VOL: 101, ISSUE: 14, PAGE NO: 50
Samantha Prigmore, MSc, RGN, is respiratory nurse consultant, St George’s Healthcare NHS Trust, London
Breathlessness is a subjective experience, which has been described as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990).
Patients experiencing breathlessness are often described as being dyspnoeic, or having dyspnoea. This is derived from the Greek word, which, when translated, means ‘difficulty in breathing’
Patients describe dyspnoea in a number of ways; for example:
- ‘Like suffocating’;
- Tightening feeling of fear in your chest and mind’;
- ‘Going to take your last breath’;
- ‘Feels like I am not going to breathe again’;
- ‘Could not get enough air in’.
Causes of dyspnoea include (Fig 1):
- Airway difficulties (obstruction, restriction);
- Cardiac problems (ischaemia, failure);
- Biochemical factors (anaemia or hypoxaemia);
- Psychological factors (anxiety, panic attacks).
Acute causes of dyspnoea include asthma, myocardial infarction and pulmonary embolism. Dyspnoea may also be associated with chronic illness; for example, chronic obstructive pulmonary disease, lung cancer, heart failure and obesity. Acute and chronic dyspnoea can lead to life-threatening situations.
Once the underlying cause of the dyspnoea is diagnosed it may be possible to treat, reduce and alleviate it, but many patients have to learn to cope with it on a daily basis.
Nursing involves caring and supporting patients, and allows opportunities for trust to develop between the patient and the nurse. These patient-nurse interactions are an important aspect of managing patients with dyspnoea. A thorough nursing assessment and measurement of systemic observations allows the nurse to gain an understanding of how patients are managing their breathlessness.
A typical assessment will include asking patients questions about the following:
- What makes them breathless;
- What makes their breathing easier/worse;
- Their previous medical history;
- Current and past medications;
- Their smoking history.
The information obtained from the assessment will inform the patient’s nursing care plan.
Observation of the patient
Observing patients provides information about their breathing. This will include:
- Recording and observing respirations (Boxes 1, 2 and 3);
- Observing the patient’s colour - cynaosis is a blue discoloration of the skin and mucous membranes and is most noticeable around the lips, earlobes, mouth and fingers. It can indicate a severe lack of oxygen. In dark-skinned patients, signs of poor perfusion or cyanosis may be detected if the area around the lips or nail beds appears dusky in colour;
- Observing the patient’s position: sitting upright, with shoulders hunched up, suggests that the patient is working hard to breathe.
A visual analogue scale can be a useful tool to assess patients’ experience of their dyspnoea and when any intervention has been beneficial.
Observations should be accurately and clearly recorded on patients’ observations charts and in their nursing records. Any abnormalities must be reported to medical staff.
Other commonly used observations in a respiratory assessment include pulse oximetry (measuring the percentage of oxyhaemogloblin present in the capillaries), and the peak expiratory flow rate. This measures the maximum flow rate that can be expelled from the lungs, which can indicate airway obstruction.
Dyspnoea can be very frightening for patients and may result in increased anxiety, causing them to become more breathless. Nursing intervention can break this cycle. Allowing time with breathless patients, talking calmly to them and instructing them to breathe slowly, and breathing with them, can be highly effective.
For some patients, a more tactile approach, with gentle rubbing of the back and stroking of an arm, can sometimes help to relax them, thus reducing the respiratory effort. Some people, however, do not find this approach helpful, therefore it is important to discuss tactile approaches with them.
Ensuring the room is well ventilated can be of benefit and some patients find the use of a fan blowing air on to their face provides some relief.
Distraction can help some patients take their mind off their dyspnoea, and many will report that they are less aware of their symptoms when they are occupied with something else.
Patients with dyspnoea may be too breathless to speak more than one or two words. Using closed questions, which can be answered with a nod or a shake of the head can allow them to communicate. This requires time and patience and it is essential that the nurse does not make assumptions on behalf of the patient. Alternatively, enabling patients to write on paper or to use flash cards can help them to communicate effectively.
Some patients will require oxygen therapy with an oxygen mask, which is a further barrier to communication. Nasal cannulae are a useful alternative, as they allow the nurse to observe lip movements and lip read.
The aim when positioning a patient with dyspnoea is to maximise respiratory function while reducing physical effort, therefore the individual should be comfortable and well supported. Ensure that the pillows are supporting the small of the patient’s back (Nicol et al, 2004). Too many pillows can cause a patient to ‘sink’ into them, so restricting their chest movements. Slightly raising the foot of the bed can prevent the patient from slipping down.
Many patients find it comfortable sitting on the edge of the bed or in an armchair, leaning forward with their arms resting on a pillow on a bed table.
Vulnerable pressure points include heels, ankles, sacrum and elbows and these should be carefully assessed and monitored. Hypoxia is a risk factor associated with skin breakdown. Patients should be encouraged or assisted to relieve pressure points regularly, and pressure-relieving devices may be of benefit in preventing skin breakdown.
Patients who experience dyspnoea when they are walking should be encouraged to adopt a position that allows good lung expansion; for example, leaning against a wall, resting their head on raised arms or leaning over a banister.
Breathing exercises and sputum clearance
Specific breathing exercises can be highly beneficial for patients with chronic dyspnoea. Controlled breathing techniques should be taught to patients while they are not breathless, and they should be encouraged to practise them regularly. When they become breathless, they should be able to use these techniques to control their respiratory rate and reduce their discomfort.
Removing sputum can reduce dyspnoea, and patients should be encouraged to expectorate and dispose of sputum in a tissue or sputum pot. In hospitals, sputum pots should be changed at least daily to reduce the risk of cross-infection.
As it can take patients who are breathless several hours to wash, it is useful to discuss coping strategies and additional help that they may require. Some may need oxygen during washing and bathing.
The nose provides natural humidification to inspired air. Breathing through the mouth at an increased respiratory rate can result in a drying effect on the oral mucous membranes, and can be very uncomfortable. Fluids should be encouraged, along with regular mouth care. Oral candidiasis is a common side-effect from inhaled corticosteroids, although this can easily be corrected with good oral hygiene. Rinsing the mouth after using an inhaler should be encouraged.
Eating and drinking
It is not uncommon for patients with dyspnoea to find it difficult to eat and drink and this can result in malnourishment and dehydration. Unless contraindicated, patients should be encouraged to drink up to two litres of fluid daily to minimise the risk of dehydration, which may result in a dry mouth, retention of sputum, and constipation. Patients will often complain of feeling more breathless following a large meal because the contents of the stomach restrict the diaphragm and because of the effort that is involved in eating a large meal. Offering several small, regular, balanced meals/snacks throughout the day can help to reduce discomfort and improve nutritional intake.
If the patient requires oxygen therapy this can be delivered via a nasal cannula during meal-times.
The distress caused by dyspnoea can be alleviated by pharmacological interventions, the most common being oxygen therapy and inhaled bronchodilators.
Oxygen therapy - This is used to treat hypoxia (a low level of arterial oxygen). Anecdotal evidence suggests that some patients gain psychological benefit from using oxygen.
Oxygen is a drug, and must be prescribed. It is normally delivered by face mask, with a fixed or variable flow of oxygen, or by a nasal cannula (Fig 2). Nurses should ensure that they are familiar with how to set the flow-rate of oxygen to ensure that the correct percentage of oxygen is delivered.
Humidification may be required to prevent drying of the oral mucous membranes, and to prevent tenacious sputum and sputum retention. Bateman and Leach (1998) recommend that humidification be given to patients receiving more that four litres/minute of oxygen via a face mask or if it is delivered directly into the trachea (via a tracheostomy).
Inhaled bronchodilators - These are commonly prescribed to treat dyspnoea, especially when the cause of the breathlessness is due to airway obstruction, for example, asthma and chronic obstructive pulmonary disease. These drugs help to open the airways by relaxing the bronchial smooth muscle, and are most likely to be delivered via an inhaler or nebuliser (Fig 3). Nurses need to ensure that patients are able to use their inhaler correctly so as to ensure adequate drug deposition in the lung. Nebulised drugs require a compressed gas (air or oxygen) to break a liquid form of the drug into a fine mist, which is then inhaled by the patient. It is essential that the driving gas is prescribed and set at the correct flow rate of >6 litres/minute (Muers and Corris, 1997).
Other forms of pharmacological interventions include corticosteroids to reduce airway inflammation, diuretics to reduce fluid overload, and antibiotics to treat pulmonary infections.
Living with breathlessness
Caring for patients who have chronic breathlessness allows the nurse to assess the impact it may have on their daily life. It may be appropriate to refer these patients to other members of the multidisciplinary team. These will include occupational therapists, who will assess the home environment; physiotherapists, who will teach patients breathing control and sputum clearance techniques, and social workers, who can assist with the provision of home care and assessment for financial benefits.
Pulmonary rehabilitation is successful in improving quality of life in patients with chronic obstructive pulmonary disease, as it provides education and self-management strategies and encourages physical exercise (British Thoracic Society, 2001).
Dyspnoea is a frightening experience. Patients require a thorough nursing assessment and nursing care that is tailored to alleviate their distress.
- Related articles in Nursing Times
Brooker, R. (2004)The effective assessment of acute breathlessness in a patient. Nursing Times; 100: 24, 61-67.
Brooker, R. (2004)Causes and management of chronic breathlesssness in adults. Nursing Times; 100: 38, 46-50.