What is Dyspnoea?


The end product of dyspnoea is shortness of breath. There are many factors however that all contribute to dyspnoea. These stem from the cascade of events that occur in response to COPD. Considine (2005: 625) notes that dyspnoea predisposes patients to adverse events such as respiratory and cardiac arrest in the right conditions when a patient presents with an exacerbation of COPD. It is for this reason that control of dyspnoea is critically important in the management of COPD. Dyspnoea may be short acting and transient post physical activity or chronic and long term as disease progresses. Jantarakupt and Porock, (2005: 796-797) discuss the main sources of dyspnoea. Firstly, decreases in arterial oxygen levels PaO2 and/or increases in arterial carbon dioxide levels PaCO2 are detected in the chemoreceptors and baroreceptors located in the aortic arch and carotid arteries. These receptors communicate with the respiratory centre in the brain located in the medulla and this serves to increase respiratory rate to either increase oxygen or decrease carbon dioxide. Secondly, the respiratory muscles including the accessory muscles are innervated via the efferent neural pathways to assist ventilation by increasing workload in the form of contraction. This serves to increase the surface area of the thoracic cavity to allow for more airflow. Thirdly, hormones are released in the form of adrenaline to increase respiratory rate, noradrenaline which causes bronchoconstriction, and cortisol which contributes to the inflammatory response in the presence of an inflammatory trigger. This produces cholinergic effects such as increased mucous production. In addition, hyperinflation of the lungs due to constrictive airways and remodelling of the alveoli leads to resistive lungs and static muscles which further reduces ventilation and contributes to muscle fatigue (Barnett, 2009: 7).



Anxiety contributes to dyspnoea because of the cascade of events in the mechanics of dyspnoea. Barnett (2009: 6) argues that the feeling of ‘breathlessness’ can be a terrifying experience in some patients and may lead to panic attacks. Patients may express a sensation of suffocation or may express that they can’t breathe.


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Figure 13. The cycle of dyspnoea Source http://www.rocksauna.com



As can be seen from the diagram above, dyspnoea is a cycle that if not arrested can lead to anaerobic respiration leading to decreased energy production. This will lead to further deterioration in physical function, muscle fatigue, increased work of breathing, reduction in alveoli surface tension, atelectosis and eventually respiratory arrest. For this reason, dyspnoea should be assessed by examining the patient’s work of breathing and respiratory rate early.



Management of dyspnoea involves rest for energy conservation, use of short acting bronchodilators in a rescue dose, and supplemental oxygen if required. Patients often report that they require air moving over their bodies to assist with dyspnoea, so the use of a fan is helpful. Spending some time and calmly talking to the patient in a reassuring manner can assist with anxiety. In more severe cases of anxiety, the use of a benzodiazepine or an alternate anxiolytic may be helpful. Morphine may be beneficial in its ability to vasodilate and thereby reduce preload contributing to pulmonary congestion. It is also thought that morphine reduces the sensitivity of chemoreceptors to hypoxia and hypercapnia, and may assist with anxiety (Jantarakupt & Porock, 2005: 787).



There are also positioning and breathing techniques that can be used to assist with reducing dyspnoea. These will be explored in the next section.



The goal of positioning is to improve the surface area of the thoracic cavity to allow more gas flow and therefore gas exchange. Have you ever noticed how a patient with dyspnoea needs to lean over an object to improve their lung expansion? This technique is known as the tripod position and usually is performed subconsciously in any patient with dyspnoea. This position should be encouraged in patients with dyspnoea (Finesilver, 2003: 86).




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Figure 14. Tripod position for breathing. Note the need to lean forward onto something- in this case his knees. This optimises the function of pectoral muscles to expand thoracic cavity. Source http://www.blscprtraining.com











Any position that will assist to decrease tension on the diaphragm is useful in a patient with COPD. Positioning is an individual decision. That is, positions that work for some may not for others. Generally, patients will avoid lying flat as it impedes the ability of accessory muscles to assist with ventilation. In assisting your patient to become comfortable, you will need to experiment with different positions whilst communicating with your patient in relation to determine the most effective position at the time (Barnett, 2009: 12). There are also positions that a patient can use at home to aid ventilation and conserve energy. The following link to a site by Hillsman (2008) may assist your knowledge of other positioning techniques that patients can use at home.


http://www.sierrabiotech.com/bt_copd_positions.html






Pursed Lip Breathing

As the name suggests, pursed lip breathing involves exhaling through partially closed or pursed lips.


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Figure 15. Pursed lip breathing technique. Source http://www.medlineplus.gov



As you can see from the picture, the concept of pursed lip breathing is to slow respiration and increase the length of time to exhale CO2. The patient inhales through pursed lips for the count of two seconds, and exhales through pursed lips for the count of four seconds. People often unconsciously practice this technique when short of breath after exercise, for example climbing a flight of stairs; however the patient with COPD will often use this technique for many tasks. Fager, Stahle and Larsen (2008: 679) conducted a study to determine the effectiveness of pursed lip breathing during exercise. Their study found that pursed lip breathing significantly improved oxygenation and exercise tolerance when employed against normal respiration. In an acute exacerbation of COPD where dyspnoea is present, encouraging your patient to use pursed lip breathing may assist them to reduce their feelings of dyspnoea and improve their recovery time.



Diaphragmatic Breathing

Cigna and Turner-Cigna (2005: 582) describe the technique of diaphragmatic breathing as inhaling through the nose and exhaling through pursed lips. The concept is to inhale deeply and extend the diaphragm into the abdominal region in order to reduce the workload occurring in the muscles of the upper chest and neck. To determine the effectiveness of this technique, the patient should place their hands flat across their abdomen in order to feel the rise and fall of their abdomen as they breathe. This process is also designed to relax breathing and the patient to reduce work of breathing and respiratory rate. The time for inhalation and exhalations are the same as for pursed lip breathing.



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Figure 16. Diaphragmatic breathing. Source http://www.ameliaburton.com.au



A fact sheet on dyspnoea and management strategies can be found from the lung foundation of Saskatchewan at the following link



http://www.sk.lung.ca/brochure/COPD/Breathlessness_Fact_Sheet.pdf



Energy conservation


It is important for the patient with COPD to conserve energy. This will allow dyspnoea to be managed and allow the patient to have the ability to remain active. Psychosocially, the patient who is able to continue to remain active will also feel a stronger sense of self worth and will feel less reliant on others for their care needs. There is also a reduced cost to the health care system if the patient can continue to contribute to their own care needs (Paz-Diaz, Montes de Oca, Lopez & Celli, 2006).



The concept of energy conservation is to learn to plan and organise tasks into more manageable stages to allow for rest during and after the task. For example, minimising the number of times stairs are climbed in a two storey house by using a clothes basket to carry things, and organising the house so that most things required during the day are on the ground level. Sitting whilst bathing/showering/shaving will result in less energy being used during the process. The patient should consider planning shopping trips around being able to sit when needed. Walking aids may also be required to assist with energy conservation (Barnett, 2009: 12).




A fact sheet on energy conservation may be found at the following link



http://www.sk.lung.ca/brochure/COPD/Energy_Conservation_Fact_Sheet.pdf

Pulmonary Rehabilitation and Exercise


It is important for the patient with COPD to engage in some form of pulmonary rehabilitation early. However the degree of this program is relative to the disease progression that your patient experiences. Studies have revealed that where pulmonary rehabilitation is used in the early phases of an admission, the length of stay has fallen, and representations with acute exacerbations have also fallen (ZuWallack, 2008; Eaton, Young, Fergusson, Moodie, Zeng, O’Kane, Good, Rhodes, Poole & Kolbe, 2009; Carr, Hill, Brooks & Goldstein, 2009).



In examining the above studies, it is evident that pulmonary rehabilitation has an effect on motivation, self esteem, improves depression, and has a beneficial effect on other co morbidities that are affected by COPD. Pulmonary rehabilitation may assist to improve or stabilise symptoms of COPD. It will also assist with strategies to formulate COPD action plans, and review patient’s techniques at delivering bronchodilators. Barnett (2010: 7-8) states that a program of pulmonary rehabilitation followed by regular exercise reduces fatigue and increases exercise tolerance with overall improvements to the patient’s physical and mental well being.



Monitoring nutritional status and weight is equally important improving activity levels, as a balance is required to produce enough energy to assist in maintaining activity levels (Odencrants, Ehnfors & Grobe, and 2007: 62).