Dyspnea

Dyspnea is a subjective feeling of shortness of breath. Dyspnea may be observed, for instance in a person noticeably struggling to breath. However, it is primarily the patient’s subjective experience that the clinician must assess. A description of dyspnea may include: “I feel like I’m suffocating” or “my chest feels tight” or “I can’t seem to get enough air”.

Common reasons for experiencing dyspnea include lung disease and heart disease. Dyspnea is also a common symptom during the dying process. The onset of dyspnea is generally a progressive occurrence; therefore, a sudden onset should be considered a medical emergency.

• Assessment Dyspnea can be subjectively assessed, like all symptoms, by using the PQRSTU mnemonic (see Symptom Assessment) or other numeric scales such as the ESAS (see Symptom Assessment). Objective clinical assessment should be based on diagnosis. For instance, a person with a history of lung disease will require a thorough lung exam. The patient may also benefit from pulse oximetry and chest x-ray among other diagnostics, depending on patient-centered goals.
• Treatment Primary treatment of dyspnea is generally focused on the underlying medical cause. For instance, a person experiencing dyspnea secondary to decompensated heart failure should be treated with a diuretic if possible. Non-pharmacologic treatment can include teaching pursed lip breathing, opening a window or providing a fan to increase air movement across the face, or oxygen. While many patients and their caregivers may ask for supplemental oxygen in the treatment of dyspnea, it has only been found efficacious in patients who are hypoxic. For those whose symptoms are refractory to standard care, such as a diuretic or nonpharmacologic management, opiates are the most common treatment. A referral to palliative care may be helpful to manage treatment at this time.
  
  People with any type of lung disease may experience anxiety as dyspnea occurs or even in anticipation of dyspnea. Therefore, anxiolytics such as benzodiazepines are often used. Antidepressants have also been found to be helpful for those with frequent debilitating anxiety. Consult an evidence-based guideline for further information in the palliative treatment of dyspnea.

Additional Resources

Clinical Practice Guidelines

• American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients with Advanced Lung or Heart Disease
• Agency for Healthcare Research and Quality
• Fast Facts
• Fraser Health
• National Comprehensive Cancer Network (requires free registration)
• Qaseem, A., Snow, V., Shekelle, P., Casey Jr., D. E., Cross Jr., T. J., and Owens, D. K. “Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians.” Annals of Internal Medicine 148 (2008): 141-146.

References

• Kamal, A. H., McGuire, J. M., Wheeler, J. L., Currow, D. C., and Abernethy, A. P. “Dyspnea Review for the Palliative Care Professional: Assessments, Burdens, and Etiologies." Journal of Palliative Medicine 14 no. 10 (2011): 1167-1172.
• 2. Kamal, A. H., McGuire, J. M., Wheeler, J. L., Currow, D. C., and Abernethy, A. P. “Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options.” Journal of Palliative Medicine 15 no. 1 (2011): 106-114.
• Kuebler, K. K., Heidrich, D. E., and Esper, P. Palliative and End-of-Life Care: Clinical Practice Guidelines, 2nd ed. (St. Louis, MO: Saunders, 2007).
• Wrede-Seaman, L. Symptom Management Algorithms: A Handbook for Palliative Care, 3rd ed. (Yakima, Washington: Intellicard, Inc, 2009).