Management of breathlessness Flashcards
definitions- tachypnoea, hyperpnoea, hyperventilation
T- rapid breathingq, Hyper- increased ventilation in response to metabolic requirements (exercise), ventilation- ventilation in excess of metabolic requirements
definitions- dyspnoea, breathlessness,
dyspnea- a subjective term generally applied to the unpleasant sensation of an awareness of breathing discomfort- breathing laboured or distressing
breathlessness- one of many descriptions used by patients to convey their experience of dyspnea- is an awareness of the intensity of breathing or suggests unrewarding respiration/chest tightness or inability to get air in
what is work of breathing
work done to overcome the resistive forces of the airways, lungs and chest wall.
during quiet respiration
the WOB is performed entirely by the inspiratory muscles, expiration is passive, powered by elastic recoil of the lungs, as breathing becomes more difficult the muscles work harder and the WOB increases
conditions that affect the efficiency of respiratory muscles
increased WOB- emphysema,a post op patients (GA), rib fractures, kyphoscoliosis, obesity and pregnancy, any cardiac disease
dyspnea/breathlessness- influenced by
perceived threats to respiratory homeostasis are unpleasant and accompanied by emotional responses, breathlessness and be perceived as life threatening, dyspnea is affected by- psychological state/ experiences/memory/fear/anxiety/depression/ anger/effort/discomfort
measures of dyspnoea/breathlessness
modified borg scale of perceived breathlessness, dyspnea intensity can be easily quantified
other causes of breathlessness
increased metabolic rate- increased ventilation e.g. fever, exercise
cardio-vascular issues- inadequate cardiac output, anaemia, deconditioning- lactate accumulates at low exercise levels causing increased ventilation, perfusion limitations- large V/Q mismatch due to wasted ventilation
what is anaemia
affects carrying capacity of haemoglobin, present with breathlessness on minimal activity, can’t be treated by physios
other causes of breathlessness
metabolic, neurogenic, neuromuscular
mechanical causes of increased WOB- increased resistive load
pathology- obstructive airway disease, asthma, chest infection, lung tumour
problem- increased secretions, inflammation in the airway, bronchospasm, obstruction in the airway
mechanical causes of increased WOB- increased elastic load
pathology- fibrotic lung, surfactant depletion, hyperinflation, pregnancy, distended abdomen, obesity, abdominal surgery, kyphoscoliosis, ankylosing spondylitis
problem- reduction in lung compliance increases the inspiratory muscle work required to overcome the elastic recoil of lungs, increase insp muscle work, increased alveolar surface tension, reduction in chest wall compliance
mechanical causes of increased WOB- decreased energy supply
pathology- eating difficulties, hypovolemic shock
problem- malnutrition, lack of perfusion to the respiratory muscles
mechanical causes of increased WOB- increased drive to breath
pathology- parenchymal disorders- pneumonia or fibrosis, acidosis and anemia
problem- stimulates nerve impulses from interstitial receptors increasing drive to breathe
mechanical causes of increased WOB- respiratory muscle dysfunction
pathology- neuromuscular disorders (MND, MS, GBS), chronic lung disease, chest wall disorders (kyphoscoliosis and malnourished)
problem- reduced ability to cope with normal WOB, neuromuscular deficiency, disadvantaged diaphragm due to HI lung, fatigue, weakness
mechanical causes of increased WOB- increased alveolar surface tension
pathology- pulmonary oedema, acute respiratory distress syndrome, surfactant depletion
problem- increased resistance to expansion
mechanical causes of increased WOB- rib fracture
disrupted mechanics of thoracic cage, a segment of the chest wall which is flail unable to contribute to lung expansion
dyspnea- emphysema
increase in expiratory airflow resistance/ increases expiratory muscle work, severe hypoxaemia may contribute to WOB by stimulating drive to breathe, muscles and joints are at a mechanical disadvantage due to passive and dynamic hyperinflation, increased inspiratory muscle work occurs to hold open floppy airways, even during exhalation
increased WOB signs
use of accessory muscles, disturbed speech inability to complete sentences, pursed lip breathing, prolonged expiratory time, paradoxical breathing (Hoovers sign), in-drawing/recession/retraction of soft tissue of chest wall on inspiration caused by excessive negative pressure in the chest, this destabilizes chest wall increasing the WOB further
increased WOB in acutely unwell
increase RR/ HR, decreased SpO2, mouth breathing, altered depth and pattern of breathing, use of accessory muscles, deranged ABG’s, CO2 retention, peripheral vasodilation can= warm hands/ bounding pulse/ flapping tremor of the hands
increased WOB in the acutely unwell- later signs
restless, irritable, confused, and coma, increase or decreased HR/ BP, cardiac arrest, fatigue
what do do with a breathless patient
treat by addressing the cause where possible, medication if appropriate, physiotherapy, pulmonary rehabilitation, breathlessness clinic if severe/end stage disease
treatments for breathlessness patient
positions of ease- allows respiratory muscles to work on respiration, purse lip breathing, breathing re-educate, relaxation- mindfulness apps, balance between supply and demand of energy, fan therapy, sleep, pacing and work sequencing
why do we position patients for breathlessness
many breathless patients automatically adopt a posture which eases breathing, allows accessory muscles to work on expiration
breathing re-educating for breathlessness
to reduce WOB, increase confidence, desensitisation to breathlessness, pulmonary rehabilitation, breath enhancing positions, increase awareness of the pattern that is being used, encourage relaxation general or specific, nose breathing slow and low, facilitation of lower chest breathing through relaxation
balance between supply and demand
increase supply- sleep, relaxation, rest, education, nutritional management, oxygen therapy, exercise training, purse lip breathing
decrease demand- treatment of cause, pacing, work sequencing, positioning, breathing control, stress reduction, exercise training
how does fan therapy work
works with patients who are breathless, reduced perceived breathlessness, blows air across the Trigeminal nerve- alters feedback to brain which reduces feeling of breathless
purse lip breathing
breathing out through actively pursed lips keeping facial muscles relaxed, patients can learn technique themselves, the positive pressure on exhalation prolonged expiratory time and reduces airway collapse in floppy airways of emphysema, particularly good during activity as reduces dynamic hyperinflation during exercise
pacing, work sequencing
energy conservation, coordination of activity with breathing, sequencing, pacing- ensure breaks
pacing, work sequencing
energy conservation, coordination of activity with breathing, sequencing, pacing- ensure breaks
NIV
generated by volume or pressure cycled machines, patient triggered or automatic, synchronised assisted TV
acute effects- reduced PaCO2, increased pH, increased alveolar ventilation, rest respiratory muscles, decrease load in the respiratory muscles
NIV- indications for use
hypercapnia, respiratory acidosis, respiratory muscle fatigue, ventilatory failure, weaning from ventilator, physiotherapy, palliative care- symptom control
NIV- set up
blood gases, mask fit (nose, face or full)- check skin, granuflex to nose, no leaks
aim to capture patients RR and pattern, set trigger level, airway pressure should be 10-35cm H20, no set recipe for set up
selection of patients for NIV
must be able to control airway, cough reflex, spontaneous respiration, functioning GI tract, some degree of understanding and cooperation
advantages and problems for NIV
advantages- non-invasive, no sedation, can be ward managed, low cost, easy to withdraw, easy to manage at home, allows communication, mobility, sleep
problems- facial surgery, problems with nasal breathing, eating and drinking, gastric surgery, paralytic ileus, head injury fractured BOS, undrained pneumothorax, hypotension
other treatment ideas- respiratory muscle training
offers a resistance to inspiration and/or expiration and aims to strengthen the respiratory muscles, from a physiological and pathological point of view
other treatment ideas- mannual therapy
stretches to the vertebral and shoulder girdle joints to reduce tension, thoracic mobility exercises,
