Read about management of dyspnea

According to American Thoracic Society, Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is compromised of qualitatively distinct sensation that vary with intensity. The sensation of dyspnea originate with the activation of sensory systems within the lung, chest wall and respiratory muscles that give rise to awareness of breathing discomfort.

Mechanism

It is caused by one or the combination of the following:

1. Increase in airflow resistance e.g. obstructive lung disease

2. Decrease energy supply e.g. malnutrition

3. Increase elastic load e.g. rigid chest, fibrotic lungs

4. Decrease power e.g. neuromuscular deficiency, fatigue, weakness

5. Increase drive to breathe e.g. ILD

6. Decrease alveolar surface tension e.g. ARDS

Task which can cause breathlessness

• Dressing

• Wash/Shower/Bathing

• Cooking

• Eating

• Speaking

• Climbing stairs

• Going to toilet

• Reach over the head

• Lifting

• Bending down

• Dusting/Ironing/Gardening

Outcome Measures:

Grading of Dyspnea (ATS scale)

Borg Scale.

Management:

1) Relaxation techniques

If dyspnea occurs because of anxiety or pain relaxation techniques would decrease the dyspnea. Support, comfort and a restful atmosphere are basic condition for general relaxation.

Methods includes:

Quite environment

Comfortable position

Loose clothing

Slow abdominal breathing with deep breaths and slow expiration

Systematic tensing and relaxing of muscles

Yoga and meditation

Other therapy includes: hypnotherapy, acupuncture, taichi.

2) Manual therapy

Muscle tension and abnormal mechanics of breathing reduce thoracic mobility and stiffen posture which further increases the work of breathing.

Following techniques have found to be beneficial which includes:

Maitland mobilizations to vertebra and scapular joints

Passive thoracic extension

Stretching of muscles around the shoulder

3) Breathing exercise

a) Pursed lip breathing

Patient position: relaxed comfortable position

Procedure: Ask patient to breathe in slowly and deeply through nose and breathe out slowly and gently through your pursed lips.

b) Diaphragmatic breathing

Patient position: Relaxed and comfortable position

Procedure: Place a hand gently on your tummy just beneath your ribs.

Breathe in slowly and deeply through the nose and breathe out through the mouth

Hand should rise slightly during inspiration and fall during expiration.

4) Increasing movement of cold air

Symptomatic relief can be achieved by increasing the movement of cold air onto patient face e.g. using of a fan, sitting by a open window. n. The air stimulates mechanoreceptors in the face which in turn stimulate the brain to slow down the rate of breathing.

5) Exercise training

It includes:

Upper limb training, lower limb training, inspiratory muscle training.

Method:

Exercise training includes warm up and cool down period.

Warm up:

Stretching exercises are encouraged e.g. trunk rotation or pectoral stretch with patient’s hands on his or her lower back. Other muscles that need stretching includes neck muscles, hamstring and calf muscles.

Exercise prescription:

According to FIIT Principle for Upper and Lower limb training:

Frequency: 3 to 5 days/week

Intensity: According to patient tolerance. (Decide by exercise testing prior to exercise training)

Time: 30-40minutes/session

Type:

Aerobic or resistance training

Continuous or interval training

Upper limb training: e.g. Arm ergometry with weight and therabands

Lower limb training: e.g. walking, stationary cycling, leg press, quadriceps exercise.

Cool down:

Patients are asked to slow down their activity to prevent sudden pooling of blood in lower extremities

Inspiratory muscle training

IMT can improve inspiratory muscle strength and endurance by reducing the severity of dyspnea and improving exercise capacity.

Devices includes:

a) Flow dependent inspiratory muscle trainer

b) Pressure threshold inspiratory muscle trainer

Frequency : 5-7 days/week for 4 week

Duration: 30 minute session/day

6) Activity modification and energy conservation

Sit when possible while completing the chores.

Avoid unnecessary motions.

Break the jobs in steps.

Use good posture and body mechanics.

Minimize steps into tasks.

Use breathing techniques while performing the tasks.

Avoid overreaching and bending while arranging the equipment.

Coordinate breathing with activity e.g. inhale with pulling and exhale with pushing.

Plan and organise the workspace to reduce clutter.

Use a stool for kitchen activities.

Develop economical lifting methods using leg power rather than the back and shoulders.

7) Self-management

Symptom management

Recognition for need of medical attention e.g. change in symptoms or new symptoms.

Management of the environment e.g. indoor exercise if outside air is polluted.

Breathing techniques.

Posture to improve breathing.

Relaxation techniques.

Monitoring triggers and intensity of shortness of breath.

Teach about different factors that may make dyspnea worse or better.

Recording the intensity and timing of dyspnea in daily log or health diaries.

Early recognition of signs and symptoms of infection.

Correctly use metered dose inhaler.

Bhumika khandwani

Bachelor's of physiotherapy

BITS Institute of Physiotherapy

References:

Physiotherapy for respiratory and cardic problem fourth edition by pryor

Physiotherapy in respiratory care by Alexandra Hough