Factors contributing to breathlessness and it's management Flashcards
Define breathlessness.
Awareness of increased effort which is unpleasant and recognised as inappropriate.
Define Orthopnoea.
Breathlessness upon lying down.
Define Paroxysmal nocturnal dyspnoea (PND)?
Occurs after 1-2 hours of being supine ( Increased VR puts excess load on the right side of the heart).
What does the term breathlessness mismatch refer to?
breathlessness mismatch due to a mismatch between demand for ventilation and afferent information about actual ventilation.
Reminder
see LC at 14:00 for understanding about eh load-capacity relationship = a model for understanding breathlessness.
What is the aetiology of breathlessness?
- Increased respiratory drive
- increased load
- impaired capacity
What things can increase your reparatory drive?
- Hypercapnia/acidosis
Poor relationship between elevated CO₂ and dyspnoea but strong correlation between hypercapnia and resulting in increased VE. - Hypoxia
(Caused by; anaemia, high altitude, V(=ventilation)/Q(=perfusion) mismatch)
poor correlation between hypoxia and breathlessness but strong correlation between hypoxia resulting increase in Ve.
What can increase the load on the respiratory muscle pump?
- Reduced compliance of the lungs
- Obesity
- Airflow obstruction
What can impair the capacity of the respiratory muscle pump?
- Respiratory muscle impairment;
- force-length relationship
- force-velocity relationship (respiratory muscles, velocity is measured as flow)
*Peripheral muscle impairment (occurs when you avoid activity and have deconditioned, you produce more lactic acid and have to breath more for a given activity)
also hyperinflation
reminder
see LC at 21:00 for the breathing, thinking, functional clinical model.
During assessment of breathlessness what sensations would you measure?
- Intensity
- Unpleasantness
- Sensory aspect
How could you assess the function/ impact of breathlessness?
- Modified MRC scale
- BORG scale
- Chronic respiratory questionnaire (CRQ)
- St George’s respiratory questionnaire.
What are some general aims of management of breathlessness?
- Reduce ventilatory demand;
Reduce metabolic load.
Reduce central drive. - Reduce load (ventilatory independence).
- Increase capacity.
- Alter central perception.
How can you reduce metabolic load?
- Exercise training = reduction in lactate for a given activity.
- Supplement O₂
(Very little support evidence though, mainly thought to be related to reduction in ventilation) only to be used in hypoxaemia.
How can you reduce their central drive for management of breathlessness?
- Oxygen therapy:
Reduced hypoxic drive from chemoreceptors proportional to reduction in ventilation. (remember the supporting evidence for this is poor) - Pharma logical therapy; e.g. Opiates
(reduce Ve at rest and during exercise - alter central processing of neural signals within CNS to reduce sensations associated with breathing).
(supporting evidence also poor with variable results).
How can you alter their central perception for management of breathlessness?
- Education: help them understand what causes their breathlessness.
- Cognitive behaviour (desensitisation)
- Drug therapy
- Vibrations
- Fans (seems particularly effect for cancer)
How can you increase their capacity of the reparatory muscle pump to aid management of breathlessness?
- Reduce lung hyperinflation.
(By Lung volume reduction surgery LVRS)
or Breathing retraining (slower deeper breathing patterns will reduce physiological dead space and improve removal of CO₂, but has limited supporting evidence)
- Improve inspiratory muscle function. by; - Optimising nutrition Positioning - Inspiratory muscle training (not always appropriate e.g. degenerative neuromuscular disorder or chronic lung disease)
- Partial ventilatory support (effective)
- Minimise steroids. (small amount of supporting evidence)
In the management of breathlessness what’s the role of a Physiotherapist?
- Education and reassurance
- Positioning
- Pursed lip breathing
- Breathing control
- Exercise training
How can a physiotherapist best educate and reassure patients struggling with breathlessness?
- Remember that breathlessness is normal when you exercise.
- Adopt a position that helps. (forward lean sitting)
- Breath as quickly as you feel you need to.
- Relax shoulders.
- Encourage patients to wear comfortable and suitable clothing e.g. trainers, no tight pants e.g. suit pants ETC.
Why is the forward lean sitting position good for breathlesness?
- Increases force generation of the diaphragm
- Reduce accessory mm activity
- Reduce breathlessness.
How does pursed lip breathing ease breathlessness?
(its of limited use not
necessarily going to help)
- Increases intra-thoracic pressure
- Patients adopt this technique spontaneously
- Some evidence to suggest it’s of benefit to COPD patients during exertion.
What breathing control techniques would you teach a patient to aid breathlessness?
- Gentle breathing: normal tidal breathing
- Relax shoulders and upper chest
- Arms supported and hands relaxed (forward leaning is useful for this)
- Never impose a breathing rate on a patient
- Useful as part of an active cycle of breathing techniques (ACBT), during exercise and acute exacerbations.
- Paced breathing e.g.
when using stairs, breath in for one step, out for 1 or 2 steps DEPENDS ON THE PERSON!!!!
= “Blow as you go”
What techniques would you use as part of an exercise training programme for breathlessness?
- Use breathing control
- Paced breathing
- Blow as you go
- Walking aids
- Energy conservation.
How do walking aids help with the management of breathlessness?
- Forward leaning and fixing shoulder girdle with a rollator frame.
- Increases ventilatory capacity:
Reduced dyspnoea.
Reduced fatigue.
