What is shortness of breath?

The medical term for shortness of breath is dyspnea. It is defined as an uncomfortable awareness of breathing. People who are experiencing shortness of breath feel that they can’t get enough air. Breathing may be faster or slower than usual, and can feel difficult or painful.

Shortness of breath is a feeling experienced by someone rather than something that is observed in someone. Generally, when we observe that someone is breathing quickly, or appears to be working hard to breathe, they will describe feeling short of breath. However, there are times when people appear to be breathing quite comfortably, yet they will describe feeling short of breath. There are also times when people appear to be breathing quickly or with difficulty, yet feel quite comfortable. The only way to know for sure if someone is feeling short of breath is to ask.

Causes of shortness of breath

Breathing is controlled by the body’s respiratory system. This system takes in the oxygen that the body needs and removes the carbon dioxide that it does not need.

When we breathe, a process inside each lung allows oxygen to pass into the bloodstream and carbon dioxide to pass out of the bloodstream and out of the body. The red blood cells in the bloodstream then deliver the oxygen to the rest of the body.

Almost everyone has experienced shortness of breath. For some people, breathing difficulties come only after activities like walking or climbing stairs. For others, the sense of breathlessness happens while just talking or eating, or even during times of rest.

People can feel short of breath for many reasons, including these:

General weakness – Overall weakness can limit the amount of energy available for the work of breathing.

Blockage – Tumours and swelling may block air flow through the windpipe (trachea).

Other medical problems – People who have a history of heart problems or other lung problems such as emphysema or asthma may have more trouble with shortness of breath.

Low red blood count (anemia) – Low hemoglobin levels in the blood means that there are fewer “oxygen carriers” to move oxygen through the body.

Anxiety – Feelings of anxiety can make people feel short of breath and feeling short of breath can make people feel even more anxious. This can create a cycle where one symptom feeds the other. This is why treatment for shortness of breath often includes treatment for anxiety.

Sorting out symptoms

To determine possible causes of shortness of breath, the health care team will often ask questions, complete a physical examination, or may arrange for further testing.

Questions from the health care team

The medical team will likely ask many questions about shortness of breath in order to understand the potential causes of the problem and decide on a treatment plan.

How severe is the shortness of breath?

Mild, moderate, or severe?

Rate shortness of breath severity on a scale from 0 to 10. Zero means no shortness of breath; while 10 means the worst possible shortness of breath. Measuring shortness of breath this way is very common.

Are there any other methods being used to help shortness of breath such as breathing exercises, relaxation or others?

How is the shortness of breath affecting daily life?

Is shortness of breath preventing participation in regular activities?

What feelings surround shortness of breath?

Physical examination

The health care professional may want to do a general physical exam in order to understand possible causes of the shortness of breath. The examination will usually include listening to the heart and lungs with a stethoscope.

Tests

Chest x-ray
This may be done to look for problems that may be causing the shortness of breath. The chest x-ray would focus on any problems that may be present in the lungs or heart.

Oxygen saturation testThis is a simple test, done by putting a soft clamp on a finger. Within a few seconds, the machine attached to the clamp shows the oxygen level in the blood. This test can be done at rest or after a small amount of exercise.

Blood tests
These may be ordered to check the oxygen level in the blood or to check for anemia. Anemia is a low red blood cell count.

Other tests may be considered, depending on the assessment of the health care team and discussions with the patient.

What you can do

Plan ahead

Sometimes shortness of breath is predictable. If certain activities always cause shortness of breath, let the medical team know. Taking medication before the activity happens can help.

Attempt to reduce anxiety and stress

A stressful or worrying atmosphere can have a major influence on a person’s shortness of breath. In many cases, when anxiety gets worse, so does the shortness of breath. Feelings of anxiety should be discussed with the health care team so that prevention and treatment options can be explored. Some people find that medications to reduce anxiety are helpful. Others may choose to cope with the anxiety of breathlessness through relaxation or breathing techniques. No matter what solution is chosen, the health care team should be a part of the plan. Some of these tips may help to reduce your anxiety and perhaps improve your breathing ability.

Sit upright. Try sitting up in bed with pillows under the arms and behind the back and head. Keeping the head and upper body upright seems to help breathing. In a hospital bed, try raising the bed to a more upright position. At home, try sitting in a reclining chair (one with a footrest that swings out).

Open a window to get some fresh air or place a fan on low speed nearby.

If there is an obstruction in one lung, try lying on the side that is blocked. This may allow more air to enter into the better functioning lung.

Limit activity to what is necessary and plan for rest periods in between.

Taking medication (such as opioids) before activities may help. Ask a health care professional for advice on how to time medicines.

Try to avoid activities that can make shortness of breath worse, like climbing stairs and bending down. Pull on shoes and socks while sitting down.

Keep rooms cool with low humidity.

Change bed clothes more frequently if they are damp with sweat.

Use lip balm on dry lips. Rinsing and spitting water can help a dry mouth feel better.

Avoid cigarette smoke. (Never smoke or light a match in a room where oxygen is being delivered because there is a real danger of starting a fire.)

Avoid allergens that may worsen shortness of breath.

Try relaxation strategies

Since anxiety often makes shortness of breath worse, these strategies are meant to be calming and relaxing. If any of these strategies produce more stress, you should stop following them.

Breathing exercises
Breathe in through the nose and out through the mouth as though you were blowing bubbles through a straw. Concentrating on breathing may help make the shortness of breath feel better.

Distraction
Sometimes watching TV or listening to music can help distract a person from their breathing difficulties.

Imagery
Imagery is like a deliberate daydream to reduce stress and anxiety. The idea is to imagine a scene that is relaxing and then focus on the calm, soothing images.

Progressive muscle relaxation
This is a technique where muscles are tightened and relaxed throughout the body. Start at the feet, squeezing and loosening the muscles there and then slowly work up the body. Relaxing the body may help to relax the mind.

Massage
Massage can be very soothing for some people. With a bare hand, muscles can be stroked, brushed or rubbed in a circular motion. Massage relaxes muscles and encourages blood flow in the area that is being touched.

TIP: No matter what the treatment for shortness of breath, the health care team must rely on the perception of the person being treated to know how well the treatment is working. The person’s own description of shortness of breath is more reliable than whether or not the person seems to be showing difficulty breathing.

A note for family members

It’s not always easy to tell if someone is feeling short of breath, since shortness of breath is something that someone experiences rather than something seen or observed in someone.

Generally, someone who is breathing quickly, or appears to be working hard to breathe, will describe feeling short of breath. However, there are times when people appear to be breathing quite comfortably, yet they will describe feeling short of breath. There are also times when people appear to be breathing quickly or with difficulty, yet feel quite comfortable.

The best way to know if someone is feeling short of breath is to ask.

If you are caring for someone who is short of breath, try to provide calm reassurance. Your calm presence may lead to an improvement in the person’s breathing. If possible, try to avoid emotional upsets.

Concerns about sleepiness

Consider talking to the medical team if there are concerns about the degree of sleepiness the patient is experiencing. Family members should also know about, or be involved in, discussions about balancing medications for shortness of breath while minimizing sedation. Both drowsiness and shortness of breath can be stressful for family members.

Sleepiness can also be caused by the general decline of the patient. The immense work of the body that is required to breathe can affect the level of alertness of the patient.

Breathing changes near death

There are often specific changes in a person’s breathing that happen in the final hours or days of life. These changes do not necessarily mean that the person is feeling short of breath.See also:When Death Is Near

What your health care team can do

If shortness of breath is causing great distress, the first priority is to treat the feeling of being hungry for air. While this is being done, the health care team may want to search for the cause of the problem.

Sometimes the cause of the shortness of breath is not treated. It may be that treatment is not possible, or that you and your health care team feel the tests and treatments will be too burdensome or difficult.

Fortunately, even if the cause of the shortness of breath is not treated, there are several ways to treat the shortness of breath itself in palliative care. The main treatments are:

medications

oxygen

lifestyle changes.

Treating shortness of breath with opioid medications

Opioids are a family of drugs that include these medications:

codeine

morphine

hydromorphone

fentanyl

oxycodone

methadone

These drugs are safe when used under the supervision of an experienced health care professional.

Often people with shortness of breath are already taking opioids for pain control. In that case, increasing the dose of the opioid may be enough to relieve the "hunger for air."

No one is certain exactly how opioid medications help to control shortness of breath, but they have been shown to make people more comfortable breathing. There is a widely held misconception among health care professionals that opioids should never be used to treat shortness of breath, due to the potential risk of depressing the breathing. However, there is substantial evidence indicating that appropriately adjusting opioids such as morphine in response to breathing distress is safe.

Treating shortness of breath with other medications

When shortness of breath is moderate to severe, or the person is very anxious about breathlessness, other medications may be given in combination with opioids, such as:

Medications for anxiety
These include lorazepam (Ativan®), midazolam or diazepam. Potential side effects of these medications include drowsiness, and sometimes confusion, particularly in frail or elderly people.

Medications for restlessness
These include chlorpromazine (Largactil® and others) and methotrimeprazine (Nozinan®). Side effects of these medications may include drowsiness, lowering of blood pressure, and tremours and muscle rigidity similar to Parkinson’s disease.

Keep in mind that if there is treatment being directed at the underlying cause of shortness of breath, other medications may be required. For example, there may be medications used for managing an infection, or chronic lung or heart problems.

Treating shortness of breath with oxygen

The use of oxygen may be suggested for a palliative patient who is short of breath, particularly if tests have indicated that blood oxygen content is low.

Oxygen delivered by a face mask or by nasal prongs (small plastic tubes that fit into the nose) may help take away the feeling of not getting enough air. The face mask sends oxygen into the mouth and nose, but some people find a mask makes them feel claustrophobic and more anxious about breathing. Many times, nasal prongs are a good option. These plastic tubes are effective even if the person seems to be breathing only through the mouth, since the oxygen that is being delivered through the nasal prongs is drawn into the lungs even with "mouth breathing."

At home, oxygen can be delivered through a portable oxygen tank or by a machine that concentrates oxygen out of the air.

Caution: Oxygen and chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease (COPD) refers to a group of lung diseases that includes emphysema and chronic asthma. For most of us, breathing is triggered when our bodies recognize an increase in carbon dioxide in the bloodstream. For some people with COPD, breathing is triggered by low oxygen levels.

If a person with COPD receives high concentrations of oxygen, their body may not be triggered into breathing, because there is lots of oxygen in their system already. The person may actually end up breathing less than needed, which can be dangerous.

In these situations, oxygen is given in low doses and adjusted upward as tolerated. Special masks may also be used to deliver more accurate amounts of oxygen than the nasal prongs can deliver.