Shortness of breath or breathing difficulties can be a frightening symptom, whether it is something that has happened to you ‘out of the blue’ or something you have had to learn to live with through chronic disease.
Shortness of breath is the most common reason for attending Accident and Emergency and one of the most common reasons for calling an ambulance, yet not so many people consult their GP about their breathing as they should.
Around 10 per cent of the UK adult population suffer with shortness of breath and almost a third of the older population. Many people struggle on with symptoms at home and could better manage their breathlessness by working with their medical team closely.
We talk to Dr Louise Wiseman about some possible causes of feeling breathless in adults.
What is shortness of breath?
The medical term is dyspnoea. Shortness of breath can be subjective, in other words, when we are not breathing as we normally do. We may feel that we cannot take a deep breath in, or that our breathing is shallower and faster than normal, or difficult and uncomfortable. This may affect us when sitting still or only when we exert ourselves.
Real breathlessness can be related to many physical factors within our body and our environment and how we are feeling in ourselves. If we are feeling anxious our symptoms may worsen and a vicious cycle develops.
Causes of shortness of breath in adults
Exercise is like a natural test for our heart and lungs. It is normal and healthy to get ‘out of breath’ when you exert yourself, whether this be running a mile or walking up the stairs. Your own limit will depend on your overall fitness and level of exertion that you exhibit daily. With exercise training, you will usually notice your tolerance improves and shortness of breath becomes less of a problem as you climb the stairs at the shopping mall car park.
Sometimes though, exercise can unveil a medical problem that you would not notice at rest. Exercise may bring on asthma or may reveal cardiac problems if you are suddenly limited more than normal.
For this reason some asthma medications, e.g long acting beta-agonists, are slow release helping to stop the airways spasming on exertion and are used prior to exercise.
Anxiety or panic attack
Our body reflects closely the activity in our brain and if you are generally feeling anxious your heart and breathing rate may increase. You can recognise the feeling and the need to calm yourself. Sometimes though, this feels out of control and can become a panic attack. You can find yourself hyperventilating (over-breathing) or breathing fast.
Slowing down your breathing can help reverse the feeling. When you hyperventilate, you ‘blow out’ your carbon dioxide more than normal and this causes physiological changes in your body that can make your hands tingle and you feel light headed. To stop this, you must try and increase your carbon dioxide back up. If you know you are hyperventilating, you can try breathing slowly into a paper bag or cupped hands and breathe deeply into your tummy more than shallowly into your chest. Concentrate on slowing your breathing and relaxing.
If panic attacks or anxiety are a recurrent problem, you should discuss with your doctor. Cognitive Behavioural Therapy or similar is hugely helpful and of course you must address the underlying cause of your anxiety. Mindfulness Based Stress Reduction techniques can be remarkably useful for everyone with a busy, stressful life.
Hay fever or sensitivity to house dust mites and similar can trigger asthma in sensitive individuals. You may be aware that with the pollen calendar you suffer at certain points of the hay fever season and that sneezing and upper respiratory inflammation can worsen your asthma.
Ensure you take your antihistamine as prescribed by your doctor and any preventative and treatment inhalers during this time.
The most common symptoms of asthma are wheezing, breathlessness, tight feeling in chest and coughing. You can have each of these symptoms in other conditions, but if they happen frequently you must see your doctor to get a proper diagnosis. They may happen randomly or in response to pet fur or exercise, sometimes symptoms are worse at night and early in the day. The asthma is due to the airways being extra responsive and tightening or going into spasm.
A severe asthma attack needs urgent medical attention and may include; severe wheezing/coughing/tightness of the chest, being unable to speak, eat or sleep, racing heart and breathing faster, drowsiness, dizziness, confusion, fainting, blue lips or fingers
Management of asthma is by combined care with your GP, practice nurse and often local respiratory hospital team. Success is by knowing your body and your asthma and working to prevent flare ups.
A good approach is to be aware of the following points:
• Have an 'asthma action plan' – this will tell you what medicine to use if things worsen. You may have a peak flow diary where you measure how your airways are by breathing into a special peak flow meter at home.
• Using your preventer medicine well – will mean using it when you are well as it builds up protection over time
• Carrying your reliever inhaler with you and knowing how much extra use means a consultation is sensible e.g. more than three times a week
• Using your inhaler properly which may mean use of a spacer
• Attending your annual asthma review
• Having your annual flu vaccine if appropriate
Your medicine will be a combination of relievers (to treat any symptoms promptly) and preventers (to prevent flare ups).
Relievers work quickly in the lungs to relax the spasm that can occur.
Preventers usually contain a low dose of steroid medication to reduce inflammation and swelling in the lungs. You may not need one, or only need it for seasonal use or be advised to use it daily. If taking it for hay fever, sometimes it is advised to start it two weeks before your season. Because there is steroid in most preventers they can cause thrush or sore throat symptoms – these are prevented by using a spacer, a good technique and rinsing your mouth with water and spitting out after use.
Inhalers can be a spray, or an inhaler where you need to inhale to activate it, or a dry powder. Your nurse will check your technique in your annual check.
Obesity, breathing and sleep apnoea
Apart from obesity making every day activities a little more difficult for the body, there are many ways it can affect breathing. Extra fat around the chest and neck can make the work of breathing heavier but also put pressure on the heart and lungs in terms of the work they have to do. Extra fat may produce hormones that affect the metabolism. This can all make the feeling of breathlessness more likely.
Your doctor may examine you and calculate your BMI or measure your waist circumference. Sometimes obesity can affect sleep and breathing at night and sleep apnoea may be a problem. Losing weight and steadily increasing exercise to be at a healthy BMI and lose waist circumference can reverse this. CPAP machines at night can help prevent sleep apnoea and will often be provided after specialist consultation at a sleep clinic.
Chronic Obstructive Pulmonary Disease (COPD)
Most cases of COPD (chronic bronchitis and emphysema) are caused by smoking or rarely environmental pollutants or genetic factors. The flow of air in the lungs is limited and unlike asthma not so easily reversed. This can have a huge impact on quality of life causing chronic breathlessness
As with many other lung conditions you will usually have shared care between the GP and a specialist clinic. Lung function tests including chest x-rays, spirometry and scans will be used to assess extent and progress of your disease.
There will be a low threshold for treating any infections and you will most likely be managed with regular inhalers. Pulmonary rehabilitation really helps patients optimise their fitness and breathing techniques may be taught to help catch your breath and focus on breathing out not in which is because the body is not able to get rid of carbon dioxide so well with this disease. Simple measures like a handheld fan can help.
Acid reflux can be more common if you are overweight or have a hiatus hernia. Acid comes up the oesophagus and can irritate upper airways or trigger a response to cause an asthma-like reaction. Patients will often describe acid reflux as being worse when lying down or at night, after eating or exercising, gardening leaning forward and so on.
Losing weight can help, as can reducing stomach acid by medication such as proton pump inhibitors or antacids. A wedge shaped or extra pillow at night can help elevate the upper body and reduce reflux. At worse reflux could potentially lead to an aspiration pneumonia as an acute cause of infection and shortness of breath.
Any infection can lead to shortness of breath, whether it is a simple cold causing viral induced wheeze or sinusitis causing congestion. More severe infections can cause pneumonia which can impair the lung’s ability to exchange gases across the surface and will require medical treatment and possible hospital admission. You may have a productive or dry cough alongside shortness of breath.
Your doctor will assess the whole clinical picture by asking you questions and examine your chest for signs of infection and organise investigations and treatment as appropriate.
In light of COVID, an excellent resource for managing breathlessness at home under guidance of your doctor has been produced by King's college. This would of course be alongside any medical advice given to you by your GP and should not replace it.
Pulmonary Embolism (PE)
Pulmonary embolism is a blood clot (or many clots) in the lungs and this can damage the lung, decrease oxygen levels in the blood and affect other organs. It can of course be fatal. They are often caused by a deep vein thrombosis from the leg or pelvis and these can be from trauma e.g. muscle or bone injury, being immobile (long plane ride/hospital bedridden stay) or certain medical conditions (e.g. malignancy, surgery). Other factors such as pregnancy and certain hormonal contraception can put you more at risk as can genetic factors.
This is a medical emergency and alongside shortness of breath there will also be a rapid heartbeat and possible coughing up blood and chest pain.
Heart or cardiac causes of breathlessness
Various heart conditions can cause shortness of breath – two-thirds of cases of breathlessness in all are actually due to cardiopulmonary causes.
Examples are heart attack, heart valve problems, heart failure, heart rhythm problems.
Symptoms may include chest pain or irregular or fast heart beat, fainting or dizziness and in cases of heart failure swelling of ankles and possible worsening of symptoms when lying flat. These are complicated scenarios that need careful clinical assessment.
Anaemia means there is less oxygen carrying capacity of the blood so it stands to reason that our breathing will increase to try and compensate so we feel as though we are out of breath. There are many causes of anaemia and these would be investigated by blood tests and other investigations by your doctor. With treatment of anaemia one would expect shortness of breath to resolve if it was the primary cause.
Chronic lung disease
All of these conditions require specialised care:
Lung disease is a cause of chronic breathing difficulties and illness. Examples include;
Cystic fibrosis is a genetic condition causing the body to produce thick mucus affecting lungs and digestive system and requires specialist management.
Pulmonary fibrosis is a disease that occurs when lung tissue damaged and scarred and because it is thickened it makes it difficult for the lungs to function properly. Patients tend to become slowly progressively short of breath.
Bronchiectasis involves one or more of the large airways being abnormally widened allowing more mucus to collect and more chance of infection. This can occur after other infections causing damage or immune problems or certain fungi allergies. Often the cause is unknown.
Tips for reducing breathlessness
If you are otherwise well but still experiencing breathlessness, the following tips may help:
Quitting smoking is a massive component of reducing lung disease, shortness of breath symptoms and preventing many diseases and causes of premature death. Talk to your doctor if you feel you cannot give up smoking alone ‘cold turkey’ as there are many options that can help.
Improving your fitness levels and reducing excess weight in turn help reduce the load on our hearts and lungs and will improve any breathing problems. Start gently and listen to your body and always discuss with a healthcare professional if you have ongoing health problems and are thinking of drastically changing your lifestyle.
Cardiac and pulmonary rehabilitation
After a heart attack or spell in hospital for lung disease, many patients are seen by physiotherapy and rehabilitation specialists who may advise special breathing exercises to maximise lung capacity and oxygen levels. These may be good habits for dealing with mild shortness of breath at home.
Knowing your medicine
Understanding any medicine for your breathing is paramount in getting you to take it and for it to work correctly. Make sure you attend medication reviews with your doctor and if something feels like it is no longer working report it to your practice or respiratory nurse.
Diagnosis for shortness of breath
It is important that you do not simply self-diagnose your own shortness of breath. Your clinician will make a diagnosis based on talking to you, asking some simple questions and examining you. They may also perform some investigations to get a clear clinical picture.
Types of questions your doctor will ask you in a consultation include:
• When did it start – was it sudden or gradual? Do you normally have an inhaler and is it helping? Do you have allergies or hay fever?
• Did anything trigger it – how severe it is? How far can you walk or exercise?
• Have you been abroad? Have you had a fever or recent virus? Exposed to unusual infections such as TB? Long duration on an aeroplane or immobile?
• Do you have any chest pain? Do you ever notice your lips or fingers going blue?
• Do you have a cough? Is there any sputum or blood? Weight loss?
• Are your ankles or leg swollen? Is it worse when you lie down?
For chronic shortness of breath, such as with COPD, a doctor will often use a special scale devised by the Medical Research Council to assess how your daily life is affected.
When to seek urgent medical advice
You must call 999 if you are struggling to breathe or suddenly become short of breath, and:
- Your chest feels tight or heavy
- You have chest pain spreading down your arms, back, neck or into your jaw
- You feel nauseous or are being sick
- you have blue lips or fingers, are coughing up blood, are confused or slurring your speech.
Other reasons to speak to your doctor urgently include:
- Shortness of breath that won’t go away
- Chest pain
- No relief from your normal inhaler medicine
- Fever alongside shortness of breath
- Changes in your mucus that you cough up
- Barking cough
Last updated: 11.08.2020
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