out of breath? know when to see a physician stuart rich, m.d. professor of medicine director,...

Out of Breath?

Know When to See a PhysicianStuart Rich, M.D.

Professor of MedicineDirector, Pulmonary Vascular Disease Program

Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

How we normally breathe

Breathlessness a.k.a. Dyspnea

• It is normal to be aware of breathlessness when we exercise beyond our normal tolerance.• It is not normal if it occurs with little or no exertion. • Next to pain, breathlessness is the most common symptom for which

patients seek help from their doctor. • It is often associated with fear and can be disabling and severely

diminish quality of life.

What causes breathlessness?

• Breathlessness is the sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand. • Breathlessness can be classified by its speed of onset as: • Acute breathlessness: • develops over minutes, hours, or days.

• Chronic breathlessness: • develops over weeks or months.

Acute causes of breathlessness

• Cardiac causes:• Pulmonary edema (fluid build-up in the lung from heart disease)• Heart attack• Arrhythmia (abnormal heart rhythm)• Pericarditis (inflammation around the heart)

Acute causes of breathlessness

• Pulmonary causes • Pneumonia• Pneumothorax (collapsed lung)• Pulmonary embolism (blood clot)• Asthma• Chronic lung disease (COPD)• Large airway obstruction (foreign body, compression)

Other causes of acute breathlessness

• Pain• Drugs • Trauma• Altitude sickness• Hyperventilation and panic attack

Chronic causes of breathlessness• Cardiac causes:• Congestive heart failure• Heart valve disease • Arrhythmias• Pulmonary hypertension (high blood pressure in the lungs)

Chronic causes of breathlessness• Pulmonary causes:• Asthma• COPD• Pulmonary fibrosis• Pleural effusion (fluid in the chest)• Lung cancer

Chronic causes of breathlessness• Other causes:• Severe anemia• Psychogenic - eg, anxiety• Neuromuscular causes• Thromboembolic disease• Thyroid disease• Obesity

The Goddess Ondine and The Curse• Ondine was a beautiful goddess who married the handsome young Palemon.

• Palemon vowed "My every waking breath shall be my pledge of love and faithfulness to you."

• After Ondine gave birth to their son, her beauty began to fade.

• Palemon's eye began to wander to the younger women he met at court.

• When Ondine became aware, she gave him the following curse:• For as long as you are awake, you shall breathe. But should you ever fall into

sleep, that breath will desert you."

How Severe Is It?

• Grade 0: not troubled except on strenuous exertion.• Grade 1: short of breath when hurrying on level ground or walking up

a slight incline.• Grade 2: walks slower than contemporaries because of

breathlessness.• Grade 3: stops for breath after walking about 100 yards or stops after

a few minutes of walking on level ground.• Grade 4: too breathless to leave the house or breathless on dressing

or undressing

The downward spiral

Breathlessness and Denial

• Patients will often become aware that they are getting more out of breath with activity, but will choose not to seek help because:

“I’m getting older”“I put on weight”“I’m out of shape”“It’s not so bad”

Contact your physician if the following occur with breathing difficulties• Chest discomfort, pain, or pressure - these are symptoms of angina• Fever• Shortness of breath after only slight activity or while at rest• Shortness of breath that wakes you up at night or requires

you to sleep propped up to breathe• Tightness in the throat or a barking, croupy cough• You have breathed in or choked on an object

(foreign object aspiration or ingestion)• Wheezing

Examining the patient

•General:• Patient distress, color of skin and lips, cyanosis, • Respiratory rate• Pulse - rate, rhythm• Height and weight

• A good history and physical exam may often reveal the source of breathlessness.

Helpful medical tests

• Lung function tests• Pulse oximetry• Chest X-ray• Arterial blood gases• Electrocardiogram• Imaging:• Echocardiogram• Chest CT scan• V/Q scan

How do doctors treat dyspnea?

• The primary goal is to identify the underlying cause:• It may arise from one specific cause• It may arise from the combination of causes

• Initiate treatment to rectify the immediate problem if possible (e.g.):• Supplemental oxygen• Diuretics• Analgesics

• Address correction of any underlying condition

"Life is not measured by the number of breaths we take, but by the moments that take our breath away." -- Hillary Cooper