Management of breathlessness

Question 1

definitions- tachypnoea, hyperpnoea, hyperventilation

Answer 1

T- rapid breathingq, Hyper- increased ventilation in response to metabolic requirements (exercise), ventilation- ventilation in excess of metabolic requirements

Question 2

definitions- dyspnoea, breathlessness,

Answer 2

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

Question 3

what is work of breathing

Answer 3

work done to overcome the resistive forces of the airways, lungs and chest wall.

Question 4

during quiet respiration

Answer 4

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

Question 5

conditions that affect the efficiency of respiratory muscles

Answer 5

increased WOB- emphysema,a post op patients (GA), rib fractures, kyphoscoliosis, obesity and pregnancy, any cardiac disease

Question 6

dyspnea/breathlessness- influenced by

Answer 6

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

Question 7

measures of dyspnoea/breathlessness

Answer 7

modified borg scale of perceived breathlessness, dyspnea intensity can be easily quantified

Question 8

other causes of breathlessness

Answer 8

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

Question 9

what is anaemia

Answer 9

affects carrying capacity of haemoglobin, present with breathlessness on minimal activity, can’t be treated by physios

Question 10

other causes of breathlessness

Answer 10

metabolic, neurogenic, neuromuscular

Question 11

mechanical causes of increased WOB- increased resistive load

Answer 11

pathology- obstructive airway disease, asthma, chest infection, lung tumour
problem- increased secretions, inflammation in the airway, bronchospasm, obstruction in the airway

Question 12

mechanical causes of increased WOB- increased elastic load

Answer 12

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

Question 13

mechanical causes of increased WOB- decreased energy supply

Answer 13

pathology- eating difficulties, hypovolemic shock

problem- malnutrition, lack of perfusion to the respiratory muscles

Question 14

mechanical causes of increased WOB- increased drive to breath

Answer 14

pathology- parenchymal disorders- pneumonia or fibrosis, acidosis and anemia
problem- stimulates nerve impulses from interstitial receptors increasing drive to breathe

Question 15

mechanical causes of increased WOB- respiratory muscle dysfunction

Answer 15

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

Question 16

mechanical causes of increased WOB- increased alveolar surface tension

Answer 16

pathology- pulmonary oedema, acute respiratory distress syndrome, surfactant depletion
problem- increased resistance to expansion

Question 17

mechanical causes of increased WOB- rib fracture

Answer 17

disrupted mechanics of thoracic cage, a segment of the chest wall which is flail unable to contribute to lung expansion

Question 18

dyspnea- emphysema

Answer 18

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

Question 19

increased WOB signs

Answer 19

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

Question 20

increased WOB in acutely unwell

Answer 20

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

Question 21

increased WOB in the acutely unwell- later signs

Answer 21

restless, irritable, confused, and coma, increase or decreased HR/ BP, cardiac arrest, fatigue

Question 22

what do do with a breathless patient

Answer 22

treat by addressing the cause where possible, medication if appropriate, physiotherapy, pulmonary rehabilitation, breathlessness clinic if severe/end stage disease

Question 23

treatments for breathlessness patient

Answer 23

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

Question 24

why do we position patients for breathlessness

Answer 24

many breathless patients automatically adopt a posture which eases breathing, allows accessory muscles to work on expiration

Question 25

breathing re-educating for breathlessness

Answer 25

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

Question 26

balance between supply and demand

Answer 26

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

Question 27

how does fan therapy work

Answer 27

works with patients who are breathless, reduced perceived breathlessness, blows air across the Trigeminal nerve- alters feedback to brain which reduces feeling of breathless

Question 28

purse lip breathing

Answer 28

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

Question 29

pacing, work sequencing

Answer 29

energy conservation, coordination of activity with breathing, sequencing, pacing- ensure breaks

Question 29

pacing, work sequencing

Answer 29

energy conservation, coordination of activity with breathing, sequencing, pacing- ensure breaks

Question 30

NIV

Answer 30

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

Question 31

NIV- indications for use

Answer 31

hypercapnia, respiratory acidosis, respiratory muscle fatigue, ventilatory failure, weaning from ventilator, physiotherapy, palliative care- symptom control

Question 32

NIV- set up

Answer 32

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

Question 33

selection of patients for NIV

Answer 33

must be able to control airway, cough reflex, spontaneous respiration, functioning GI tract, some degree of understanding and cooperation

Question 34

advantages and problems for NIV

Answer 34

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

Question 35

other treatment ideas- respiratory muscle training

Answer 35

offers a resistance to inspiration and/or expiration and aims to strengthen the respiratory muscles, from a physiological and pathological point of view

Question 36

other treatment ideas- mannual therapy

Answer 36

stretches to the vertebral and shoulder girdle joints to reduce tension, thoracic mobility exercises,