VOL: 100, ISSUE: 38, PAGE NO: 46
Rachel Booker, RGN, DNCert, HV, is head of student support, National Respiratory Training Centre, Warwick
Chronic breathlessness is most frequently characterised by continuous and often slowly progressive symptoms. Many chronically breathless patients also experience episodes of acute breathlessness during exacerbations of their underlying condition.
Whatever the underlying cause, chronic breathlessness affects an individual’s ability to perform normal activities of daily living. It reduces confidence and has a negative impact on quality of life. It eventually impacts on every aspect of a patient’s life.
Causes of chronic breathlessness
- Asthma is typically episodic and reversible. The goal of asthma management is for patients to live symptom-free lives (British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2003) and most people achieve this with appropriate treatment. However, some patients with asthma do experience chronic and persistent symptoms. This results in permanent changes in the airways and irreversible, chronic airflow obstruction.
- Chronic obstructive pulmonary disease (COPD) is characterised by slow, progressive breathlessness. COPD is an umbrella term encompassing chronic bronchitis and chronic bronchiolitis (small airway disease), emphysema and some cases of chronic asthma (Bellamy and Booker, 2004). It is overwhelmingly smoking related.
- Bronchiectasis results from inflammation and infection of the bronchial wall. This becomes irreversibly damaged and dilated, leading to impaired mucociliary clearance and cycles of chronic infection, inflammation and damage to the airways. The end result is progressive fibrosis and disruption to gas exchange in the lungs (Bourke and Brewis, 1998).
- Interstitial lung disease - for example, cryptogenic fibrosing alveolitis - causes progressive fibrosis of the lung tissue (pulmonary fibrosis), which disrupts gas exchange and reduces lung volumes (Bourke and Brewis, 1998). Occupational lung diseases often result in pulmonary fibrosis. Occupational asthma can also cause fixed airflow obstruction unless the offending agent is identified at an early stage. Those caring for patients with respiratory disease must be aware of the occupational causes of lung disease.
- Tumours arising in the bronchi or the lung tissue can produce chronic breathlessness.
- Valvular heart disease, in the form of obstruction (stenosis) or leaking (incompetence) of the valves, disrupts the flow of blood through the heart. The aortic valve (between the left ventricle and the aorta) and the mitral valve (between the right ventricle and the pulmonary artery) are commonly affected. The consequences are shown in Fig 1 (Gray et al, 2002).
- Left and right ventricular heart failure induce breathlessness by disrupting the flow of oxygenated blood to the tissues. In addition, left ventricular failure causes back pressure into the pulmonary circulation and the accumulation of fluid in the lungs (pulmonary oedema). This reduces the lungs’ capacity to inflate and therefore disrupts gaseous exchange. Ventricular failure can be the result of a variety of conditions (Table 1) (Gray et al, 2002).
- Recurrent pulmonary embolism leads to pulmonary fibrosis and increased pressure in the pulmonary arteries and veins. This places an additional workload on the right side of the heart and can result in right heart failure. Pulmonary fibrosis reduces the lungs’ capacity to inflate, disrupts gaseous exchange and reduces the flow of oxygenated blood to the tissues (Bourke and Brewis, 1998).
- Terminal illness due to a variety of causes can result in chronic breathlessness. For example, neurological diseases such as motor neurone disease affect respiratory muscle strength and lead to breathlessness. Chronic breathlessness is also present during the terminal stages of many cancers.
- Dysfunctional breathing (also known as chronic hyperventilation syndrome) can result in chronic breathlessness, as well as other symptoms including: palpitations, chest tightness, dizziness and faintness, and gastrointestinal symptoms.
Patients usually attribute their symptoms to organic disease. Anxiety about their health can perpetuate the problem (Chaitow et al, 2002).
- Obesity places an additional workload on the cardiovascular and respiratory system and can lead to chronic breathlessness.
Once the cause of chronic breathlessness has been diagnosed, optimal medical management is the first priority. However, there will be some patients for whom a ‘cure’ will not be possible. The focus of management for them must shift from ‘cure’ to enabling them to have the best possible quality of life.
It may be helpful to view the impact of breathlessness in two ways:
- Disability- the impact on an individual’s ability to function and perform normal day-to-day activities;
- Health status - the wider impact on an individual’s quality of life, and social and psychological functioning.
The perception of breathlessness, like pain, is individual. Some patients will perceive the symptoms of breathlessness more acutely than others. There is often a poor correlation between the severity of the underlying disease and its impact on the patient (Williams and Bury, 1989). For example, a patient with a heavy, physical job will be disabled at an earlier stage than someone with a sedentary occupation.
Likewise, health status is linked less to the severity of the underlying disease than to the individual’s psychological make-up. One person may continue to be active and cheerful, when another with less severe disease may be house-bound and depressed.
Assessment of disability It is possible to make measurements of disability using cycle ergometer or treadmill walk tests. These tests are quite complex and simpler tests have been developed. They measure walking distance, so-called ‘field-exercise testing’ (Table 2). Patients can also be asked to assess the degree of their breathlessness while doing certain tasks using a breathlessness scale (Table 3).
Formal assessment of disability is central to the assessment of patients undergoing cardiac or pulmonary rehabilitation. However, caution is needed when using exercise tests with cardiac patients, for example, those with ischaemic heart disease. Resuscitation equipment must be readily available.
When formal measures of disability are not undertaken it is still possible to gauge the impact of breathlessness on a patient’s functional ability. Practitioners can ask which activities of daily living they find most difficult or can no longer perform without help, and how far they can walk.
Assessment of health status There is a range of tools available to assess the global impact of breathlessness, including the impact on physical, psychological and social functioning. The Beck Depression Inventory (Beck et al, 1986) and SF-36 (Brazier et al, 1992) are applicable to all patients. Other tools are specific to particular conditions, such as the St George’s Respiratory Questionnaire for chronic lung disease (Jones et al, 1991) (Table 4).
Although the use of formal assessment tools can be time-consuming, they do help in achieving a thorough assessment.
Pulmonary rehabilitation is mainly offered to patients with COPD, but is also beneficial for patients with a variety of chronic lung diseases. Pulmonary rehabilitation for patients with COPD aims to ‘optimise physical and social performance and autonomy’ (American Thoracic Society, 1999). The recently published NICE COPD management guideline (National Collaborating Centre for Chronic Conditions, 2004) recommends that rehabilitation should be available for all suitable patients with COPD and offered to all who consider themselves functionally disabled. It is hoped that the NICE guideline will provide the impetus to improve the level of service provision (British Lung Foundation and British Thoracic Society, 2003).
Pulmonary rehabilitation consists of an individually prescribed exercise programme lasting at least six weeks with a minimum of two supervised group-exercise sessions a week. Programmes also contain an educational component to improve the patient’s understanding of her or his condition and self-management skills. It is delivered by a multidisciplinary team and is highly effective (BTS, 2001).
Physiotherapists are also involved in cardiac rehabilitation. The National Service Framework for Coronary Heart Disease recommends that programmes should be available for all patients hospitalised as a result of coronary artery disease (Department of Health, 2000). Like pulmonary rehabilitation it is most effective when provided by a multidisciplinary team, offering physical fitness training, education and psychological therapy. The NSF suggests that such programmes should be fully integrated into both primary and secondary care.
Physiotherapists are also skilled at helping patients to relieve breathlessness by appropriate body positioning, breathing control techniques and relaxation. They can help patients with dysfunctional breathing by raising their awareness of faulty breathing patterns and helping them to relearn normal patterns.
The World Health Organization defines palliative care as ‘the active total care of patients whose disease is not responsive to curative treatment’ (WHO, 1990). Its goal is the best possible quality of life for patients and their families. Relieving breathlessness is an important aspect of this care.
Chronic breathlessness is a common symptom of end-stage disease, including:
- Chronic lung disease, for example COPD;
- Cardiac disease, for example heart failure;
- Respiratory and non-respiratory cancers;
- Neurological disease such as motor neurone disease.
Around 50 per cent of patients with advanced cancer will experience breathlessness, and this rises to 70 per cent in the last six weeks of life (Davies, 1997). Some 75 per cent of patients with lung cancer report symptoms of breathlessness (Driscoll et al, 1999) compared with 50 per cent of those with motor neurone disease (O’Brien et al, 1998). Most patients dying from respiratory disease will be breathless.
The palliative care approach begins with an assessment of the cause and impact of breathlessness. Although it may appear self-evident that the cause is ‘end-stage’ disease, it is important that other causes are excluded. For example, a patient may have a treatable co-morbid condition that is adding to their breathlessness, for example anaemia or heart failure.
The assessment tools described for assessing disability and health status are also appropriate for palliative care. Also, the breathlessness assessment guide (Corner and Driscoll, 1999), specific to palliative care and appropriate in most settings - except for those very close to death - can be used to promote a holistic approach.
Management depends on the patient and her or his carer’s preferences, and should start with a frank discussion of what can realistically be achieved. The focus may be to alleviate symptoms, treat associated anxiety and depression or improve the patient’s quality of life.
Oxygen can be used but this approach is not well supported by research. It should be remembered that not all breathlessness is due to lack of oxygen and only a minority of patients will require continuous treatment (Davies, 1997). Patients may become unnecessarily dependent on oxygen therapy.
Practical advice and support to help patients and their families cope with day-to-day living can be useful. The provision of aids such as bath and shower seats, or a wheelchair, may enable a patient to remain independent.
Chronic breathlessness is a distressing and disabling symptom, and its optimal management usually requires a multidisciplinary approach. Well informed and empathetic nurses are a vital part of this team approach.