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 inervated 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.
Figure ? 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.
Positioning
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).
Figure ? Tripod position for breathing. Note the need to lean forward onto
something- in this case his knees. This optimises the function of pectoralis
majoris 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 may assist your knowledge of other
positioning techniques that patients can use at home.
http://www.sierrabiotech.com/bt_copd_positions.html
Breathing Techniques
Breathing difficulties occur in patients who have COPD due to hyperinflation of
the lungs and entrapment of air leading to increased dead space and
decreased ventilation. This also leads to hypercapnia because the patient has
difficulty in exhaling CO2. Breathing techniques are utilised to slow
respirations, and increase tidal volume and exhalation time (Jantarakupt &
Porock, 2005:791). There are two types of breathing techniques that we will
discuss here, pursed lip breathing and diaphragmatic breathing.
Pursed Lip Breathing
As the name suggests, pursed lip breathing involves exhaling through partially
closed or pursed lips.
Figure ? 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 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 further 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.
Figure ? 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-Dıaz, 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, 2007: 62).