What is shortness of breath

Shortness of breath is also called dyspnea or breathlessness, is an intense tightening in your chest, air hunger, a feeling of suffocation or difficulty breathing. Shortness of breath is when you feel like you can’t get enough air into your lungs when you breathe. Very strenuous exercise, extreme temperatures, massive obesity and high altitude all can cause shortness of breath in a healthy person. Outside of these examples, shortness of breath is likely a sign of a medical problem.

Shortness of breath might not be anything to worry about, but sometimes it can be serious and you’ll need to get medical help.

There are literally hundreds of reasons why someone may feel short-of-breath, some more serious than others. The most common causes are due to a problem in the lungs such as pneumonia (infection of the lungs), bronchitis or emphysema or COPD, chronic airflow limitation, asthma, heart failure, dementia, multiple sclerosis and AIDS. But problems in other organs including the heart, kidneys or liver can also lead to the sensation that it is hard to breathe. Examples of other common problems that can lead to shortness of breath include anxiety, panic attacks, anemia and even constipation. The majority cancer patients also experience some degree of shortness of breath, even if the primary cancer did not arise in the lung.

If you have unexplained shortness of breath, especially if it comes on suddenly and is severe, see your doctor as soon as possible.

The experience of shortness of breath can range from a general feeling that happens only with physical movement, such as walking up stairs, or it can be so severe that the patient cannot talk, walk or eat. You should tell your doctor about mild shortness of breath as soon as possible. Severe shortness of breath may be a medical emergency.

Warning signs that severe shortness of breath needs to be evaluated immediately by a health care professional include:

• Shortness of breath occurring with chest pain or a change in mental function (change in alertness, memory, language)
• Shortness of breath so severe that the patient cannot walk, talk or eat, or his/her lips or fingernails have turned blue

Shortness of breath or breathlessness is normally worse on exertion or exercise. Doctors grade the severity of your shortness of breath according to the degree of activity that causes the symptom. Grade four is the worst and this is associated with shortness of breath at rest. Breathlessness caused by diseases of the heart may become worse when you lie down. This is called orthopnea. Sometimes shortness of breath is caused by no disease at all and may be associated with poor fitness and reduced exercise tolerance. It may however still be worth be checked by your doctor.

How does shortness of breath develop?

In general, there are four main mechanisms which can make someone feel short of breath:

• Decreased oxygen levels in the blood stream.
• Increased levels of carbon dioxide in the blood stream.
• Decreased ability of the lung to expand.
• Increased workload associated with normal breathing.

What causes shortness of breath

Shortness of breath has lots of different causes. Most cases of shortness of breath are due to heart or lung conditions. Your heart and lungs are involved in transporting oxygen to your tissues and removing carbon dioxide, and problems with either of these processes affect your breathing. Don’t try to self-diagnose the cause of your shortness of breath – always see a doctor. Any treatment you may need depends on what’s causing your shortness of breath symptoms.

Common causes of shortness of breath include a cold or chest infection, being overweight, and smoking. It can also be a sign of a panic attack or anxiety.

But sometimes shortness of breath could be a sign of something more serious, such as a lung condition called chronic obstructive pulmonary disease (COPD) or lung cancer.

Shortness of breath can be caused by many things, including:

• Asthma
• Other lung diseases (including emphysema, which is a lung disease that is most often caused by smoking)
• Heart failure
• Panic attacks
• Allergies

If you are short of breath with a cough and/or fever, you may have a chest infection or pneumonia. Less common causes of breathing problems are lung cancer, a blood clot in the lungs, air leakage around the lungs, and scarring of the lung tissue.

Shortness of breath that comes on suddenly (called acute) has a limited number of causes, including:

• Asthma (bronchospasm)
• Carbon monoxide poisoning
• Cardiac tamponade (excess fluid around the heart)
• Heart attack
• Heart failure
• Low blood pressure (hypotension)
• Pneumonia (and other pulmonary infections)
• Pneumothorax (collapsed lung)
• Pulmonary embolism (blood clot in an artery in the lung)
• Sudden blood loss
• Upper airway obstruction (blockage in the breathing passage)

In the case of shortness of breath that has lasted for weeks or longer (called chronic), the condition is most often due to:

• Asthma
• COPD (chronic obstructive pulmonary disease)
• Deconditioning
• Heart dysfunction
• Interstitial lung disease
• Obesity

A number of other health conditions also can make it hard to get enough air. These include:

Lung problems

• Airway obstruction- Obstruction of the air passages in the nose, mouth or throat can cause breathing difficulties. A characteristic example of obstructive lung disease is asthma. In this condition the bronchi (large airways) are narrowed and clogged with lots of mucous. Other obstructive airway disease include chronic obstructive pulmonary disease (COPD), emphysema, bronchiectasis and acute or chronic infection (bronchitis).
• Croup (especially in young children)
• Impaired ventilatory movement- Pain in the chest, abnormalities in the abdomen (that compress on the lungs), deformities of the chest wall (such as kyphosis) and weakness of respiratory muscles (caused by diseases such as multiple sclerosis) may all reduce the amount the lungs expand.
• Lung cancer
• Pleurisy (inflammation of the membrane surrounding the lungs)
• Pulmonary edema (excess fluid in the lungs)
• Clots in the lungs called pulmonary emboli (PE) cause a sudden onset of shortness of breath because blood is unable to reach the airspaces to pick up the oxygen needed by the body.
• Pulmonary fibrosis (scarred and damaged lungs)
• Pulmonary hypertension (high blood pressure within the lungs’ blood vessels)
• Sarcoidosis (collections of inflammatory cells in the body)
• Tuberculosis

Lung cancers often lead to breathlessness in the later stages of disease. This often occurs because the cancer invades or obstructs airways, causes lobar collapse or produces malignant pleural effusion (fluid around the lung that prevents it from expanding). Lung cancer can also cause a condition called lymphangitis which is thickening of the lymphatics in the lung. Lung cancer may cause other symptoms such as chest pain or hemoptysis (coughing up blood) and is frequently associated with smoking. Cancers in other parts of the body can also cause shortness of breath from cachexia, anemia or metastasis (spread) to the lung.

Heart problems

• Cardiomyopathy (problem with the heart muscle)
• Heart arrhythmias (heart rhythm problems)
• Heart failure
• Pericarditis (inflammation of the tissue around the heart)

Heart failure, mitral valve disease, cardiomyopathy, pericarditis and many other cardiac problems frequently cause shortness of breath. This occurs because the heart is unable to pump enough blood to supply enough oxygen to the rest of the body. In addition, heart problems can cause pooling of blood and fluid in the lungs (pulmonary edema) which further limits gas exchange in the lungs. Heart diseases usually first cause shortness of breath during exertion but later they develop the characteristic types of breathlessness called orthopnea (breathlessness whilst lying flat so you may find it more comfortable sleeping on several pillows) and paroxysmal nocturnal dyspnea (breathlessness that wakes you up from sleep).

Other problems

• Anemia
• Broken ribs
• Choking: First aid
• Epiglottitis (swelling of the “lid” of your windpipe)
• Foreign object inhaled: First aid
• Generalized anxiety disorder
• Guillain-Barre syndrome
• Myasthenia gravis (condition causing muscle weakness)

Anemia is associated with a reduced amount of red blood cells in the bloodstream. These are the primary cells involved in transporting oxygen from the lungs to the body. They do this by binding oxygen to a special protein called hemoglobin. Without enough blood cells, tissues do not receive adequate oxygen and the heart compensates by trying to pump more blood. This eventually can cause permanent cardiac damage and worsening of angina and congestive heart failure both of which may lead to dyspnea.

Sometimes emotional distress or anxiety (nervousness) can cause you to breathe faster (hyperventilation) and make you feel short of breath. This can create a vicious cycle as you can become more worried because you feel breathless which leads to more difficulty breathing. Obesity, hyperthyroidism and other metabolic problems can also cause you to become breathless. >Fatigue is another possible cause because the level of effort required to breathe cannot be sustained. Therefore there are a large number of conditions causing breathlessness that do not arise in the lungs. In the case of breathlessness, it is first important to rule out all the serious causes such as acute asthma, pulmonary embolus, pneumothorax, hemothorax, acute pulmonary edema and pneumonia, before considering some of the other causes.

Shortness of breath during pregnancy

You may feel shortness of breath later in your pregnancy, when your baby’s big and pressing on your diaphragm (the muscle that helps you breathe). Even if you feel shortness of breath, your baby’s getting oxygen in the womb.

To help make breathing easier:

• Don’t smoke. If you need help to quit smoking, tell your health care provider.
• Sit or stand up straight to give your lungs room to expand. Move slowly.
• Try to breathe clean air. Stay away from secondhand smoke (smoke from someone else’s tobacco) and other air pollutants.

See your doctor if:

• There’s a big change in your breathing.
• You have a cough.
• You have pain in your chest.

Shortness of breath after eating

Shortness of breath can make eating hard work. If you use all your energy preparing a healthy meal, you may find yourself unable to eat and/or enjoy what you have prepared. Here are a few practical suggestions on how to conserve energy and get the most from your meals.

• Eat five or six smaller meals instead of three big meals daily.
• Plan to eat before you are too hungry or tired.
• Breathe evenly while you are chewing and eating.
• Stop eating if you need to catch your breath.
• Relax at mealtime.
• When cooking or baking, double or triple your favorite recipes to keep your freezer full for times when you do not feel like cooking.
• Use prepared foods to save time and energy in the kitchen. Frozen meals, prepared foods or take-out meals from a restaurant can make your life easier.
• Do the tasks that require the most effort when you have the most energy.
• Don’t stand in the kitchen when you can sit. Bring your chopping, cutting and mixing projects over to the kitchen table and sit while you prepare the food or keep a barstool by the kitchen counter.

Limit the foods that cause gas. Keep a food diary to determine which foods cause problems for you.

Foods that commonly cause gas:

• asparagus
• beans (pinto, kidney, black, navy)
• broccoli
• brussels sprouts
• cabbage
• carbonated drinks
• cauliflower
• cucumbers
• garlic
• melons
• peas (split, black-eyed)
• peppers
• turnips
• onions (raw)
• radishes
• rutabagas
• sausage
• spicy foods

Can shortness of breath be prevented or avoided?

Whether you can prevent shortness of breath depends on what is causing it. If your shortness of breath is caused by allergies, you may be able to prevent it by identifying your allergy trigger. Once you know what triggers your allergies, you can do your best to avoid it. If your shortness of breath is caused by smoking, stopping can help prevent it. Other causes of shortness of breath may not be as easy to avoid.

Shortness of breath signs and symptoms

Shortness of breath can manifest as a variety of signs and symptoms, due to the large number of possible causes. However, the most common frequent presentation is breathlessness and cough. Other common symptoms include cyanosis (blue discoloration often of fingers, toes or mouth due to an increase in the concentration of deoxygenated hemoglobin), chest pain, hemoptysis (coughing up blood), abnormal sputum and altered breathing patterns. If you have a fever associated with your breathlessness you may have an infection of the lungs (pneumonia). All problems with breathing whether of sudden onset or long-term and regardless of other symptoms should be considered seriously. Although many of the possible causes are harmless and easily treated, you should still see your doctor for a thorough medical evaluation.

Shortness of breath diagnosis

When you attend a doctor’s surgery with shortness of breath, the doctor will need to ask several detailed questions to determine the likely cause of your breathing difficulties. The following information is very important:

• The onset and duration of your shortness of breath.
• When the shortness of breath occurs and any triggers.
• Description of the episodes of shortness of breath.
• Effect of position on the degree of your shortness of breath.
• Other symptoms such as wheezing, grunting, chest pain etc.
• Past medical history- Paying particular attention to previous respiratory disease/surgery. Recent illnesses such as the cold, flu or other infections are also important.
• Your current medications (including oxygen) and any allergies.
• The effect of the shortness of breath on your life and daily activities. Your doctor will ask specific questions such as how far you can walk, how many flights or stairs you can climb and whether you can dress yourself without becoming breathless.
• Smoking history as smoking is the major cause of respiratory disease.
• Your occupational history as some jobs are associated with exposure to lung irritants (e.g. asbestos exposure).

Next your doctor will examine you in particular looking at your general color, demeanour and breathing pattern. They will also thoroughly examine your chest (lungs), heart and upper airways. In most cases the examination findings, description of your breathlessness and knowledge of past respiratory problems is sufficient for your doctor to make a reasonably accurate diagnosis.

Tests and investigations

Sometimes your doctor will order some tests to find more information. The two most important initial investigations for breathlessness are chest x-ray and pulmonary function tests. These are ordered in all cases where the cause of breathlessness is doubtful. Other useful tests that may be used include:

• Full blood picture mainly looking at the number of blood cells (to exclude anaemia) and any evidence of infection. Arterial blood gases are particularly useful to monitor the severity of disease and type of respiratory failure. For this a sample of blood is taken from the wrist (near pulse) via a syringe.
• Pulse oximetry- This is a clip device placed on the toe or finger that measures oxygen saturation.
• Cardiac investigations- ECG, echocardiography (ultrasound or picture of the heart) and cardiac enzymes may be ordered if the breathlessness is thought to be due to a heart problem.
• Further imaging of the respiratory tract such as CT, MRI or ventilation/perfusion scanning (useful to exclude PE).
• Lung/pleural biopsy- Taking a sample of lung tissue for examination under the microscope.

Shortness of breath treatment

Any treatment you may need depends on what’s causing your shortness of breath. Your doctor will figure out the best treatment options for you after looking into the cause of your shortness of breath. The first test your doctor will likely perform will be to place a small device over your finger, a pulse oximeter, to measure the amount of oxygen in your blood. In addition, a chest X-ray and electrocardiogram are usually given to look for common lung and heart problems.

Your doctor may prescribe medications to ease your breathing. For example, antibiotics may be helpful in cases of bacterial pneumonia, while anti-anxiety medications are used to treat patients with anxiety or panic attacks. Other commonly used drugs include bronchodilators to widen the bronchial tubes, diuretics to remove excess fluid from the body and steroids to reduce inflammation.

Oxygen, usually given through a small tube placed in the nose, or through a mask placed over the nose and mouth, is almost always used as a first treatment, but not all patients will feel better with oxygen. Your doctor will ask you whether or not the oxygen is helpful and decide if oxygen therapy should be continued.

Many patients will feel better by changing the position of their bodies. Typically, sitting up, rather than lying down can help. A calm reassuring family member at the bedside can also be very helpful. A bedside fan or open window with a breeze are also simple but very effective treatments to lessen dyspnea.

In severe cases, when there is no simple treatment that can relieve dyspnea, your doctor may prescribe morphine. Morphine is very effective at reducing the feeling of shortness of breath. Your doctor will give you detailed instructions on the best way to use morphine to help you feel better.

General treatments

Severe cases of breathlessness may require hospitalization. Here it is likely you will receive oxygen and a several different medications aimed at treating your breathing difficulty. Treatment will vary between patients due to the numerous different causes for breathlessness. For example if you suffer from a heart problem, you will be treated with cardiovascular drugs that reduce blood pressure and the workload of the heart, and diuretics to drain the excess fluid off the lungs. If you are anemic, treatment will focus on increasing your blood counts by an iron rich diet and iron supplements. Symptoms of shortness of breath will then tend to resolve with treatment.

Regardless of the cause of breathlessness, some general methods help to relieve symptoms in most patients. These include:

• Morphine – Opioid medications given intravenously can help to slow down your breathing.
• Benzodiazepines – Anti-anxiety drugs (given under the tongue) can help breathlessness by reducing your worry and calming you down. The above two drugs have been proven to be beneficial in clinical trials but should NOT be used in acute asthma attacks.
• Oxygen – Most patients will benefit from oxygen by a mask or nasal prongs to help restore the low levels of oxygen in the blood. However high levels of oxygen can be hazardous in some patients with chronic breathlessness as it can reduce their drive to breathe.
• Bronchodilators – Drugs such as ventolin and steroids are helpful in some patients who are breathless as they open up the airways.

Treatments at home

There are several things you can do yourself to reduce your shortness of breath. Your doctor will teach you breathing exercises such as slow, deep breathing, all the way to your abdomen. Relaxation methods are also useful. If your experience an episode of breathlessness at home make sure you sit upright in a supportive chair, try to breathe slowly and deeply and administer oxygen and opioids as prescribed by your doctor. If the shortness of breath does not resolve make sure you seek medical attention.

To help keep chronic shortness of breath from getting worse:

• Stop smoking. Once you’re tobacco-free, your risks of heart and lung disease and cancer begin to drop — even if you’ve been smoking for years.
• Avoid exposure to pollutants. As much as possible, avoid breathing allergens and environmental toxins.
• Lose weight if you are overweight.
• Take care of yourself. If you have an underlying medical condition, take care of it.
• Have an action plan. Discuss with your doctor what to do if your symptoms become worse.
• Keep elevation in mind. Avoid exertion at elevations higher than 5,000 feet (1,524 meters).
• Regularly check your equipment. If you rely on supplemental oxygen, be sure your supply is adequate and the equipment works properly.