2. Definition
• Breathlessness is an unpleasant sensation of uncomfortable, rapid or
difficult breathing. People say they feel puffed, short of breath or winded.
The medical term is dyspnoea. Your chest may feel tight and breathing
may hurt. Everyone can experience breathlessness if they run for a bus or
exert themselves to an unusual extent. But it is important to seek medical
attention if you experience breathlessness, as it may be due to a serious
underlying problem
• Undue awareness of breathing and is normal with strenuous physical exercise
• Sense of awareness of increased respiratoryeffort that is unpleasant and that is
recognizedby the patient as being inappropriate
• Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable
need to breathe..
• Patients use terms such as ‘shortness of breath’,difficulty getting enough air in’,
‘tiredness’,‘difficult, laboured, uncomfortable breathing;it is an unpleasant type of
breathing, though it isnot painful in the usual sense of the word’
3. MRC (medicalresearch council)Dyspnoea Scale
Grade Degree of breathlessness related to activity
1 Not troubled by breathlessness except on strenuous exercise
2
Short of breath when hurrying on a level or when walking up a
slight hill
3
Walks slower than most people on the level, stops after a mile (1.6
km) or so, or stops after 15 minutes walking at own pace
4
Stops for breath after walking 100 yards (90 m), or after a few
minutes on level ground
5
Too breathless to leave the house, or breathless when
dressing/undressing
4. New York HeartAssociation (NYHA) Functional
Classification
Grade Symptoms
Grade 1 ( Mild ) No limitation on physical activity. Ordinary physical activity doesn't
cause undue fatigue, palpitation, dyspnoea
Grade 2 ( Mild )
Slight limitation of physical activity. Comfortable at rest but
ordinary physical activity results in fatigue,
palpitation,
dyspnoea.
Grade 3 ( Moderate )
Marked limitation of physical activity. Comfortable at rest. Less
than ordinary activity causes fatigue, palpitation, or dyspnea.
Grade 4 ( Severe )
Unable to carry out any physical activity without discomfort.
Dyspnoea present at rest, if any physical activity is undertaken the
discomfort increases.
5. Common Causes
System Acute dyspnoea
Cardiovascular Acute pulmonary oedema
Respiratory
Acute severe asthma
Acute exacerbation of COPD
Pneumothorax
Pneumonia
Pulmonary embolus
ARDS
Inhaled foreign body
Lobar collapse
Laryngeal oedema
Others
Metabolic acidosis
Psychogenic hyperventilation
6. System Chronic exertional dyspnoea
Cardiovascular
Chronic heart failure
Myocardial ischaemia
Respiratory
COPD
Chronic asthma
Bronchial carcinoma
Interstitial lung disease
Chronic pulmonary thromboembolism
Lymphatic carcinomatosis
Large pleural effusions
Others
Severe anaemia
Obesity
Deconditioning
Common Causes
7. History
taking
• Patient's details :
Name
Age
Sex
Occupation : paint
sprayers, rubber industry
workers are prone to lung
disease
Address
Date of Admission
8. History
taking
• Chief Complaints
oShortness of breath for how many days
/ weeks
• History of Presenting Illness
oOnset : gradual/sudden
• oProgression : worsen/better
• oSeverity : NYCA/MRCA grading
oDiurnal variability : worsen at night /
morning- asthma
oPostural variability : orthopnoea ,
oAggravating factors : pollen, dust, cold
climate - asthma, sinusitis
oRelieving factors : rest, medication
10. History
taking
• Associated symptoms :
c) Haemoptysis :
oDuration, onset, progression
oAmount of blood?
oAssociated with melena or epistaxis?
oMight be due to malignancy
d) Chest pain :
oOnset, duration, progression
oSite? Bilateral/ unilateral
oType of pain
oRadiating - CVS pathology
oPain on deep inspiration, pain relief
when lie on same side- pleuritic chest
pain
11. History
taking
• Associated symptoms:
e)Fever :
oOnset, progression, duration
oAssociated with chills or rigor,
night sweats
oHigh / low grade
oEvening rise of temp - TB
f) Wheezing – asthma
g)Weight lost - TB, malignancy
h)Palpitation - CVS pathology
i) Sinusitis
j) Rhinitis
12. History
taking
• Past History :
oHistory of TB, Measle/whopping cough,
Asthma/ allergy, IHD, chest trauma/
surgery , similar complains, DM/HTN
• Personal History :
oDiet, Addiction, Bowel/Bladder
movement, Sleep, Appetite
oSmoking- highly ass with Emphysema
oAlcoholism - Aspiration Pneumonia
oLost of appetite & weight - TB,
Malignancy
• Family History :
oAsthma, TB, Cystic Fibrosis,
Malignancy
oAnyone with similar complaints
14. General Physical Examination
• BMI –
• Normal : 18.5 – 22.9 ( Asian )
18.5 – 24.9 ( Non-Asian )
• Obesity might be the cause of the
breathlessness
oExtra weight in the chest and
abdomen
Increased work load on muscles
that control breathing
15. Head to ToeExamination
1. Nails and Hands
Pallor ( Left Heart Failure ,COPD)
Cyanosis ( Cardiac Failure , COPD , Pulmonary oedema )
Clubbing ( Carcinoma of Bronchus , Pulmonary Fibrosis
,Bronchiectasis , Lung Abscess , Pleural Empyema )
Koilonychia ( Anaemia )
2 Neck :
JVP increased ( Right Heart Failure caused by Chronic Pulmonary
Hypertension in severe lung disease such as COPD )
3. Face :
Eyes – Pallor (Anaemia )
Lips and Tongue – Cyanosis ( Cardiac Failure , COPD )
oIndicate poor oxygenation of blood
4. Lower limb :
Pitting Pedal Oedema
oUnilateral – DVT
oBilateral – Congestive Heart Failure
16. Respiratory System Examination
Auscultation
• Stridor ( Laryngeal Oedema ,
Foreign bodies )
• Diminished Vesicular Breath
Sounds ( Obesity , Pleural
Effusion , Pneumothorax , COPD ,
Lung collapse )
• Bronchial Breath Sounds ( Lung
consolidation in pneumonia )
• Vocal Resonance ( over
consolidated lung , the spoken
numbers are clearly audible but
over an effusion or collapse they
are muffled )
• Rhonchi / Wheeze ( COPD ,
Bronchial Asthma )
• Pleural Rub ( Pneumonia , TB )
• Crackles
17. Examination Sequence
1. Note the patient’s
general appearance and
demeanour.
2. Look for central cyanosis
of the
lipsandtongue.
3. Examine the skin for
rashes and nodules.
4. Listen for hoarseness
and stridor.
5. Examine the hands
for finger clubbing,
peripheral cyanosis and
tremor.
6. Measure the blood pressure.
7. Examine the neck for
raised JVP
andcervical lymphadenopathy.
8. Record the respiratory
rate.
9. Observe the breathing
pattern, and look for
use of accessory
muscles.
10. Inspect the chest
front and back for
abnormalities of shape and
scars.
11. Feelthe trachea and
cardiacapex beat for
evidence of mediastinal shift.
12. Percuss the chest front
and back for areas
of dullness or hyperresonance.
13. Listen to the chest front
and back for altered breath
sounds and added sounds.
Certain groups of physical signs
are typically associated with
particular pathological changes
in the lungs.
20. Bedside investigations
Pulse Oximetry Peak Flow Rate
• A spectrophotometric device that
measures arterial oxygen saturation
by determining the differential
absorption of light by
oxyhaemoglobin and
deoxyhaemoglobin .
• This allows detection and ongoing
monitoring of hypoxaemia with
initiation of oxygen supplementation
as necessary, while undertaking
diagnostic work-up for its cause
• Person's maximum speed of
expiration.
• Normal test results depends on
age year gender and sometimes
occupation.
• Helps to differentiate between
pulmonary and cardiac causes
of dyspnoea. Low peak flow
rates are associated with
obstructive lung disease such as
asthma, COPD, and cystic
fibrosis.
• Normal: 80-100 per cent of
usual flow
rate.
21. Radiology
Chest X-Ray
• To determine the lobe / area in
which the lung is affected.
• Make out any cardiomegaly in
the PA view of the x-ray
• Check for any fluid /
consolidation of the lungs.
• Check for any structural
damage such as a broken rib
Chest fluoroscopy / Sniff test
• Determines how well lungs,
diaphragm, or other parts of
your chest are working.
• Uses more radiation than a
standard
chest X-ray.
• It detects the movement of the
diaphragm when the patient
breathes.
• Hence able to detect any
abnormal
diaphragmatic conditions.
23. Pharmacological
• The treatment of breathlessness is complex. It depends on the
underlying causes.
• Opioids-either oral or parenteral-are now considered to be the
gold standard in reducing ventilator demand. A slow release
preparation of morphine has been found to be beneficial
• Anxiolytics such as benzodiazepines may assist in the anxiety
component of breathlessness. However, these may be poorly
tolerated in some patients, especially in those with liver
failure.
• Long acting beta agonists may be beneficial in breathlessness due
to COPD in reducing the work of breathing.
• Bronchodilators help in relaxing muscles and improving
muscle tone in the airways.
24. Oxygen Treatment
• Evidence have shown oxygen treatment is of no use in
a patient with breathlessness WITHOUT hypoxia.
• Otherwise, high flow oxygen of >60 percent is used
except in COPD patients.
25. Non-pharmacological
• There does seem to be a relationship between anxiety and
breathlessness, however, which one comes first is difficult to
tell. Strategies such as relaxation training and distraction do
seem to help as do cognitive behavioural therapies.
• Controlled breathing exercises and techniques such as an
upright leaning forward position and pursed lip breathing are
also beneficial therapies.
• Chest wall vibration, neuro-electrical muscle stimulation,
walking aides, and breathing training.
26. There are some breathing control techniques that can help to reduce
breathlessness. Examples include:
• Relaxed, slow, deep breathing: breathe in gently through your nose and
breathe out through your nose and mouth. Try to stay feeling relaxed and
calm.
• Paced breathing: this may help when you are walking or climbing stairs.
Try to breathe in rhythm with your steps at a speed you find comfortable.
• Controlled breathing. This involves using your diaphragm and lower chest
muscles to breathe instead of your upper chest and shoulder muscles.
Breathe gently and keep your shoulders and upper chest muscles relaxed.
27. Use different comfortable seating and standing positions when you feel
breathless. Different positions suit different people but examples include:
• When standing up, lean from the hips with your forearms resting on
something at a comfortable height, such as a chair or kitchen work surface.
• When standing put your hands on your waist or in your back pockets.
• When sitting, lean forwards, resting your forearms on your knees, on the
arms of a chair, or on a table.
Arrange the things you use every day to make sure they are easy to reach.
Try to stay active but take a rest when you feel breathless and then start
again.
28. Avoidance/prevention
• Quit smoking, alcohol
• Weight loss
• Regular exercise
• Avoid going to areas with dust, smoke, air pollution
• Cholesterol management
• Bp management
• Diabetes control
• diet
