Vol. 21 •Issue 1 • Page 23
Dyspnea Presents Therapist Challenges
Increased Anxiety Complicates the Problems Patients Face
People with asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disorder, cardiac diseases or neuromuscular disorders experience a common and inconvenient handicap.
They all generally experience difficult, labored and uncomfortable breathing commonly referred to as either dyspnea or significant breathlessness.
Dyspnea usually originates from multiple sources and varies widely by degree among patients. A unifying theory, however, suggests it results from a brain-generated mismatch of the control of respiratory motor activity and incoming information generated from receptors in the airways, lungs and chest wall structures.
Regardless of the roots of the dyspnea, our primary mission as respiratory therapists centers on relieving the symptoms, identifying the cause and correcting our patients’ core breathing problems.
To accomplish that task, we need to initially consider options like exercise training, pharmacologic therapy, the use of continuous positive airway pressure (CPAP) or steroids and the improvement of nutrition and enhanced body positioning.
Attention to these areas will, at the very least, address some of the preliminary causes of dyspnea until a thorough clinical diagnosis can be arranged to determine specific ones.
There are five interrelated factors often running through the minds of a patient experiencing dyspnea: fear, anxiety, loss of vitality, a concern of legitimacy of breathing complaints and preoccupation with an ability to breathe.
Needless to say, the fear factor, fueled by any loss of self-control, increases a patient’s anxiety level.
Health care providers have to detect fear and identify individuals caught up in a cycle of trepidation and work to defuse the terror their patients with dyspnea experience.
Personal Encounters
When working in the emergency department one day, I encountered an end-stage, male COPD patient admitted for extreme shortness of breath.
His fear and anxiety were so intense he begged to be intubated. We immediately performed that task; and the patient displayed such quick relief that even I began to breathe easier.
Therapist skills are not confined to hospital situations either. One day when I was shopping in the produce section at a local supermarket, I noticed a woman tethered to an oxygen E cylinder.
She appeared to be doing fine shopping with her sister for holiday recipe items. But later while I was standing in the checkout line, I noticed the same woman experiencing severe dyspnea in what appeared to be a classic case of acute respiratory distress.
After I found a chair for her to sit in so she could relax a bit, I began to instruct her on the pursed lip breathing technique and was able resolve much of the dyspnea occurring even though she was on a 2-liter flow. It was very disconcerting for me to discover she had never been shown this basic life-saving technique.
A clinical evaluation for dyspnea begins with a thorough history and physical examination with attention paid to the duration and severity of any labored breathing episode and to events that initiated the occurrence that progressed to a full-fledged dyspnea incident.
Laboratory testing includes spirometry, a chest X-ray, ECG and a complete blood work up. If these efforts are inconclusive, full pulmonary function testing to include lung volumes and single-breath diffusing capacities should be performed as can be related illness tests.
Exercise testing is recommended if dyspnea is associated with exertion to differentiate it from dyspnea caused by myocardial ischemia, asthma, pulmonary vascular disease and physical de-conditioning.
This important process of elimination should be performed by a specialist.
Psychological Issues
There is one dyspnea component that deserves attention. It is psychogenic dyspnea and is particularly interesting because it is usually a diagnosis of exclusion. Patients experiencing this type of dyspnea are often prone to high-anxiety situations and experience hyperventilation, visual complaints, dizziness, finger tingling and numbness.
Unlike other types of dyspnea caused by a physiological problem, this psychological component requires constant biofeedback of the individual patient from qualified counselors.
There is always a temptation in some of these cases to prescribe antidepressants or other sedatives in order to assist with the psychological element of the event. That might not be the best solution.
I believe people with a psychological condition linked to a clinical problem or disorder are fearful of others’ attitudes toward them. It is a stigma most are more than willing to hide from their family members, friends and in many instances even themselves.
They often feel themselves labeled as individuals unable to control their personal life challenges and fear they may be considered to have a mental condition.
Subsequently, many patients, especially men, are hesitant to speak with a counselor or therapist about the feelings that may be related to their dyspnea let alone their consideration of the benefits of taking a drug designed to address anxiety or depression.
Their fears of being stereotyped as mental cases are sometimes accelerated when they have a near-death experience resulting from severe shortness of breath and possible suffocation.
There is one type of dyspnea which appears in middle-aged individuals with mild heart or lung disease. These patients may find it difficult or be unable to take a deep breath which can trigger a desire to do just that.
This effort, however, will fail because physiological sighing is an involuntary action.
This in itself can increase the level of anxiety, fear and feeling of helplessness.
Treating dyspnea is most effective when the underlying cause of the problem is identified.
But while caregivers are striving to find a diagnosis, the patients themselves are often in a holding pattern and face a tremendous amount of stress and frustration.
The time factor itself can be stressful because several doctors may be involved as part of the team trying to identify the problem, and there may be extreme waiting periods involved as a patient is trying to set up appointments with conferring physicians.
Remember at this point the patient may be experiencing shortness of breath too and that condition in itself can be considered life-threatening.
Some Surgical Options
Extreme pulmonary disease often can require invasive techniques like lung reduction surgery, which can significantly relieve dyspnea by reducing the functional residual capacity of the lung and the patient’s work of breathing.
This option remains controversial, but it is available to some patients experiencing dyspnea as a result of an extreme progressive disease state.
Respiratory therapists have come to a point where taking a passive role in the care of patients is no longer an option. By joining the battle for better breathing, a therapist’s independent participation will raise personal confidence levels and provide a sense of control.
That being said, to remain on top of the game, therapists must remain current with research on clinical issues like medications, pathophysiology and treatments for dyspnea and underlying disease conditions.
The life a therapist saves in the process is, after all, a reflection of quality care.
Michael Donnellan is a California practitioner.
