the bifurcation of the common carotid arteries, and the aortic bodies are located within the aortic arch. Once stimulated by hypoxia, they send a signal via cranial nerve IX (the glossopharyngeal nerve) to the nucleus tractus solitaries in the brain which, in turn, stimulates excitatory neurons to increase ventilation. It has been estimated that the carotid bodies comprise of 15% the total driving force of respiration.
Central chemoreceptors hold the majority of control over the respiratory drive. They function through sensing pH changes within the CNS. Primary locations within the brain include the ventral surface of the medulla and the retrotrapezoid nucleus. The pH change within the brain and surrounding cerebrospinal fluid are derived primarily by increases or decreases in carbon dioxide levels. Carbon dioxide is a soluble lipid molecule that freely diffuses across the blood-brain barrier. This characteristic proves to be rather useful in that rapid changes in pH within the cerebrospinal fluid are possible. Chemoreceptors responsive to pH change are located on the ventral surface of the medulla. As these areas become acidic, sensory input is generated to stimulate hyperventilation, and carbon dioxide within the body is reduced through the increased ventilation. When pH rises to more alkalotic levels, hypoventilation occurs, and carbon dioxide levels decrease secondary to decreased ventilation.
Respiratory centers located within the medulla oblongata and pons of the brainstem are responsible for generating the baseline respiratory rhythm. However, the rate of respiration is modified by allowing for aggregated sensory input from the peripheral sensory system which monitors oxygenation, and the central sensory system which monitors pH, and indirectly, carbon dioxide levels along with several other portions of the cerebellar brain modulate to create a unified neural signal. The signal is then sent to the primary muscles of respiration, the diaphragm, external intercostals, and scalene muscles along with other minor muscles of respiration.
Causes of Dyspnea
- Dyspnea is a symptom of the disease, rather than a disease itself. As such, its etiology can be designated as arising from four primary categories: respiratory, cardiac, neuromuscular, psychogenic, systemic illness, or a combination of these.
- Respiratory causes may include asthma, acute exacerbation of or chronic congestive obstructive pulmonary disorder (COPD), pneumonia, pulmonary Embolism, lung malignancy, pneumothorax, or aspiration.
- Cardiovascular causes may include congestive heart failure, pulmonary edema, acute coronary syndrome, pericardial tamponade, valvular heart defect, pulmonary hypertension, cardiac arrhythmia, or intracardiac shunting.
- Neuromuscular causes may include chest trauma with fracture or flail chest, massive obesity, kyphoscoliosis, central nervous system (CNS) or spinal cord dysfunction, phrenic nerve paralysis, myopathy, and neuropathy.
- Psychogenic causes may include hyperventilation syndrome, psychogenic dyspnea, vocal cord dysfunction syndrome, and foreign body aspiration.
Electrolyte abnormalities and channelopathies form a substrate for reentry arrhythmias.
A mechanical force such as the chest thump maneuver induces but also terminates reentry.[rx]
Chronic cardiac stretch leads to remodeling and fibrosis that changes the electrical properties of the myocardiocytes.
Scar tissue following infarction is the basis of anatomical reentry.
Congenital heart disease and surgery performed to treat it can cause reentry.
Genetic culprits are related to reentry tachycardias. Roberts et al. identified genetic culprits SCN5A and LMNA as a cause of idiopathic bundle branch reentry ventricular tachycardia.[rx]
Hypertensive heart disease
Coronary artery disease
Valvular heart disease
Congenital heart disease
Infiltrative cardiac disease
Sick sinus syndrome
Chronic lung disease
Post-surgical (seen in 35% to 50% of patients post coronary artery bypass graft)[rx]
A Number Of Factors Can Cause The Heart and Lung To Work Incorrectly, They Include
- Alcohol abuse
- Drug abuse
- Excessive coffee consumption
- Heart disease like congestive heart failure
- Hypertension (high blood pressure)
- Hyperthyroidism (an overactive thyroid gland)
- Mental stress
- Scarring of the heart, often the result of a heart attack
- Some dietary supplements
- Some herbal treatments
- Some medications
- Structural changes in the heart
Obstructive sleep apnea
Chronic kidney disease
Atrial flutter with variable block
Atrial tachycardia (AT)
Multifocal atrial tachycardia (MAT)
Wolff-Parkinson-White syndrome (WPW)
Atrioventricular nodal reentry tachycardia (AVNRT)
Atrioventricular reentry tachycardia (AVRT)
Junctional ectopic tachycardia
Symptoms of Dyspnea
- Shortness of breath after exertion or due to a medical condition
- Feeling smothered or suffocated as a result of breathing difficulties
- Labored breathing
- Tightness in the chest
- Rapid, shallow breathing
- Heart palpitations
- Clearly audible, loud, labored breathing
- An anxious, distressed facial expression
- Flaring nostrils
- Protrusion of the abdomen and/or chest
- Cyanosis (pale or blue face, mouth, lips, or extremities)
- Bloody sputum,
- Chest injury
- Chest pain,
- Chest tightness
- Heart palpitations,
- Labored breathing,
- Neck pain,
- Pain with inspiration (pleurisy),
If dyspnea occurs suddenly or if symptoms are severe, it may be a sign of a serious medical condition.
Diagnosis of Dyspnea
- A number of labs may be helpful in determining the cause of shortness of breath. D-dimer, while useful to rule out a pulmonary embolism in those who are at low risk, is not of much value if it is positive, as it may be positive in a number of conditions that lead to shortness of breath.[rx]
- A low level of brain natriuretic peptide is useful in ruling out congestive heart failure; however, a high level, while supportive of the diagnosis, could also be due to advanced age, renal failure, acute coronary syndrome, or a large pulmonary embolism.[rx]
- Pulse oximetry – a device is clipped to your finger or ear lobe, and a light on it measures how much oxygen is in your blood.
- Blood tests, including a complete blood count (CBC) – to see if you have anemia (when your body doesn’t make enough red blood cells) or infection and other tests to check for a blood clot or fluid in your lungs.
- Chest X-ray or a computerized tomography (CT) scan – to see if you have pneumonia, blood clot in your lung, or another lung disease. A CT scan puts several X-rays taken from different angles together to make a more complete picture.
- Electrocardiogram (ECG) – to measure the electrical signals from your heart to see if you’re having a heart attack and find out how fast your heart is beating and if it has a healthy rhythm.
- Patients should be tested for electrolyte abnormalities – endocrine disorders (specifically hyperthyroid) drug-induced causes, infections, drug or chemical withdrawal, and echocardiography to check for structural heart disease. In patients presenting with ischemic stroke and with no prior history of AF, 72-hour Holter monitoring improves the detection rate of silent paroxysmal.[rx]
- Screening spirometry – Can assess how much air you can breathe
- Complete pulmonary function testing – Can evaluate your breathing capabilities in more detail than screening spirometry by measuring how much air you can breathe in and out, as well as how quickly
- Arterial blood gas measurement – Provides a measure of the oxygen content of your blood, which alerts your doctors if you are becoming low in oxygen
- Echocardiography – May be ordered if your EKG suggests that you have heart disease
- Standard exercise treadmill testing – Evaluates your breathing when you have increased oxygen demands
- Complete cardiopulmonary exercise testing – Evaluates your heart and lung function in detail
Treatment of Dyspnea
An important step in managing dyspnea is treating the cause, such as the tumor or a blood clot. The doctor may also recommend the following to help relieve your symptoms
- Receiving extra oxygen
- Sitting in front of a fan
- Breathing cooler air by lowering the temperature in a room
- Breathing cleaner air by opening a window, using a humidifier, or getting rid of smoke and pet dander
- Getting a sense of open space by seeing a view of the outside, opening windows, or being in an empty room
- Keeping your head lifted, for example, by using pillows so that you are nearly sitting
- Practicing techniques that take your focus away from the problem, such as relaxation and meditation
- Taking pain medications, such as morphine, nitroglycerin, montelukast that help control the central nervous system.
- Bronchodilators to open your airways
- Steroids to help reduce swelling in the lungs
- Antianxiety medicines to help break the cycle of panic. This cycle can lead to more breathing problems.
- Pain medicines to make breathing easier
There are pharmacologic and non-pharmacologic treatments. Pharmacologic interventions can be thought of as disease-modifying when they treat the underlying disease that triggered the dyspnea. A symptom-based approach aims to reduce awareness of the intensity and discomfort of dyspnea.[rx][rx]
- Antianxiety medications – If you are experiencing anxiety with your dyspnea, depending on the cause, your healthcare provider may prescribe an anti-anxiety medication, called an anxiolytic. These medications will help you to relax. These may include lorazepam or alprazolam. It is important to take these medications only when you are feeling anxious. Do not operate heavy machinery, or drive an automobile while taking these. These medications must be used very cautiously if you have severe dyspnea. Discuss the risks and benefits of taking this medication with your doctor or healthcare provider.
- Antibiotics – If your doctor or healthcare provider suspects that you have a lung infection, he or she may order antibiotic pills or intravenous (IV), depending on how severe your illness is, and your overall health status. Commonly prescribed antibiotics for bronchitis, pneumonia and respiratory (breathing) problems include azithromycin and levofloxacin. If you are prescribed antibiotic pills, take the full prescription. Do not stop taking pills once you feel better.
- Anticoagulants – These medications prevent your blood from clotting, or may be ordered by your healthcare provider if you have a blood clot. Each of them works in a variety of ways. Depending on your overall health status, the kind of chemotherapy you are receiving, and the location of the blood clot, your healthcare provider may suggest warfarin sodium or enoxaparin ).
- Anticholinergic agents – these drugs are given to persons with chronic bronchitis, emphysema, and chronic obstructive lung disease (COLD). Anticholinergic agents work in a complex manner by relaxing the lung muscles, which will help you to breathe easier. A commonly prescribed drug is ipratropium bromide.
- Bronchodilators – These drugs work by opening (or dilating) the lung passages, and offering relief of symptoms, including shortness of breath. These drugs, typically given by inhalation (aerosol), but are also available in pill form.
- Beta-adrenergic receptor agonists (beta-agonists) – Beta-agonists can be considered bronchodilators, as these drugs relax airway smooth muscle, and block the release of substances that cause bronchoconstriction, or narrowing of your lungs if you are having a lung “spasm.” Drugs such as albuterol, or terbutaline, are commonly used.
- Corticosteroids – Steroids work by decreasing inflammation and swelling, which may be present with certain lung disorders. People may benefit from steroids, either inhaled, by pill form, or in the vein (IV).
- Beclomethasone – an inhaled steroid, is useful in the treatment of chronic asthma and bronchitis. Inhaled steroids act directly on the lung tissue, so there are fewer long-term side effects, compared with a pill or IV form.
- People who have an outbreak of severe shortness of breath and airway inflammation may be ordered a steroid pill, such as prednisone, for a short period of time. This is usually given with inhaled steroids.
- Patients with severe asthma may require IV administration of another steroid, methylprednisolone.
- Cough medications/Decongestants – may help you to be more comfortable if you are coughing a lot. Guaifenesin is an active ingredient in many cough medications, may be given alone, but is often combined with other drugs, such as codeine, to help your cough. Guaifenesin may also be combined with pseudoephedrine as a decongestant, or anyone of many medications, depending on your symptoms. Another common medication you may receive is Hydrocodone Bitartrate-Homatropine Methylbromide. This is a narcotic antitussive (anti-cough medication), which will help relieve your cough.
- Diuretics – may be known as “water pills” as they work to prevent or treat lung congestion by making you urinate out extra fluid. Some examples of this medication may include furosemide and Hydrochlorothiazide. You may receive this medication alone or in combination with other medications.
- Oxygen therapy – If you are experiencing shortness of breath at rest, or on exertion, your healthcare provider may see if oxygen therapy is right for you. You may take oxygen when your symptoms are at their worst. For example, some people are only on oxygen at nighttime, and not during the day. Some take oxygen when they are performing activities, but not all the time.
- Disease-Modifying Medications – Diuretics treat fluid overload in congestive heart failure, renal failure, and hepatic failure. Beta-adrenergic agonists and muscarinic antagonists can reduce symptoms in advanced stages of chronic obstructive pulmonary disease.[rx] Oxygen administration can improve dyspnea but only in patients with hypoxemia.
- Opioids – are considered a mainstay of treatment for dyspnea. The evidence is most robust regarding the use of immediate-release morphine. Opioids, via the mu-opioid receptors, reduce the discomfort of air hunger but less the discomfort of the increased effort to breathe. It is theorized that morphine decreases spontaneous respiratory drive and the sensitivity of the central breathing center. Opioids may also affect the cortical processing of dyspnea as they do in the setting of pain.[rx][rx]
- The use of benzodiazepines – reduces the anxiety often associated with dyspnea, but not the sensation of dyspnea.[rx] Nebulized furosemide has some evidence of efficacy in patients with chronic obstructive pulmonary disease (COPD). It is thought to activate pulmonary mechanoreceptors. In animal models, inhaled furosemide increases the activity of pulmonary vagal stretch receptors.[rx]
- Nebulized lidocaine or morphine – has no evidence of benefit. Dexamethasone may be useful to improve dyspnea in lung cancer patients or those with COPD.[rx] Mirtazapine has been shown to have some beneficial effect in patients with chronic dyspnea.[rx]
- Non-invasive ventilation may provide symptomatic improvement in those with increased work of breathing but less helpful in situations of VQ mismatch or alveolar-arterial diffusion defects.
- Cold air and the use of fans blowing air on the face can significantly improve dyspnea. Sensory afferents may mediate this effect in the second and third branch of the trigeminal nerve. Supplemental oxygen has only been shown to be useful in patients with hypoxia.[rx][rx]
- Pulmonary rehabilitation has proven beneficial, with exercise being the most beneficial component. Cognitive-behavioral therapy and anxiety-reduction techniques can address effective components.[rx]
- Caregiver education with an emphasis on patient positioning, a personal crisis plan, and the use of pharmacologic and non-pharmacologic options may help reduce anxiety and provide an increased sense of control. Additionally, caregiver participation in dedicated support groups may help with coping.
Diet and exercise
- If obesity and a poor fitness level are the cause of dyspnea you may be experiencing, eat healthier meals and exercise frequently.
- If it’s been a long time or you have a medical condition that limits your activity level, talk with your doctor about how to begin a safe exercise routine.
- COPD and other lung problems require the care of a pulmonologist, a doctor who specializes in the health of your lungs and respiratory system.
- You may need supplemental oxygen in a portable tank to help keep you from feeling out of breath. Pulmonary rehabilitation may also be helpful. This is a program of supervised exercise and education about breathing techniques to help you overcome lung disease.
- Heart-related causes are treated by a cardiologist, a doctor specializing in heart disorders. If you have heart failure, it means your heart is too weak to pump enough oxygenated blood to meet your body’s requirements. Dyspnea is one of several symptoms of heart failure.
- Cardiac rehabilitation can help you manage heart failure and other heart-related conditions. In serious cases of heart failure, an artificial pump may be needed to take over the blood pumping duties of a weakened heart.
Physiotherapy and Pulmonary Rehabilitation
- Individuals can benefit from a variety of physical therapy interventions.[rx] Persons with neurological/neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal, abdominal and/or other muscles needed for ventilation.[rx]
- Some physical therapy interventions for this population include active assisted cough techniques,[rx] volume augmentation such as breath stacking,[rx] education about body position and ventilation patterns[rx] and movement strategies to facilitate breathing.[rx]
- Pulmonary rehabilitation may alleviate symptoms in some people, such as those with COPD, but will not cure the underlying disease.[rx][rx] Fan therapy to the face has been shown to relieve shortness of breath in patients with a variety of advanced illnesses including cancer. [rx]
- The mechanism of action is thought to be the stimulation of the trigeminal nerve.
- Systemic immediate-release opioids are beneficial in emergently reducing the symptom of shortness of breath due to both cancer and non-cancer causes;[rx][rx] long-acting/sustained-release opioids are also used to prevent/continue treatment of dyspnea in the palliative setting.
- There is a lack of evidence to recommend midazolam, nebulized opioids, the use of gas mixtures, or cognitive-behavioral therapy.[rx]
Try a Humidifier
- If the air in your home is too dry, which can easily occur with heat use in the winter, you may want to try using a humidifier. The moist air produced by a humidifier can really help improve dry nasal passages and make breathing feel easier.
- According to Mayo Clinic, humidifiers are known to improve respiratory conditions. Just make sure to keep your humidifier clean since a dirty one can harbor mold or bacteria. If you know you have allergies or asthma, check with your doctor to make sure a humidifier is a good choice for you. [rx]
Practice Helpful Breathing Techniques
One way to recover from an episode of shortness of breath due to coughing or physical activity is to: [rx]
- Tilt your chin down to your chest.
- Breathe out through your lips in short bursts 10 times.
- When your neck muscles feel less stressed, breathe in through your nose.
- Breathe out through pursed lips three times.
- Breathe in through your nose for four counts.
- Breathe out through an open mouth making an “ah” sound for eight counts.
- Repeat three times.
Another helpful breathing exercise called “quick sniffles” can help to strengthen the diaphragm, which is your principal muscle of respiration. Simply close your mouth and then breathe in and out of your nose quickly for 15 to 30 seconds. Aim to do this exercise several times, until you reach 60 seconds.
Reduce Stress and Relax Daily
- In addition to breathing exercises, which are excellent for stress reduction, you my also want to try some other techniques known for their calming effects, including yoga, prayer, and meditation. These practices can be incorporated into your daily life so you can reap their health benefits on a regular basis and hopefully feel calmer, which always helps to make optimal breathing come easier. A tense body is an antithesis of good, healthy breathing, so do what you can to release tension daily.
- Massage therapy is another great way to boost mood and overall wellness. A scientific article published in 2018 points out how after a massage, levels of the stress hormone cortisol are reduced, while levels of serotonin and dopamine (two happiness-inducing neurotransmitters) are increased. [rx]
Change Your Angle or Outlook
- For people with dyspnea, especially people with orthopnea (dyspnea when lying flat), keeping the head lifted can really help to improve symptoms. You can use pillows to keep yourself propped up to a level that makes you feel more comfortable and helps you to breathe easier.
- When you feel like breathing is difficult, it can make you feel very smothered and confined. If you can, increase your perception of openness around you by opening a nearby window, going into a bigger or emptier room, going outside or simply taking in a pleasant view of the outdoors. These are all simple yet effective ways to give yourself a helpful feeling of having more open space, which may feel like more room to breathe.
Try Acupressure and/or Acupuncture
- Experts say both acupressure and acupuncture can help some people feel less short of breath. Both practices focus on the meridians and acupressure points of the body to optimize energy flow and release blockages. Both are generally very relaxing and helpful.
If you experience unexplained shortness of breath, especially if it comes on suddenly and is severe, seek emergency medical attention. If your shortness of breath is accompanied by chest pain, nausea or fainting, it’s possible you are experiencing a heart attack or pulmonary embolism.
It’s also important to see your doctor if you have shortness of breath as well as:
- Wheezing or a cough
- Difficulty breathing when you lie flat (orthopnea)
- High fever or chills
- Swelling in your feet and ankles
- What is dyspnea? It’s the sensation of difficult or labored breathing.
- Dyspnea is a symptom, not a health condition. It can be acute or chronic and has many possible causes.
- Is orthopnea the same as dyspnea? Orthopnea is shortness of breath (dyspnea) that occurs when lying flat.
- Once you know the underlying cause of your dyspnea, you should address the root cause with the help of a healthcare professional.
- Improving your surrounding air quality and flow
- Using a humidifier
- Practicing helpful breathing techniques
- Reducing stress and relaxing daily by practicing yoga, prayer, meditation or whatever you find to be most helpful
- Changing your angle or outlook
- Trying acupressure, acupuncture and/or massage therapy
- Remember that you should ALWAYS seek emergency medical attention if you experience unexplained shortness of breath, especially if it comes on suddenly, is severe or is accompanied by other symptoms.