Shortness of breath causes, symptoms, and treatments

What is shortness of breath?

Shortness of breath is an uncomfortable feeling of running out of air or inability to breath deeply enough and feeling “air hungry”. The medical term for this is “dyspnea”, which may occur while walking, climbing stairs, performing daily activities like cooking, cleaning or even while sitting still. Shortness of breath can come on gradually over weeks or months or happen suddenly. (https://www.lung.org/lung-health-diseases/warning-signs-of-lung-disease/shortness-of-breath/learn-about-shortness-of-breath) 

What is paroxysmal nocturnal dyspnea (PND) and sighing dyspnea? 

PND is a feeling of being short of breath one to two hours after falling asleep. Sighing dyspnea is sighing a lot after taking deep breaths in to try to relieve the feeling of dyspnea. 

What are acute and chronic dyspnea?

Acute dyspnea can come on quickly and doesn`t last very long (hours to days). Allergies, anxiety, exercise and illness (like the common cold or flu) can cause acute dyspnea. More serious conditions, like a heart attack, sudden airway narrowing (anaphylaxis) or blood clot (pulmonary embolism) can also cause acute dyspnea. 

Chronic dyspnea is shortness of breath that lasts a long time (several weeks or longer) or keeps coming back. Ongoing health conditions like asthma, heart failure and COPD can cause chronic dyspnea. Not getting enough exercise can also result in feeling breathless very often because muscles are trying to get more oxygen. (https://my.clevelandclinic.org/health/symptoms/16942-dyspnea) 

What are the causes of dyspnea?

Causes of acute dyspnea may include:

• Asthma
• Anaphylaxis
• Carbon monoxide poisoning 
• Cardiac tamponade (excess fluid around the heart) 
• Chronic obstructive pulmonary disease
• COVID-19
• Heart attack
• Heart failure
• Heart arrythmia
• Pneumonia
• Pneumothorax
• Pulmonary embolism
• Sudden blood loss
• Upper airway obstruction
• Infections of the lung 

Causes of chronic dyspnea may include:

• Asthma 
• Chronic obstructive pulmonary disease e.g. emphysema
• Deconditioning
• Cardiac dysfunction
• Interstitial lung disease
• Obesity
• Pleural effusion
• Pulmonary hypertension
• Infections of the lung 
• Pulmonary oedema
• Pulmonary fibrosis
• Anemia 
• Guillain – Barre syndrome
• Myasthenia Gravis
• Neuro-muscular disease like motor neuron disease (https://www.mayoclinic.org/symptoms/shortness-of-breath/basics/causes/sym-20050890) 

How is shortness of breath or dyspnea diagnosed?

Detailed medical history, thorough physical exam and question about onset and pattern of shortness of breath will help a health care provider to diagnose the condition. Specific questions about shortness of breath like:

• What are the triggers (e.g. smoking) or activities (e.g. brisk walking)?
• Accompanying other symptoms like chest pain, dizziness, cough, wheezing, lips turning blue, trouble breathing while sleeping or lying down and swelling in feet or ankles
• Frequency of having shortness of breath 
• Does dyspnea make daily chores or daily tasks difficult? List the tasks.

Physical exam includes auscultation of the heart and lung areas on the chest. Additional procedures may include blood tests, X-ray, CT scan imaging, lung function test like spirometry and echocardiogram. (https://www.lung.org/lung-health-diseases/warning-signs-of-lung-disease/shortness-of-breath/diagnosing-treating) 

It is essential to see a doctor to know the diagnosis and plan appropriate intervention. Certain conditions may require multi-disciplinary team approach in the treatment of dyspnea for e.g. a physical therapist can teach breathing techniques to facilitate relaxation and improve lung function. 

Is physical therapy indicated to treat dyspnea?

Physical therapy is indicated in many cardio-pulmonary conditions in the form of pulmonary & cardiac rehabilitation. Exercises prescribed during rehabilitation can strengthen heart and lungs to improve oxygen uptake with relatively less work of breathing. You maybe referred for rehabilitation after a detailed consultation with the doctor. 

A huge number of studies have shown that pulmonary rehabilitation improves exercise tolerance, physical & mental health, quality of life and reduces dyspnea (https://pubmed.ncbi.nlm.nih.gov/16354848/)  

What is pulmonary rehabilitation?

Pulmonary rehabilitation is a health program to help improve symptoms of chronic lung disease. A team of healthcare providers guides you through physical activities (based on your tolerance levels), education and techniques to help you manage your breathing during daily activities. 

In chronic lung disease, the breathing muscles weaken resulting in dyspnea and limitations in daily tasks. This can create a cycle that leads to further muscle weakness and progressive decline of physical endurance. Pulmonary rehabilitation can get you moving again at a pace that is right for you. It will not cure the lung disease, but it will help reduce the symptoms and improve muscle strength and quality of life. 

What conditions is pulmonary rehabilitation used for?

Pulmonary rehabilitation can help several chronic conditions which include:

• Chronic obstructive pulmonary disease
• Interstitial lung disease
• Asthma 
• Cystic fibrosis
• Bronchiectasis
• Pulmonary hypertension
• Lung cancer

Lung transplant

How is pulmonary rehabilitation designed?

One or more of the following tests conducted by a healthcare professional helps to design a pulmonary rehabilitation program.

• Exercise stress test to measure oxygen level, blood pressure and heart rate while exercising. 
• Breath function test to check how well your lungs are working.
• Six-minute Walk test to measure distance covered with vital parameter check. (https://www.nhlbi.nih.gov/health/pulmonary-rehabilitation) 

What happens in pulmonary rehabilitation?

Pulmonary rehabilitation focuses on exercise and education. Your physical therapist will help design a tailor-made program suitable to your symptoms and body capacity. Components of pulmonary rehabilitation may include:

• Exercise: Physical activity is the main component of pulmonary rehabilitation. The physical therapist designs a program by carefully selecting exercises based on your physical capacity and symptoms. You may have exercise sessions two to three days in the week under the supervision and guidance of the physical therapist. Symptoms throughout the session will be monitored and recorded to plan progression. Pulmonary rehabilitation exercises might include: 
  • Warm-up and cool down
  • Flexibility training (stretching exercises)
  • Respiratory muscle training – this might involve breathing in or out forcefully through a handheld device.
  • Endurance or interval training – this might be cycling, walking or using sitting elliptical machine.
  • Resistance or weight training by using resistance bands, kettle bell or dumbbells
• Education: Includes learning how to managing shortness of breath with other symptoms, understanding medications, monitoring oxygen, preventing flares and infections and learning how to use at-home equipment. 
• Breathing retraining: Learning to adapt to shortness of breath can make daily activities easier to manage. Techniques may include: 
  • Controlled breathing techniques
  • Relaxation techniques
  • Positions that help relieve shortness of breath 
  • Coughing and breathing techniques: help open airways and loosen mucus for e.g. huffing technique. 
  • Airway clearance vest: Or a high frequency chest wall oscillation device, is an inflatable vest that vibrates to loosen mucus. 
  • Postural drainage and percussion: is a type of physical therapy where gravity-assisted body positions enhance mucus clearance. It can be accompanied by chest wall clapping and percussions by the therapist. 
• Mental health support: it can be stressful to live with chronic health condition. The health care professional can help manage anxiety, depression, stress and other mental health conditions with: 
  • Relaxation and distraction techniques
  • Counseling
  • Support groups
  • Medication
• Nutrition: Dietary recommendation like proteins to increase muscle mass maybe given. Swallowing techniques can be taught to reduce the risk of aspiration. (https://my.clevelandclinic.org/health/treatments/pulmonary-rehabilitation) 
• Yoga, mediatation and relaxation: helps relax muscles, reduce excessive muscle tension, reduces the work of breathing and improves tissue oxygenation. 

Positive expiratory pressure (PEP): PEP devices provide resistance in expiration which helps to propel the mucus out. Oscillating PEP devices like flutter or acapella creates vibration which helps to loosen the mucus for expulsion. 

Chest physiotherapy and airway clearance: is included in the program when certain conditions cause mucus production in the lungs and airways. Mucus clearing techniques include:

Transcutaneous neuromuscular electrical stimulation to activate weak muscles with small amounts of electricity. 

How long is the pulmonary rehabilitation program?

Usually, it is a 2 or 3 days per week session which lasts for several weeks or months depending upon the diagnosis, symptoms and functional limitations. 

The healthcare team will conduct reassessment testing to find changes in cardio-respiratory functions and plan for further rehabilitation.