2. Outline
• What is breathlessness?
• How do we measure it?
• Why is it important to treat
• What is the cause of breathlessness in
COPD
• Non pharmacological interventions
• Pharmacological interventions
3. Definition
• A subjective experience of breathing
discomfort that consists of qualitatively
distinct sensations that vary in intensity.
• The experience derives from interaction
among multiple physiologic,
psychological, social, and environmental
factors and may induce secondary
physiological and behavioral
responses”.
American Thoracic
society
4. Patients descriptions
“Its the worst feeling in the
world, the worst way to die, its
like smothering to death……to
lose control of your breathing”
“a frightening feeling
where you don’t think
you’ll get
another breath and
because it is
accompanied by fear and
panic, you can actually feel
tightening feeling of fear in
your chest and mind”
“We feel very
isolated
especially at night”
5. Breathlessness is a common and
distressing symptom that could be
better managed for the same
resource:
5
Over 54,000 emergency calls to the
London Ambulance Service a year are
due to acute breathlessness
‘Existing community services
could be better used with some
restructuring of appointments is
needed to enable an initial
assessment of 20-30 minutes
and there is also a case to be
made to restructure outpatient
services for people with severe
disease’
PCRS
6. Breathlessness – burden
•Breathlessness affects up to 10% of adult
population
•30% of older people
•Major cause of attendance at emergency
department BUT
•Only 1% of recorded GP consultations
•2/3 is cardio-pulmonary
•Assume all patients anxious to some extent –
how much and why?
11. NYHA Heart Failure Breathlessness scale
Table 2 - NYHAClassification - Thesymptoms of Heart Failure35
Class Patient Symptoms
ClassI (Mild) Nolimitation of physical activity. Ordinary physical activity does not
causeunduefatigue, palpitation, or dyspnea (shortness of breath).
ClassII (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, palpitation, or dyspnea.
ClassIII (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causesfatigue, palpitation, or dyspnea.
ClassIV (Severe) Unable to carry out any physical activity without discomfort. Symptoms
of cardiac insufficiency at rest. If anyphysical activity is undertaken,
discomfortis increased.
12.
13. MRC and mMRC Breathlessness Scale
Table 1 - Medical Research Council dyspnoea scale34
Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to
stop for breath when walking at own pace
4 Stops for breath after walking about 100m or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing
MMRC Dyspnea
Scale
Grade Description of Breathlessness
0 I only get breathless with strenuous exercise.
1 I get short of breath when hurrying on level ground or walking up a slight hill.
2 On level ground, I walk slower than people of the same age because of
breathlessness,
or
have to stop for breath when walking at my own
pace.
3
4
I stop for breath after walking about 100 yards or after a few minutes on level
ground. I am too breathless to leave the house or I am breathless when
dressing.
16. Diagnosis requires skilled
assessment by a doctor
combining high quality
history- taking and
examination with a limited
number of evidence-
based objective tests
21. Providing better care for
people who are breathless
would improve care for
people with COPD, asthma,
heart failure, anxiety and
obesity and break down
silos and improve
coordination
22. What are the health needs in
breathless patients?
• Knowledge of diagnosis & prognosis
• Information regarding illness,
disease management
– HCP speaking with same voice
• Psychology input
• Supervised exercise
– Often purchase equipment and too scared to
use
• Someone to listen to their concerns
• Awareness of local services
Habraken 2007, Booth 2003
23. Cardiolog
y
cause
Patient presents
with shortness
of breath
Joint diagnostic clinic – ECG, spirometry (or review of
tests performed in primary care), ECHO, BNP
Respiratory
cause
Cardiology
service
management
MDT for patients with
co-morbidities or
complexity
Respiratory service
management
Joint rehabilitation services covering a range of
abilities lifestyle change/psychological
therapies
24. Breathlessness – treatment challenges
•Strong evidence base for treatments for single conditions, but much
weaker for multiple
•But need more flu vaccination, stop smoking as treatment, support
to increase physical activity, referral to programmes of
rehabilitation, weight management, as well as NICE-
pharmacotherapy
•Needs to be locally sensitive: demography, relationships, knowledge,
services
27. Hyperinflation is a key component of
COPD
References:
1. GOLD 2015
2. Nici et al. Am J Respir Crit Care Med 2006
3. O’Donnell and Laveneziana. Eur Respir
Rev 2006
• Expiratory airflow limitation and airway
obstruction trap air progressively during
expiration, leading to hyperinflation1
• Hyperinflation is thought to develop early in
the disease, and is the main mechanism for
exertional dyspnea1
• Hyperinflation reduces inspiratory capacity,
such that functional residual capacity
increases, particularly during exercise
(dynamic hyperinflation)1
– Results in worsening of dyspnea and
limitation of exercise capacity1
• Hyperinflation manifests as:
– an increase in total lung capacity3
– an increase in residual volume (i.e.
‘gas trapping’)3
COPD
Norma
l
Reduced
IC
31. In COPD Shortness of breath is the most
bothersome symptom
• Shortness of breath is gradual in onset, so patients often relate it to the
ageing process or lack of fitness
– As lung function deteriorates, shortness of breath becomes more intrusive1,2
• Patients report that shortness of breath is the most bothersome symptom and
is the reason most seek medical attention1,2
• Patients restrict activities to avoid shortness of breath1,2
– Patients with COPD spend only a third of the day walking or standing3
– Healthy age-matched healthy individuals spend over half of their time in these
activities3
• This leads to gradual deterioration of HRQoL,4 increased dependency and
social
isolation1
HRQoL, health-related quality of
life
Reference:
1. Barnett M. J Clin Nurs. 2005;14:805–12; 2. GOLD. COPD guidelines 2014.
Available at http://www.goldcopd.org [Accessed Dec. 2015]; 3. Cooper CB. Respir
Med. 2009;103:325–34;
4. O'Donnell DE. Eur Respir Rev. 2006;15:37–41
31
32. Low BMI
Decreased exercise
capacity Mmrc score
High CRP
Ct showing
emphysema FEV1
Exacerbations
Comorbid disease
including anxiety and
depression Chronic
hypercapnia
IN COPD Prognosis is
linked to degree of
breathlessness
34. Breathing Techniques
• STOP, DROP and FLOP:
– STOP what you are doing
– Sit down or lean forward with hand on
knees and DROP shoulders
– Then FLOP by relaxing muscles around
shoulders and chest
– Focus on breathing OUT – not in
35. ‘Breathe Better, Feel Good, Do
More’ ’
Pulmonary Rehabilitation
High Value Care in COPD
36. Pulmonary
Rehabilitation
• 6-8 week exercise based
class with complimentary
education classes
• Run with the intention to
cover all aspects of self
management
• Always an MDT approach
• Aims for
lifestyle/behavioural
changes
• Goal orientated
• Common criteria – Chronic
lung diagnosis and able to
walk >10m, MRC 2-4
38. Appropriate pharmacologic therapy can reduce COPD
symptoms, reduce the frequency and severity of
exacerbations, and improve health status and
exercise tolerance.
None of the existing medications for COPD has been
shown conclusively to modify the long-term decline
in lung function.
Responsible Prescribing: Key Points
40. Long-acting inhaled bronchodilators are
convenient and more effective for symptom relief
than short- acting bronchodilators.
Long-acting inhaled bronchodilators reduce
exacerbations and related hospitalizations and
improve symptoms and health status.
Combining bronchodilators of different
pharmacological classes may improve efficacy
Responsible Prescribing:
Bronchodil
ators
41.
42.
43.
44.
45. Arm selection and patient position
• BP should initially be measured in both arms, after
which the arm with the higher reading(s) should be
used for subsequent measurements .
• Although a difference in BP measurements between
the arms can be expected in 20% of patients, if this
difference is >20mmHg for systolic or >10mmHg for
diastolic measurement, BP should be measured on
both arms for the next reading.
• If these differences are seen in three consecutive
readings (with a one-minute gap between each),
further investigation may be indicated .
47. Manual auscultatory measurement
• Manual BP measurement devices require the user to inflate the
upper-arm cuff to occlude the brachial artery, then listen to the
Korotkoff sounds through a stethoscope while the cuff is slowly
deflated. When the cuff is slowly deflated, five different sound
phases can be heard:
• Phase I – a thud;
• Phase II – a blowing or swishing noise;
• Auscultatory gap – in some patients, the sounds disappear for a
short period;
• Phase III – a softer thud than in phase I;
• Phase IV – a disappearing blowing noise;
• Phase V – silence: all sounds disappear .
• The patient’s systolic (phase I) and diastolic (phase V) BP are
recorded from the readings on the sphygmomanometer.
48. Errors in measurement
• There are numerous causes of errors in BP measurements,
including:
• Patient not being rested and relaxed when BP is measured;
• Defective equipment – for example, leaky tubing or a faulty valve;
• Too-rapid deflation of the cuff;
• Use of incorrectly sized cuff;
• Cuff not being on a level with the heart;
• Poor technique;
• ‘Digit preference’ – rounding a reading up to the nearest 5mmHg or
10mmHg;
• Observer bias – for example, expecting a young patient’s BP to be
normal;
49. Pulse
• Arterial pulses can be examined at various sites around
the body. Systematic examination normally involves
palpating in turn radial, brachial, carotid, femoral and
other distal pulses. Palpation of the abdominal aorta
would also form part of this systematic examination (to
identify abdominal aortic aneurysms for example).
• Other sites may be examined for pulses, in special
circumstances - for example, the temporal artery (for
tenderness in temporal arteritis) and the ulnar artery
(if the radial cannot be felt or before arterial access at
the radial site).
50.
51. • Rhythm, which means if the pulse is equal, with regular intervals, just like
the music and the beats.
• Strength: intensity of impact that receive the fingers that palpate the
artery. It depends on the strength of myocardial contraction.
• Amplitude: degree of excursion of the artery. 1. high, aortic insufficiency
2. small, aortic stenosis, mitral stenosis
• Tension or validity: the amount of compression that must be exercised
because the pulsation disappears downstream. The pulse will be tense
when the arterial pressure is high and hypotensive or soft in the opposite
case. Palpando the radial is exercised with the ring finger that is found
upstream, a pressure on the artery, while the other fingers can grasp the
moment in which the pulsation disappears.
• Consistency or hardness: chicken trachea.
• Duration:
1. rapid or shocking: aortic insufficiency, fever, hyperthyroidism
2. late: aortic stenosis
• Equality: normally the beats of the pulse are all the same between
them, when they are not, it is called irregular pulse.
52.
53.
54.
55. What is the pulse rate?
• A normal pulse rate after a period of rest is
between 60 and 80 beats per minute (bpm). It
is faster in children. However, if tachycardia is
defined as a pulse rate in excess of 100 bpm
and bradycardia is less than 60 bpm then
between 60 and 100 bpm must be seen as
normal.
56. What is the pulse rhythm?
• Sinus arrhythmia occurs when there is variation of rate with
breathing. It accelerates a little on inspiration and slows a little on
expiration. This can be quite marked in children and adolescents
but is uncommon over the age of 30. It can persist a little longer in
the physically fit.
• Pulsus paradoxus:
– The pulse slows on inspiration in pulsus paradoxus and it can occur
with pericardial effusion, constrictive pericarditis and severe
pneumothorax, especially tension pneumothorax, severe asthma and
severe chronic obstructive pulmonary disease (COPD)[1].
– In normal circumstances, the systolic blood pressure often falls slightly,
by less than 10 mm Hg on inspiration; however, in pulsus paradoxus it
falls by more than this[2]. This fall can be used to assess the severity of
cardiac tamponade.
57. • Irregularity is more difficult to discern if the rate is fast.
• Note if it is regularly irregular of irregularly irregular:
– Variable heart block or premature ventricular excitation will cause either an
extra beat or a missed one. Premature ventricular contraction may cause a
missed beat because the ventricle has not had time to fill adequately and so
the stroke volume is low. The beat following a missed beat, whether due to
premature excitation or failure of the ventricle to beat, may be rather stronger
than the others, as the ventricle has filled more in the longer diastole. This
irregularity will follow a regular pattern.
– A much more random irregularity is a feature of AF. If the rate is fast in AF, it
may be difficult to note if the irregularity is random or even if there is
irregularity at all. It may be helpful to measure the rate at both the cardiac
apex and the wrist and in AF there is usually a deficit at the radial pulse. This is
usually done with two people timing simultaneously but it can be done alone,
not timing but merely noting if the rates differ. The rate in AF and the rarer
atrial flutter depends upon the degree of A-V block but it can be very fast.
