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Dyspnoea / Shortness of Breath in Elderly

Introduction

  • Dyspnoea is a sensation of difficulty or uncomfortable breathing. It is the same with breathlessness or shortness of breath
  • Dyspnoea is a common symptom but can be both distressing and frightening for patients and carers
  • Dyspnoea is a result from complex interactions between neurologic stimulation, the mechanics of breathing and the related response of the central nervous system

In general, there are four main mechanisms which can make someone feels short of breath:

  • decreased oxygen levels in the blood stream
  • increased levels of carbon dioxide in the blood stream
  • decreased ability of the lung to expand
  • increased workload associated with normal breathing

The possible causes of dyspnoea / breathlessness are extensive. It can be caused by a variety of conditions affecting the lungs, heart and / or general circulation.

Risk-factors for dyspnoea are usually associated with the diseases and conditions in which dyspnoea occurs, for examples:

  • clinical risk factors includes : Asthma, Chronic Lung Disease (COPD) ,Congestive Heart Failure( CHF) ,Coronary Artery Disease (CAD)
  • consistent exposure to toxic irritants such as tobacco smoke and certain industrial toxins.
  • individuals with anemia, anxiety and panic disorders, sedentary lifestyle and obesity

The incidence of dyspnoea could not be estimated because of the broad range of disease-related causes in which it may occur.

Signs and Symptoms

Dyspnoea can manifest as a variety of signs and symptoms, due to the large number of possible causes. History is important to determinethe underlying cause.

The doctor will need several information to determine the likely cause of the breathing difficulties, for examples:

  • The onset and duration of the breathlessness
  • When the breathlessness occurs and any triggers
  • Effect of position on the degree of breathlessness ( lying down or wake up)
  • Other symptoms such as wheezing, grunting, chest pain etc
  • Past medical history – previous respiratory disease or surgery.
  • Recent illnesses such as the cold, flu or other infections
  • Current medications ( including Oxygen) and any allergies
  • The effect of the breathlessness on daily life and activities
  • Smoking history and occupational history

The degree of dyspnoea :

  • Grade 0 – no dyspnoea except with strenuous exercise
  • Grade 1 – dyspnoea when walking up an incline or hurrying on the level
  • Grade 2 – walks slower than most on the level, or stops after 15 minutes of walking on the level
  • Grade 3 – stops after a few minutes of walking on the level
  • Grade 4 – with minimal activity such as getting dressed, too dyspneic to leave the house

The most common presentations are:

  • Shortness of breath in usual activities or at rest
  • Shortness of breath at night while lying flat in bed (orthopnea)
  • Factors associated with onset of dyspnoea such as chest pain, weight loss, night sweats, anxiety or exposure to smoke or other irritants

Signs / physical findings:

  • Cyanosis ( blue discolouration of fingers, toes or mouth due to an increase in the concentration of deoxygenated haemoglobin)
  • Rapid respiration (increased respiratory rate)
    • Increased chest diameter, intercostals in-drawing
  • Wheeze or stridor
  • Rapid heart rate (tachycardia), dysrhythmia
  • Changes in the fingertips and toes (clubbing) indicate severe reduction of oxygen to the tissue
  • Tissue swelling (oedema) in the legs and presacral area
  • Enlargement of lymph gland and liver
  • Low blood pressure (hypotension), low concentration of oxygen in the blood (hypoxemia)
  • Tracheal deviation, absent breath sound

The individual may appear to be agitated or confused (altered mental status).

Complication

Complications of dyspnoea secondary to lung or heart conditions include:

  • respiratory failure
  • heart failure
  • pneumothorax

Treatment

  • Patient must get treatment from health facilities as soon as possible when dyspnoea occur
  • Severe cases of breathlessness may require hospitalisation
  • Treatment will vary between patients due to the numerous different causes for breathlessness

Investigations should be done before starting the treatment, for examples:

  • Complete blood count (CBC) to exclude anaemia or infection
  • Arterial blood oxygen (ABG) to monitor the severity of disease and types of respiratory failure
  • Blood carbon monoxide level
  • Renal function
  • Chest x-ray
  • Electrocardiogram (ECG)
  • Pulmonary Function Test
  • Echocardiogram
  • Pulse oximetry – a clip device placed on the toe or finger that measures oxygen saturation

General treatments regardless of the cause of breathlessness may help to relieve symptoms such as:

  • to maintain an open airways and providing assistive ventilation
  • supplemental oxygen therapy is given initially by mask or nasal prongs to help restore the low levels of oxygen in the blood
  • bronchodilators – drugs such as ventolin and steroids are helpful in some patients who are breathless
  • assess patient condition and its severity
  • involved multi-discipline team – depends on the underlying cause of dyspnoea

Treatment at home:

There are several things patients can do themselves to reduce their breathlessness.

  • Their doctor will teach them breathing exercises such as slow, deep breathing, all the way to their abdomen
  • Relaxation methods
  • Sit upright in a supportive chair if breathlessness occur

If the shortness of breath does not resolve, make sure patient seeks medical attention immediately.

Prevention

  • Acute dyspnoea often resolves with treatment of the underlying condition
  • Dyspnoea associated with chronic conditions such as COPD or CHF usually result in progressive dysfunction, severe disability and eventual death
  • Smoking cessation programmes are recommended for all individuals who smoke

Rehabilitation

  • Refer physiotherapist for pulmonary rehabilitation
  • Pulmonary rehabilitation can build an individual’s endurance through rehabilitation and increase the ability to work and resistance to fatigue.
Last Review : 01 July 2013
Writer : Dr. Sanidah bt. Md. Ali