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Shortness of breath

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Shortness of breath(SOB), known asdyspnea(inAmE) ordyspnoea(inBrE), is an uncomfortable feeling of not being able tobreathewell enough. TheAmerican Thoracic Societydefines 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 its distinct sensations, the degree of distress and discomfort involved, and its burden or impact on the patient'sactivities of daily living.Distinct sensations include effort/work to breathe, chest tightness or pain, and "air hunger" (the feeling of not enough oxygen).[1]Thetripod positionis often assumed to be a sign.

Shortness of breath
Other namesDyspnea, dyspnoea, breathlessness, difficulty (in/of) breathing; respiratory distress
Pronunciation
SpecialtyPulmonology

Dyspnea is a normalsymptomof heavy physicalexertionbut becomespathologicalif it occurs in unexpected situations,[2]when resting or during light exertion. In 85% of cases it is due toasthma,pneumonia,cardiac ischemia,COVID-19,interstitial lung disease,congestive heart failure,chronic obstructive pulmonary disease,orpsychogeniccauses,[2][3]such aspanic disorderandanxiety(seePsychogenic diseaseandPsychogenic pain).[4]The best treatment to relieve or even remove shortness of breath[5]typically depends on the underlying cause.[6]

Definition

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Dyspnea, in medical terms, is "shortness of breath".

TheAmerican Thoracic Societydefines dyspnea as:

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.[7]

Other definitions describe it as "difficulty in breathing",[8]"disordered or inadequate breathing",[9]"uncomfortable awareness of breathing",[3]and as the experience of "breathlessness" (which may be either acute or chronic).[2][6][10]

Causes

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Further information:List of causes of shortness of breath

While shortness of breath is generally caused by disorders of thecardiacorrespiratory system,others such as theneurological,[11]musculoskeletal,endocrine,hematologic,and psychiatric systems may be the cause.[12]DiagnosisPro, an onlinemedical expert system,listed 497 distinct causes in October 2010.[13]The most common cardiovascular causes aremyocardial infarctionandheart failurewhile common pulmonary causes includechronic obstructive pulmonary disease,asthma,pneumothorax,pulmonary edemaandpneumonia.[2]On a pathophysiological basis the causes can be divided into: (1) an increased awareness of normal breathing such as during an anxiety attack, (2) an increase in the work of breathing and (3) an abnormality in the ventilatory or respiratory system.[11]Ischemic strokes, hemorrhages, tumors, infections, seizures, and traumas at the brain stem can also cause shortness of breath, making them the only neurological causes of shortness of breath.

The tempo of onset and the duration of dyspnea are useful in knowing the etiology of dyspnea. Acute shortness of breath is usually connected with sudden physiological changes, such aslaryngeal edema,bronchospasm,myocardial infarction,pulmonary embolism,orpneumothorax.Patients with COPD and idiopathic pulmonary fibrosis (IPF) have a mild onset and gradual progression of dyspnea on exertion, punctuated by acute exacerbations of shortness of breath. In contrast, most asthmatics do not have daily symptoms, but have intermittent episodes of dyspnea, cough, and chest tightness that are usually associated with specific triggers, such as an upper respiratory tract infection or exposure to allergens.[14]

Acute coronary syndrome

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Acute coronary syndromefrequently presents with retrosternalchest discomfortand difficulty catching the breath.[2]It however may atypically present with shortness of breath alone.[15]Risk factors include old age,smoking,hypertension,hyperlipidemia,anddiabetes.[15]Anelectrocardiogramandcardiac enzymesare important both for diagnosis and directing treatment.[15]Treatment involves measures to decrease the oxygen requirement of the heart and efforts to increase blood flow.[2]

COVID-19

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Main article:COVID-19

People that have been infected byCOVID-19may have symptoms such as a fever, dry cough, loss of smell and taste, and in moderate to severe cases, shortness of breath.[citation needed]

Congestive heart failure

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Congestive heart failurefrequently presents with shortness of breath with exertion,orthopnea,andparoxysmal nocturnal dyspnea.[2]It affects between 1 and 2% of the general United States population and occurs in 10% of those over 65 years old.[2][15]Risk factors foracute decompensationinclude high dietarysaltintake, medication noncompliance, cardiac ischemia,abnormal heart rhythms,kidney failure,pulmonary emboli,hypertension,and infections.[15]Treatment efforts are directed towards decreasing lung congestion.[2]

Chronic obstructive pulmonary disease

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People withchronic obstructive pulmonary disease(COPD), most commonlyemphysemaorchronic bronchitis,frequently have chronic shortness of breath and a chronic productive cough.[2]Anacute exacerbationpresents with increased shortness of breath andsputumproduction.[2]COPDis a risk factor forpneumonia;thus this condition should be ruled out.[2]In an acute exacerbation treatment is with a combination ofanticholinergics,beta2-adrenoceptor agonists,steroidsand possiblypositive pressure ventilation.[2]

Asthma

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Asthmais the most common reason for presenting to the emergency room with shortness of breath.[2]It is the most common lung disease in both developing and developed countries affecting about 5% of the population.[2]Other symptoms includewheezing,tightness in the chest, and a non productive cough.[2] Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate.[16]Acute symptoms are treated with short-acting bronchodilators.[citation needed]

Pneumothorax

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Main article:Pneumothorax

Pneumothoraxpresents typically withpleuritic chest painof acute onset and shortness of breath not improved with oxygen.[2]Physical findings may include absent breath sounds on one side of the chest,jugular venous distension,and tracheal deviation.[2]

Pneumonia

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The symptoms ofpneumoniaarefever,productive cough,shortness of breath, andpleuritic chest pain.[2]Inspiratorycracklesmay be heard on exam.[2]A chest x-ray can be useful to differentiate pneumonia fromcongestive heart failure.[2]As the cause is usually a bacterial infection,antibioticsare typically used for treatment.[2]

Pulmonary embolism

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Pulmonary embolismclassically presents with an acute onset of shortness of breath.[2]Other presenting symptoms includepleuritic chest pain,cough,hemoptysis,andfever.[2]Risk factors includedeep vein thrombosis,recent surgery,cancer,and previousthromboembolism.[2]It must always be considered in those with acute onset of shortness of breath owing to its high risk of mortality.[2]Diagnosis, however, may be difficult[2]andWells Scoreis often used to assess the clinical probability. Treatment, depending on severity of symptoms, typically starts withanticoagulants;the presence of ominous signs (low blood pressure) may warrant the use ofthrombolytic drugs.[2]

Anemia

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Anemiathat develops gradually usually presents with exertional dyspnea, fatigue, weakness, andtachycardia.[17]It may lead toheart failure.[17]Anaemia is often a cause of dyspnea. Menstruation, particularly if excessive, can contribute to anaemia and to consequential dyspnea in women. Headaches are a symptom of dyspnea in patients with anaemia. Some patients report a numb sensation in their head, and others have reported blurred vision caused by hypotension behind the eye due to a lack of oxygen and pressure; these patients have reported severe head pains, which can lead to permanent brain damage. Symptoms can include loss of concentration, focus, fatigue, language faculty impairment, and memory loss.[18][citation needed]

Cancer

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Shortness of breath is common in people with cancer and may be caused by numerous different factors. In people with advanced cancer, periods of time with severe shortness of breath may occur, along with a more continuous feeling of breathlessness.[19]Treatments include both nonpharmacological and pharmacological interventions. Nonpharmacological interventions that showed improvement in breathlessness include fans, behavioral and pyschoeducational approaches, exercise and pulmonary rehabilitation. Integrative medicine options include acupuncture/acupressure/reflexology, meditation and music therapy, with acupuncture/reflexology found to have a beneficial effect.[20]

Other

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Other important or common causes of shortness of breath includecardiac tamponade,anaphylaxis,interstitial lung disease,panic attacks,[6][12][17]andpulmonary hypertension.It is more common among people with relatively small lungs.[21]Around 2/3 of women experience shortness of breath as a part of a normalpregnancy.[9]

Cardiac tamponade presents with dyspnea, tachycardia, elevated jugular venous pressure, andpulsus paradoxus.[17]The gold standard for diagnosis isultrasound.[17]

Anaphylaxis typically begins over a few minutes in a person with a previous history of the same.[6]Other symptoms includeurticaria,throat swelling,and gastrointestinal upset.[6]The primary treatment isepinephrine.[6]

Interstitial lung disease presents with gradual onset of shortness of breath typically with a history of a predisposing environmental exposure.[12]Shortness of breath is often the only symptom in those withtachydysrhythmias.[15]

Panic attacks typically present withhyperventilation,sweating, andnumbness.[6]They are however adiagnosis of exclusion.[12]

Neurological conditions such as spinal cord injury, phrenic nerve injuries,Guillain–Barré syndrome,amyotrophic lateral sclerosis,multiple sclerosisandmuscular dystrophycan all cause an individual to experience shortness of breath.[11]Shortness of breath can also occur as a result ofvocal cord dysfunction(VCD).[22]

Sarcoidosisis an inflammatory disease of unknown etiology that generally presents with dry cough, fatigue, and shortness of breath, although multiple organ systems may be affected, with involvement of sites such as the eyes, the skin and the joints.[23]

Pathophysiology

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Different physiological pathways may lead to shortness of breath including viaASICchemoreceptors,mechanoreceptors,andlung receptors.[15]

It is thought that three main components contribute to dyspnea: afferent signals, efferent signals, and central information processing. It is believed the central processing in the brain compares the afferent and efferent signals; and dyspnea results when a "mismatch" occurs between the two: such as when the need for ventilation (afferent signaling) is not being met by physical breathing (efferent signaling).[24]

Afferent signals are sensory neuronal signals that ascend to the brain. Afferent neurons significant in dyspnea arise from a large number of sources including thecarotid bodies,medulla,lungs,andchest wall.Chemoreceptors in the carotid bodies and medulla supply information regarding the blood gas levels of O2,CO2and H+.[25]In the lungs,juxtacapillary (J) receptorsare sensitive to pulmonary interstitial edema, while stretch receptors signal bronchoconstriction.Muscle spindlesin the chest wall signal the stretch and tension of the respiratory muscles. Thus, poor ventilation leading tohypercapnia,left heart failureleading to interstitial edema (impairing gas exchange),asthmacausing bronchoconstriction (limiting airflow) and muscle fatigue leading to ineffective respiratory muscle action could all contribute to a feeling of dyspnea.[24]

Efferent signals are the motor neuronal signals descending to therespiratory muscles.The most important respiratory muscle is thediaphragm.Other respiratory muscles include the external and internalintercostal muscles,the abdominal muscles and the accessory breathing muscles.[26]As the brain receives its plentiful supply of afferent information relating to ventilation, it is able to compare it to the current level of respiration as determined by the efferent signals. If the level of respiration is inappropriate for the body's status then dyspnea might occur. There is also a psychological component to dyspnea, as some people may become aware of their breathing in such circumstances but not experience the typical distress of dyspnea.[24]

Diagnosis

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MRC breathlessness scale
Grade Degree of dyspnea
1 no dyspnea except with strenuous exercise
2 dyspnea when walking up an incline or hurrying on the level
3 walks slower than most on the level, or stops after 15 minutes of walking on the level
4 stops after a few minutes of walking on the level
5 with minimal activity such as getting dressed, too dyspneic to leave the house
Signs of respiratory distress illustration

The initial approach to evaluation begins by assessment of theairway, breathing, and circulationfollowed by amedical historyandphysical examination.[2]Signs and symptoms that represent significant severity includehypotension,hypoxemia,tracheal deviation,altered mental status, unstabledysrhythmia,stridor,intercostal indrawing,cyanosis,tripod positioning,pronounced use of accessory muscles (sternocleidomastoid,scalenes) and absent breath sounds.[12]

A number of scales may be used to quantify the degree of shortness of breath.[27]It may be subjectively rated on a scale from 1 to 10 with descriptors associated with the number (The ModifiedBorg Scale).[27]TheMRCbreathlessness scale suggests five grades of dyspnea based on the circumstances and severity in which it arises.[28]

Blood tests

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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.[15]A low level ofbrain natriuretic peptideis useful in ruling out congestive heart failure; however, a high level, while supportive of the diagnosis, could also be due to advanced age,kidney failure,acute coronary syndrome, or a large pulmonary embolism.[15]

Imaging

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Achest x-rayis useful to confirm or rule out a pneumothorax,pulmonary edema,orpneumonia.[15]Spiralcomputed tomographywith intravenousradiocontrastis the imaging study of choice to evaluate for pulmonary embolism.[15]

Treatment

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The primary treatment of shortness of breath is directed at its underlying cause.[6]Extra supplementaloxygenis effective in those withhypoxia;however, this has no effect in those with normalblood oxygen saturations.[3][29]

Physiotherapy

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Individuals can benefit from a variety ofphysical therapyinterventions.[30]Persons with neurological/neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal, abdominal and/or other muscles needed forventilation.[31]Some physical therapy interventions for this population include active assistedcoughtechniques,[32]volume augmentation such as breath stacking,[33]education about body position and ventilation patterns[34]and movement strategies to facilitate breathing.[33]Pulmonary rehabilitationmay alleviate symptoms in some people, such as those with COPD, but will not cure the underlying disease.[35][36]Fan therapy to the face has been shown to relieve shortness of breath in patients with a variety of advanced illnesses including cancer.[37]The mechanism of action is thought to be stimulation of the trigeminal nerve.

Palliative medicine

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Systemic immediate releaseopioidsare beneficial in emergently reducing the symptom severity of shortness of breath due to both cancer and non cancer causes;[3][38]long-acting/sustained-release opioids are also used to prevent/continue treatment of dyspnea in palliative setting. There is a lack of evidence to recommendmidazolam,nebulised opioids, the use of gas mixtures, orcognitive-behavioral therapyyet.[39]

Non-pharmacological techniques

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Non-pharmacological interventionsprovide key tools for the management of breathlessness.[19]Potentially beneficial approaches include active management ofpsychosocialissues (anxiety,depression,etc.), and implementation ofself-managementstrategies, such as physical and mentalrelaxation techniques,pacing techniques, energy conservation techniques, learning exercises to control breathing, andeducation.[19]The use of a fan may possibly be beneficial.[19]Cognitive behavioural therapymay also be helpful.[19]

Pharmacological treatment

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For people with severe, chronic, or uncontrollable breathlessness, non-pharmacological approaches to treating breathlessness may be combined with medication. For people who have cancer that is causing the breathlessness, medications that have been suggested include opioids, benzodiazepines, oxygen, and steroids.[19]Results of recent systematic reviews and meta-analyses found opioids were not necessarily associated with more effectiveness in treatment for patients with advanced cancer.[40][41]

Ensuring that the balance between side effects and adverse effects from medications and potential improvements from medications needs to be carefully considered before prescribing medication.[19]The use of systematic corticosteriods in palliative care for people with cancer is common, however the effectiveness and potential adverse effects of this approach in adults with cancer has not been well studied.[19]

Epidemiology

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Shortness of breath is the primary reason 3.5% of people present to theemergency departmentin the United States. Of these individuals, approximately 51% are admitted to the hospital and 13% are dead within a year.[42]Some studies have suggested that up to 27% of hospitalized people develop dyspnea,[43]while in dying patients 75% will experience it.[24]Acute shortness of breath is the most common reason people requiringpalliativecare visit an emergency department.[3]Up to 70% of adults with advanced cancer also experience dyspnoea.[19]

Etymology and pronunciation

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Englishdyspneacomes fromLatindyspnoea,fromGreekdyspnoia,fromdyspnoos,which literally means "disordered breathing".[12][44]Itscombining forms(dys-+-pnea) are familiar from other medical words, such asdysfunction(dys-+function) andapnea(a-+-pnea). The most common pronunciation in medical English is/dɪspˈniːə/disp-NEE-ə,with thepexpressed and thestresson the /niː/ syllable. But pronunciations with asilentpinpn(as also inpneumo-) are common (/dɪsˈniːə/or/ˈdɪsniə/),[45]as are those with the stress on the first syllable[45](/ˈdɪspniə/or/ˈdɪsniə/).

In English, the various-pnea-suffixedwords commonly used inmedicinedo not follow one clear pattern as to whether the /niː/ syllable or the one preceding it is stressed; thepis usually expressed but is sometimes silent depending on the word. The followingcollationor list shows thepreponderanceof how major dictionaries pronounce and transcribe them (less-used variants are omitted):

Group Term Combining forms Preponderance of transcriptions (major dictionaries)
good eupnea eu-+-pnea /juːpˈniːə/yoop-NEE-ə[46][47][45][48]
bad dyspnea dys-+-pnea /dɪspˈniːə/disp-NEE-ə,[47][48][49]/ˈdɪspniə/DISP-nee-ə[46][45]
fast tachypnea tachy-+-pnea /ˌtækɪpˈniːə/TAK-ip-NEE-ə[46][47][45][48][49]
slow bradypnea brady-+-pnea /ˌbreɪdɪpˈniːə/BRAY-dip-NEE-ə[47][45][48]
upright orthopnea ortho-+-pnea /ɔːrˈθɒpniə/or-THOP-nee-ə,[47][45][49][46]: audio /ɔːrθəpˈniːə/or-thəp-NEE-ə[45][46]: print 
supine platypnea platy-+-pnea /pləˈtɪpniə/plə-TIP-nee-ə[46][47]
bent over bendopnea bend+-o-+-pnea /bɛndˈɒpniə/bend-OP-nee-ə
excessive hyperpnea hyper-+-pnea /ˌhaɪpərpˈniːə/HY-pərp-NEE-ə[46][47][45][48]
insufficient hypopnea hypo-+-pnea /haɪˈpɒpniə/hy-POP-nee-ə,[46][47][48][49]/ˌhaɪpəpˈniːə/high-pəp-NEE-ə[45][48]
absent apnea a-+-pnea /ˈæpniə/AP-nee-ə,[46][47][45][48][49]: US /æpˈniːə/ap-NEE-ə[45][48][49]: UK 

See also

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References

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Look updyspnea,dyspnoea,breathlessness,orrespiratory distressin Wiktionary, the free dictionary.

Shortness Of Breath (Dyspnea)StatPearls

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