September 26, 2020

Breathlessness and Difficulty Breathing (Dyspnoea)

Breathlessness is an unpleasant sensation of uncomfortable, rapid or difficult breathing. People describe it as feeling short of breath, puffed or winded. The medical term is dyspnoea. Your chest may feel tight and breathing may hurt. Everyone experiences breathlessness if they exert themselves to an unusual extent or run for a bus; however, if you experience breathlessness without unusual exertion, it is important to seek medical attention as it may be due to a serious underlying problem. The most common causes are mentioned below.

In this article:
What is breathlessness?
Who is affected by breathlessness?
How do you measure breathlessness?
What investigations will be advised?
Causes of breathlessness
Are there any treatments for breathlessness?
How can I avoid breathlessness?
What is the outlook (prognosis)?

What is breathlessness?

If you have breathlessness, you experience shortness of breath and difficulty breathing. The medical term is dyspnoea. It may come on suddenly (acute) or gradually over a period of time (chronic). The reason for breathlessness is that the body needs more oxygen than it is getting. So you breathe faster to try to increase the flow of oxygen-rich air into the lungs. From the lungs, oxygen gets into the bloodstream and is pumped round the body by the heart.

Who is affected by breathlessness?

Sudden severe breathlessness is one of the most common reasons that people call an ambulance or go to accident and emergency departments.

Breathlessness affects all of us when we exercise, especially if we are overweight or not very fit. But unpleasant breathlessness that comes on suddenly or unexpectedly can be due to a serious underlying medical condition. Pneumonia can affect the very young and the very old, asthma tends to affect young children, smokers are at greater risk of lung and heart disease and the elderly may develop heart failure. However, all these conditions can affect any age group and severe breathlessness always needs medical attention.

How do you measure breathlessness?

Breathlessness can be measured using a score system devised by the United Kingdom's Medical Research Council (MRC). The scoring system which is called MRC Dyspnoea scale or MRC Breathlessness scale stages breathlessness (dyspnoea) on a scale of 1-5 as follows:
  1. No breathlessness.
  2. Breathless on vigorous exertion - for example, running.
  3. Breathless walking up slopes.
  4. Breathless walking at normal pace on the flat; having to stop from time to time.
  5. Stopping for breath after a few minutes on the level.
  6. Too breathless to leave the house.

What investigations will be advised?

The doctor will want to know more about what you were doing when you became breathless.
  • Did it start suddenly or develop over time? Did anything trigger it?
  • How far can you walk? Are you only breathless when you move? Is it worse when you lie down?
  • Do you feel ill? Do you have a high temperature (fever), weight loss or a cough? Do you have any pain in your chest?
  • Are you coughing up any phlegm (sputum)? What colour is it?
  • Have you lost weight, coughed up blood, been in contact with anyone with tuberculosis (TB) or travelled abroad recently?
  • Have you recently been bed-bound or on a long flight?
  • Do you smoke?
These details will help the doctor to make a diagnosis. Your doctor will examine you. They will check your heart, including your blood pressure and your lungs. You may be asked to have lung function tests including a peak flow reading. You may be sent for a chest X-ray. You may have blood tests for anaemia, for an underactive thyroid gland and for heart failure. Further tests of your heart and lungs may be necessary.

Causes of breathlessness

In general, the 4 main causes are lung conditions, heart conditions, anxiety and being unfit. There are other reasons too. However, we can look at the causes in a more useful way: short-term conditions and long-term conditions that can lead to breathlessness.

Short-term/recent (acute) breathlessness

This may be caused by:
  • Asthma - you may sound wheezy and breathless. May be triggered by a cold (viral infection) or allergy (for example, hay fever).
  • Pneumonia - a severe chest infection in which you become more breathless. You feel ill, have a high temperature (fever) and cough with greenish phlegm (sputum).
  • Chronic obstructive pulmonary disease (COPD) - a long-term lung condition causing breathlessness and cough. The airways become inflamed and narrowed. It may become suddenly worse as a result of a chest infection.
  • Heart disease - for example, heart failure where the heart doesn't pump properly. Because the heart pumps inefficiently in heart failure, there is a build-up of pressure in blood vessels which feed into the heart (veins). This increased pressure makes fluid build up in the body's tissues. Because of gravity, the extra fluid shows up as ankle swelling.
  • Pulmonary embolism - a clot in the lung. Usually due to a blood clot in the leg, which causes a painful, swollen calf. The clot develops after being immobile for a long time (for example, after a long-haul flight) and travels in the bloodstream to the lungs.
  • Anxiety - can cause breathlessness, feelings of panic, rapid heartbeat (palpitations) and sweating.
  • Some medicines may cause breathlessness, especially if you already have a condition that causes breathlessness. For example, taking a beta-blocker (such as propranolol) or aspirin may cause breathlessness if you have asthma.
  • Other causes - including pain, and anaemia - can cause breathlessness.

Long-term (chronic) breathlessness

You will have been breathless for some time and it may be becoming steadily worse. Common causes include:
  • Obesity and lack of fitness. See also Childhood Obesity.
  • Asthma - which is not well controlled.
  • COPD - lung disease usually due to smoking.
  • Heart failure - gradual onset of breathlessness and swollen ankles - worse on lying down. It affects elderly people usually. It is due to the heart pumping inefficiently.
  • Heart rhythm problems - for example, an irregular heartbeat (atrial fibrillation) may make the heart work less well so oxygen isn't pumped around the body properly. This means you have to breathe rapidly to get more oxygen into your lungs. The rapid breathing makes you feel breathless.
  • Anaemia - not enough haemoglobin in the blood to carry oxygen to cells. This causes tiredness and breathlessness. The most common cause in the UK is heavy menstrual periods. Bleeding into the gut is a common cause in older people.

Are there any treatments for breathlessness?

Treatment will depend on the likely cause of your breathlessness. You will be strongly encouraged to stop smoking if you are a smoker. It will also help if you lose weight if you are overweight. See the separate article, How to Safely Loose Weight.

Woman using her inhaler for asthma symptoms
Treatment depends on cause. Woman uses her inhaler for asthma symptoms
You will probably be referred to a heart specialist (a cardiologist) or to a lung (respiratory) specialist, for further tests, depending on the most likely underlying cause. Most cases will be managed by your doctor but you may be referred for further investigation and treatment at a hospital.

What can you do if you feel very breathless?
  • Try not to panic, if possible.
  • Call the national emergency number (eg 999, 112 or 911 depending on your country) if severe and sudden with no obvious cause. Otherwise call your doctor urgently.
  • Go to the hospital Accident and Emergency as rapidly as you can, if you are able.
  • Use your reliever inhaler as instructed if you have asthma.
  • Use your oxygen if you have been supplied with it.
What can you do to help ongoing (chronic) breathlessness?
There are some breathing control techniques that can help to reduce breathlessness. Examples include:
  • Relaxed, slow, deep breathing: breathe in gently through your nose and breathe out through your nose and mouth. Try to stay feeling relaxed and calm.
  • Paced breathing: this may help when you are walking or climbing stairs. Try to breathe in rhythm with your steps at a speed you find comfortable.
  • Controlled breathing. This involves using your diaphragm and lower chest muscles to breathe instead of your upper chest and shoulder muscles. Breathe gently and keep your shoulders and upper chest muscles relaxed.
Use different comfortable seating and standing positions when you feel breathless. Different positions suit different people but examples include:
  • When standing up, lean from the hips with your forearms resting on something at a comfortable height, such as a chair or kitchen work surface.
  • When standing or walking, put your hands on your hips or in your pockets.
  • When sitting, lean forwards, resting your forearms on your knees, on the arms of a chair, or on a table.
Arrange the things you use every day to make sure they are easy to reach. Try to stay active but take a rest when you feel breathless and then start again.

How can I avoid breathlessness?

You will need to find the underlying cause and try to address it if possible. Don't smoke, or if you do smoke, get help to stop smoking because all common serious causes of breathlessness are more likely to affect smokers. If you maintain a normal weight and do regular exercise, you are less likely to get breathless.

What is the outlook (prognosis)?

This depends on the underlying cause but is generally very good. People with smoking-related diseases who continue to smoke, tend to become more and more breathless. Some people who are breathless will need oxygen.

Reference(s)
1). NICE CKS, August 2010: Breathlessness. Available online: http://cks.nice.org.uk/breathlessness
2). Wahls SA. Causes and evaluation of chronic dyspnea. Am Fam Physician. 2012 Jul 1586(2):173-82. Available online: http://www.aafp.org/link_out?pmid=22962929
3). Wiseman R, Rowett D, Allcroft P, et al. Chronic refractory dyspnoea--evidence based management. Aust Fam Physician. 2013 Mar42(3):137-40. Available online: http://www.racgp.org.au/afp/2013/march/chronic-refractory-dyspnoea
4). NICE CKS, July 2015. Palliative care - dyspnoea. Available online: http://cks.nice.org.uk/palliative-care-dyspnoea
5). Sachs S, Weinberg RL. Pulmonary rehabilitation for dyspnea in the palliative-care setting. Curr Opin Support Palliat Care. 2009 Jun3(2):112-9. Available online: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19381095

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