Shortness of Breath

Shortness of breath or dyspnea is a very common condition affecting almost 25% of people. It is one of the reasons that make a person seek medical assistance or for an emergency check-up. It is caused due to many underlying conditions and sometimes may be a symptom of certain life-threatening diseases. At present, there is limited data regarding the exact incidences and outcomes of people who seek hospital services for shortness of breath. In healthy people, shortness of breath is common after exercise, going on high altitudes, exposure to extreme temperatures or in obesity. If there are other reasons that cause shortness of breath, it is best to visit a GP or a specialist.

What is Dyspnoea (shortness of breath)?

As per the American thoracic society, dyspnoea is defined as a feeling of discomfort during breathing with distinct sensations that differ in intensity. Dyspnea or shortness of breath can be caused due to various reasons, ranging from respiratory conditions like bronchial asthma to non-respiratory conditions such as diabetic ketoacidosis. A person during an asthma attack or a person with respiratory failure may complain of shortness of breath, but for very different reasons. Identifying the exact cause for their dyspnea can be a time consuming and tedious process, especially when multiple organ systems are involved.

It is important to differentiate between the types of dyspnoea:

• Tachypnea
  This refers to an increase in the breathing pattern beyond the normal limit.
• Hyperventilation
  Increased breathing due to increased metabolic demands is called hyperventilation.
• Orthopnea
  It refers to a feeling of restlessness on lying down.
• Paroxysmal nocturnal dyspnea
  It refers to a feeling of shortness of breath that occurs 1 to 2 hours after sleep which awakens the person and is usually relieved by sitting upright.

Some uncommon types of dyspnoea include:

• Trepopnea
  Shortness of breath that is experienced by the person when lying down on the side.
• Platypnea
  Rapid breathing that occurs while sitting in an upright position, which gets better on lying down is called platypnea.

Symptoms of dyspnea can be sudden (acute) or gradual (chronic) in onset. Acute shortness of breath begins within a few minutes to a few hours. It may be accompanied with other symptoms like a cough, fever, rash or chest pain.  In chronic dyspnea, the person feels short of breath while performing daily tasks such as walking from one room to another or standing from a sitting position. In certain conditions, rapid breathing may get triggered or worsened from changing body positions. Other symptoms include:

• Feeling of breathlessness.
• Tightness felt in the chest.
• An urge to breathe (air hunger).
• Unable to breathe deeply.
• Noisy breathing.
• Fast, shallow breaths.
• Wheezing.
• Pale, cold, clammy skin.
• Using muscles of the neck and upper chest to breathe.
• Anxiety or panic attacks.

Causes

Most causes of shortness of breath are due to an underlying lung or heart diseases. Both these organs are involved in the transport of oxygen and removal of carbon dioxide for an optimal functioning of the body. Therefore, problems with either of the systems can affect breathing. Causes of acute shortness of breath include:

• Bronchial Asthma
  It is a chronic condition in which the airways get obstructed due to inflammation. A person with bronchial asthma experiences acute attacks of shortness of breath, sometimes even at night. There could be a history of allergies. The precipitating factors that bring about an attack of asthma are lung irritation, exposure to allergens like pollen, pets, mould, exercise, change of weather and respiratory infections. The symptoms are often relieved with an inhaler containing drugs called bronchodilators.
• Chronic obstructive pulmonary disease (COPD)
  People who have COPD can have shortness of breath. COPD is a condition in which there is a long-term obstruction in the lower part of the airways. According to the World Health Organization (WHO), a person is said to have COPD if he/she complains of a cough along with expectoration for more than 3 months along with inflammation and destruction of the lung tissues. Smoking is a major cause for COPD.
• Congestive heart failure
  This condition occurs when the heart muscle is unable to pump the required amount of blood. Factors like coronary artery disease, high blood pressure, in the long run, cause the cardiac muscle to get weak and reduces its blood-pumping efficiency.
• Pneumonia
  Pneumonia is an infection of the lungs which is caused by many micro-organisms including bacteria, viruses and fungi. Dyspnea is a dominant symptom of pneumonia. Along with shortness of breath, the person also has chest pain, fever and cough.
• Pneumothorax
  Pneumothorax is a condition in which a person has a collapsed lung causing an air leak in the space between the lung and the chest wall. The air causes the lungs to be pushed on one side leading to their collapse. Pneumothorax occurs due to a blunt injury, medical procedures or lung disease.
• Pulmonary embolism
  Pulmonary embolism occurs when a blood clot formed in some part of the body travels to the lungs and cause the arteries to get obstructed. Due to the clot, the blood flow gets blocked which can be an emergency situation. In this condition, dyspnea becomes worse with exertion along with chest pain which can even get mistaken for a heart attack. The chest pain becomes worse on deep breathing with blood in sputum.
• Carbon monoxide poisoning
  During carbon monoxide poisoning, the oxygen in the red cells gets replaced by carbon monoxide, which leads to tissue damage, or in some cases, even death. Faulty ventilation devices in closed spaces may cause carbon monoxide to get accumulated to critical levels.
• Guillain Barre syndrome
  This is a rare nerve disorder wherein the body’s immune system attacks the nerves. The sensations of weakness and tingling affect the body rapidly leading to paralysis of the muscles. In severe stages, the muscles that control breathing may also get involved leading to a medical emergency.

Other illnesses that may cause shortness of breath include:

• Obesity.
• Cardiomyopathy.
• Interstitial lung disease.
• Myasthenia gravis (a condition that causes muscle weakness).
• Arrhythmias (irregular heart rhythms).
• Sarcoidosis (collection of inflamed cells in the body)
• Foreign body obstruction.
• Generalized anxiety disorder.
• Lung oedema (excess fluid in the lungs).
• Lung fibrosis (damaged lungs due to scarring). (Read more - Idiopathic Pulmonary fibrosis treatment)

Risk factors

There are certain risk factors that may affect the different systems and act as triggers for the onset of breathlessness. They include:

• Previous lung diseases.
• Weak lung muscles.
• Smoking.
• Fumes, smoke.
• Dust.
• Exposure to pollens and asthma triggers.
• Weight gain.
• Broken ribs.
• Decreased haemoglobin count.
• Infections.

It is best to avoid causative factors to prevent shortness of breath. The following measures can help in preventing breathlessness:

• Avoiding exposure to pollutants, allergens and other environmental toxins.
• Losing weight to prevent sleep apnoea.
• Quitting smoking. Risk of heart and lung diseases and lung cancers drop significantly once a person avoids tobacco consumption.
• Treating other underlying conditions that might cause shortness of breath.
• If a person is relying on supplemental oxygen, ensure that the equipment is working properly and the oxygen supply is adequate.

If a person complains of breathlessness, it is best to seek immediate medical help by calling the local emergency helpline number. If the breathlessness is accompanied by chest pain, fainting, nausea, or a lack of ability to function, medical help should be sought immediately as it could be signs of a heart attack or embolism.

The doctor assesses a person’s symptoms and inquires whether:

• The shortness of breath is of an acute or chronic onset.
• It gets worse at rest or on exertion or on changing posture.
• There are problems related to various systems such as the respiratory or cardiovascular system.
• There are other causes such as thyroid disease, anaemia.
• There are any mental or emotional causes.
• The person has been exposed to certain chemicals or gases such as carbon monoxide.

It is best to visit a specialist if shortness of breath is accompanied by:

• Breathlessness on lying down.
• Swelling in feet and ankles.
• High fever, cough, and chills.
• Wheezing.
• Aggravation of pre-existing breathlessness.

The doctor will obtain a full medical history of the person regarding the cause, onset, duration of the disease as well as any triggering or aggravating factors. A complete medical examination will be carried out including chest auscultation to check if the airway is clear or for any foreign sounds which may indicate an underlying problem. Other tests to arrive at a complete diagnosis are:

• Lung function test
  This is done to check the capacity of the lungs, by measuring how much and how fast can a person blow in and out of the lungs. This test helps to diagnose asthma, COPD, etc.
• Pulse oximetry
  This measure the amount of oxygen present in the blood
• Blood tests
  Blood tests like a complete blood count help to check for anaemia and infections which could cause dyspnea. Other blood tests to suspect thyroid disease, blood clots or fluid in lungs may also be advised.
• CT scan
  It is usually advised in suspected cases of pneumonia or blood clots.
• Electrocardiogram
  It can help to look for the electrical activity of the heart and its rhythm.

Other relevant investigations may be ordered as per the doctor’s discretion.

Treatment usually depends on the cause of dyspnoea. Sometimes, the underlying cause gets completely treated but the symptoms of breathlessness may not be completely relieved. Certain medications may have side effects, hence, it is best to consult the doctor about its risks and benefits. Treatment modalities include:

• Nebulization, inhalers and oxygen therapy
  A machine that prepares an aerosol of a bronchodilator (medicine that opens the airway) is administered. There are home nebulizer kits available that can be used as per instructions. Oxygen is provided through a cylinder at the hospital or at home to ease breathlessness. In acute asthma attacks, an inhaler containing medications will help open the airway and reduce breathlessness instantly.
• Medications
  Antibiotics are prescribed to treat any infections that lead to a cough and chest pain. Expectorants can help in expressing out the mucus. Certain opium-based painkillers are helpful in relieving breathing. They also help in reducing breathing rate and improve sleep. Certain drugs are helpful in reducing secretions and open up the airway. Note that all drugs should be taken only as per the doctor’s orders.
• Fluid drainage
  Conditions like pleural and pericardial effusions, the fluid collected needs to be drained out to ease breathing.
• Radiotherapy
  If there is a tumour in the airway which is the cause of dyspnea, radiotherapy will help in decreasing the size of the mass which is blocking the airway.
• Laser
  In advanced lung cancers, laser surgery is often recommended to cut a tumour obstructing the airway.

Lifestyle management

People who experience shortness of breath can undertake the following measures to improve their health:

• Quit smoking
  The risks of lung and heart diseases and cancers can be greatly reduced by quitting smoking. Visit smoking cessation clinics that can help in curtailing the habit without any severe withdrawal symptoms. Use of nicotine gums and patches have also helped in getting rid of the habit.
• Avoid exposure to harmful pollutants
  It is best to avoid being exposed to any factor that may trigger an onset of breathlessness. Refrain from venturing out during pollination season or being in touch with any allergens, gases, toxic poisons, environmental toxins that can cause dyspnea.
• Weight loss
  Obesity can also lead to breathlessness due to a lack of activity. Any slight exertion may lead to a person being out of breath. Certain medical conditions like hypothyroidism lead to weight gain which may cause dyspnea. Hence, regular exercising can help in maintaining weight and breathlessness.
• Avoid exertion at high altitudes
  At high altitudes, beyond 5000 ft, the oxygen in the atmosphere is less which can cause laboured breathing in normal people. Breathlessness in such persons can be aggravated, hence it is recommended not to go on any trips to places that are at a high altitude.
• Supplemental oxygen
  If the person is relying on regular supplemental oxygen, ensure that the cylinder is replaced whenever necessary and the equipment is working properly.

Prognosis

The outcome of dyspnea depends on the underlying condition that leads to it. For example, in people with asthma, the outcome is good due to prompt relief by inhalers and pumps, whereas breathlessness caused due to congestive cardiac failure may not be relieved completely. The outcome also depends on the severity of the underlying disease. In advanced diseases such as lung cancer, the chances of recovery are feeble.

Complications

Complications related to dyspnea depend on the cause. Certain complications arising from dyspnea are:

• Debilitating lung function.
• Pain.
• Anxiety.
• Lung failure.
• Heart failure.
• Deterioration of existing symptoms.