What can lung conditions cause the airways to become?
Inflamed and narrowed or filled with phlegm hence its harder for air to move in and out of the lungs.
Can make the lungs stiff and less elastic so it’s harder for them to expand and fill with air.
Lung conditions that cause long-term (chronic) breathlessness:
- COPD
- Obesity
- interstitial lung disease (ILD), including pulmonary fibrosis and sarcoidosis
- bronchiectasis
- industrial or occupational lung diseases such as asbestosis, which is caused by being exposed to asbestos
- lung cancer
Lung conditions that cause short-term (acute) breathlessness:
- flare-up of asthma or COPD
- PE or blood clot on the lung
- lung infection such as pneumonia or TB
- pneumothorax or collapsed lung
- build-up of fluid in your lungs or the lining of your lungs – this might be because your heart is failing to pump efficiently or may be because of liver disease, cancer or an infection
Explain how a heart condition can cause long-term (chronic) breathlessness.
Can be due to problems with the rhythm, valves or cardiac muscles of the heart. Heart can’t increase its pumping strength in response to exercise, or the lungs become congested and filled with fluid often worse when supine (so when sleeping).
Heart conditions that cause acute breathlessness include:
Heart attack (MI)
An abnormal heart rhythm.
Explain how anxiety can cause SoB.
Feeling SoB when anxious or afraid is a normal response to stressful situations; the body is preparing for action as you get more anxious, you may start to breathe faster and tense your breathing muscles. Physical health can also impact mental health, especially if living with a lung condition you might get anxious if you don’t feel in control of your condition
If you have a lung condition, you may have symptoms that make you feel anxious. Sometimes the symptoms of lung conditions e.g. breathlessness, tightness in your chest or getting tired very easily are similar to feelings of anxiety.
What is a panic attack?
When the body’s normal response is exaggerated, you get a rapid build-up of physical responses; breathing quickens and your body also releases hormones so your heart beats faster and your muscles tense
In addition to feeling you can’t breathe during a panic attack what else happens?
- have a pounding heart
- feel faint and sick
- sweat
- have shaky limbs
- feel that you’re not connected to your body
What happens if you breathe too quickly in response to panic attack?
You may breath in more oxygen than your body needs → Called hyperventilation
When you do this, the delicate balance of the gases in your lungs is upset. An amount of carbon dioxide normally stays in the blood. If you breathe in too much air too often, the carbon dioxide is pushed out through the lungs and this affects the messages the brain receives to tell you to breathe.
Explain why being unfit or having an unhealthy weight can lead to SoB.
When we are unfit, our muscles (including respiratory muscles) get weaker. Weaker muscles need more oxygen to work, so the weaker our muscles, the more breathless we feel.
Being an unhealthy weight can also contribute to make us feel breathless. List all the reasons why.
If you’re underweight, your respiratory muscles will be weaker.
If you’re overweight, it takes more effort to breathe and move around.
Having more weight around the chest and stomach restricts how much your lungs can move.
People who are a BMI of 25 or more are more likely to get breathless compared to people with a healthy weight.
People who are severely overweight can develop obesity hypoventilation syndrome; when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in their blood.
Maintaining a healthy weight may help you to manage your breathlessness better and be more active.
Other causes of long-term (chronic) breathlessness.
- smoking
- conditions that affect how your muscles work, such as muscular dystrophy, MG or motor neurone disease
- postural conditions that alter the shape of your spine, and affect how your ribs and lungs expand - for example scoliosis and kyphosis
- anaemia
- kidney disease
- thyroid disease
What are the barriers to diagnosing breathlessness?
- think breathlessness is as a normal part of ageing, so don’t tell their doctor
- feel responsible for causing their illness and don’t feel they deserve help
- not realise they can get any help for their breathlessness
- not actually feel out of breath when they see their doctor (would be sitting down and may have only walked a short distance), so may forget what their breathlessness feels like and find it hard to describe
What can patients do to help a doctor diagnose breathlessness?
- Use an online breath test to find out if your breathlessness is something to get checked out with your doctor.
- Bring someone with them who can help describe their breathlessness
- think about how they will be describing their breathlessness in advance of seeing a doctor e.g. what they used to be able to do but can’t any more, what people of their age around them do that they find difficult and what their personal goals are for their day-to-day activity
- use local landmarks such as bus stops, shops and hills to help you describe these things
- record the sort of activities that make them out of breath to show their doctor what it looks or sounds like
What tools can doctors use to diagnose breathlessness?
- Use the MRC breathlessness scale
- Ask questions about breathlessness
- Do some tests to help diagnose what’s causing the breathlessness
MRC Breathlessness Scale
- Not troubled by breathlessness
- Breathlessness on vigorous exertion - e.g. running
- Breathless walking up slopes
- Breathless walking at normal pace on flat; having to stop from time to time.
- Stopping for breath after a few minutes on the level.
- Too breathless to leave the house.
Questions Dr’s may ask about breathlessness?
Duration
Onset
Frequency
Pattern
Time
Relieving factors e.g. lying flat
Exacerbating factors e.g. pollen, pets, medication
Smoking
Coughing/phlegm
Chest pain, palpitations, ankle swelling
Normal activity levels
Occupation
Whether breathlessness is related to certain times at work
History of heart, lung or thyroid disease, or of anaemia
Family history of breathlessness
Lifestyle changes made due to breathlessness (if any)
Feeling worried, frightened, depressed or hopeless
Coping mechanisms
What tests may help doctors to help diagnose the cause of breathlessness?
Breathing and lung function tests
Respiration rate (breaths per min)
Chest auscultation (listening)
Look and feel how chest moves during breathes
HR and rhythm
Check if fluid is building up in ankles or lungs
BP and temperature
Check height, weight, waist and BMI
Examine head, neck and armpits to see if lymph glands are swollen
Inspect eyes, nails, skin and joints
Check blood sats with a pulse oximeter
If there are signs that patient is anxious/depressed, a short questionnaire
Possible additional tests at GP surgery, local testing centre or hospital
CXR- chest X-ray
Spirometry test
ECG - if breathlessness is intermittent, wear a portable recorder for 24 hours or 7 days to record heart’s electrical activity
Echocardiogram - this is a non-invasive ultrasound of heart which can tell how well it’s working
Blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
What is SoB on exertion?
When you have additional requirements on top of your baseline needs, and don’t acquire enough oxygen to meet the needs.
Differential diagnoses that can present with SoB on exertion.
- Respiratory
- Asthma
- COPD
- Pulmonary fibrosis (lung tissue becomes fibrotic and scarred)
- Lung cancer
- PE
- Pneumothorax
- Lower RTI
- CV
- Congestive heart failure (fluid builds up within the heart and causes it to pump inefficiently)
- Pulmonary oedema (fluid collects in the numerous air sacs in the lungs, making it difficult to breathe -mainly caused by heart problems)
- Valvular defects
- Acute coronary syndrome
- Anaemia
- Renal or heart failure
- Deconditioning (being unfit/significant loss in muscle mass -affects heart and respiratory muscles)
Questions to ask Mr. Craven to help hone in differential.
- how long has he had symptoms for (to differentiate acute e.g. infection, pneumothorax and chronic e.g. COPD, asthma, pulmonary fibrosis)
- is he waking up at night; left HF results in back clog of blood in lungs (pulmonary oedema), lying down is worse as fluid remains around lungs instead of being drained away when standing
- chest pain; causes acute coronary syndrome, pneumonia, heart attack, angina, pneumothorax, PE
- cough e.g. infection
- times of breathlessness (asthma symptoms are typically worse in the morning)
- any change in physical activity
- history of cancer
Things to look out for on examination to help hone in differential of Mr. Craven:
Specific lung sounds e.g. healthy chest=smooth/lamina flow, wheezing=turbulent flow, fluid produces crackle.
Specific heart sounds e.g. look out for murmur.
Investigations to carry out on Mr. Craven:
- spirometry
- ECG
- CXR
- bloods
