Dyspnea
Dyspnea: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Typically a symptom of cardiopulmonary dysfunction, dyspnea is the sensation of difficult or uncomfortable breathing. It’s usually reported as shortness of breath. Its severity varies greatly and is usually unrelated to the severity of the underlying cause. Dyspnea may arise suddenly or slowly and may subside rapidly or persist for years.
Most people normally experience dyspnea when they exert themselves, and its severity depends on their physical condition. In a healthy person, dyspnea is quickly relieved by rest. Pathologic causes of dyspnea include pulmonary, cardiac, neuromuscular, and allergic disorders. It may also be caused by anxiety.
Emergency Actions
If a patient complains of shortness of breath, quickly look for signs of respiratory distress, such as tachypnea, cyanosis, restlessness, and accessory muscle use. Prepare to administer oxygen by nasal cannula, mask, or endotracheal tube. Ensure patent I.V. access, and begin cardiac monitoring and oxygen saturation monitoring to detect arrhythmias and low oxygen saturation, respectively. Expect to insert a chest tube for severe pneumothorax and to administer continuous positive airway pressure or apply rotating tourniquets for pulmonary edema.
History
If the patient can answer questions without increasing his distress, take a complete history. Ask if the shortness of breath began suddenly or gradually. Is it constant or intermittent? Does it occur during activity or while at rest? If the patient has had dyspneic attacks before, ask if they have been increasing in severity. Can the patient identify what aggravates or alleviates these attacks? Does he have a productive or nonproductive cough or chest pain? Ask about recent trauma, and note a history of upper respiratory tract infection, deep vein phlebitis, or other disorders. Ask the patient if he smokes or is exposed to toxic fumes or irritants on the job. Find out if he also has orthopnea, paroxysmal nocturnal dyspnea, or progressive fatigue.
CULTURAL CUE:Because dyspnea is subjective and is exacerbated by anxiety, patients from cultures that are highly emotional may complain of shortness of breath sooner than those who are more stoic about symptoms of illness.
Physical assessment
During the physical examination, look for signs of chronic dyspnea, such as accessory muscle hypertrophy (especially in the shoulders and neck). Also look for pursed-lip exhalation, clubbing, peripheral edema, barrel chest, diaphoresis, and jugular vein distention. Check blood pressure and auscultate for crackles, abnormal heart sounds or rhythms, egophony, bronchophony, and whispered pectoriloquy. Finally, palpate the abdomen for hepatomegaly, and assess the patient for edema.
Medical causes
Acute respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) is a life-threatening form of noncardiogenic pulmonary edema that usually produces acute dyspnea as the first complaint. Progressive respiratory distress then develops with restlessness, anxiety, decreased mental acuity, tachycardia, and crackles and rhonchi in both lung fields. Other findings include cyanosis, tachypnea, motor dysfunction, and intercostal and suprasternal retractions. Severe ARDS can produce signs of shock, such as hypotension and cool, clammy skin.
Amyotrophic lateral sclerosis
Also known as Lou Gehrig disease, amyotrophic lateral sclerosis (ALS) causes slow onset of dyspnea that worsens with time. Other features include dysphagia, dysarthria, muscle weakness and atrophy, fasciculations, shallow respirations, tachypnea, and emotional lability.
Anemia
Dyspnea usually develops gradually with anemia. Anemia commonly causes fatigue, weakness, and syncope; in severe cases, it may also cause tachycardia, tachypnea, restlessness, anxiety, and thirst. In advanced stages, the patient may develop pallor, inability to concentrate, and irritability. With chronic iron deficiency, nails become spoon-shaped and brittle, the corners of the mouth crack, the tongue becomes smooth, and dysphagia may develop.
Anthrax (inhalation)
Dyspnea is a symptom of the second stage of anthrax inhalation; it’s accompanied by fever, stridor and hypotension (the patient usually dies within 24 hours). Initial symptoms of anthrax inhalation, which are caused by the inhalation of aerosolized spores (from infected animals or a result of bioterrorism) from the bacterium Bacillus anthracis, are flulike and include fever, chills, weakness, cough, and chest pain.
Aspiration of a foreign body
Aspiration of a foreign body is a life-threatening condition characterized by acute dyspnea and paroxysmal intercostal, suprasternal, and substernal retractions. The patient may also display accessory muscle use, inspiratory stridor, tachypnea, decreased or absent breath sounds, possibly asymmetrical chest expansion, anxiety, cyanosis, diaphoresis, and hypotension.
Asthma
In asthma, a chronic disorder, acute dyspneic attacks occur along with audible wheezing, dry cough, accessory muscle use, nasal flaring, intercostal and supraclavicular retractions, tachypnea, tachycardia, diaphoresis, prolonged expiration, flushing or cyanosis, and apprehension. Medications that block beta receptors can exacerbate asthma attacks.
Cardiac arrhythmia
In a patient with an arrhythmia, acute or gradual dyspnea can result from decreased cardiac output. The patient’s pulse rate may be rapid, slow, or irregular, with frequent premature or escape beats. Alternating pulse may be present. Other symptoms include palpitations, chest pain, diaphoresis, light-headedness, weakness, or vertigo.
Cor pulmonale
Chronic dyspnea begins gradually with exertion and progressively worsens until it occurs even at rest. Underlying cardiac or pulmonary disease is usually present. The patient may also have a chronic productive cough, wheezing, tachypnea, jugular vein distention, dependent edema, and hepatomegaly. He may experience increasing fatigue, weakness, and light-headedness.
Emphysema
Emphysema is a chronic disorder that gradually causes progressive exertional dyspnea. The patient may exhibit barrel chest, accessory muscle hypertrophy, diminished breath sounds, anorexia, weight loss, malaise, peripheral cyanosis, tachypnea, pursed-lip breathing, prolonged expiration and, possibly, a chronic productive cough. Clubbing is a late sign.
Flail chest
With flail chest, sudden dyspnea results from multiple rib fractures and is accompanied by paradoxical chest movement, severe chest pain, hypotension, tachypnea, tachycardia, and cyanosis. Bruising and decreased or absent breath sounds occur over the affected side.
Guillain-Barré syndrome
Usually following a fever and upper respiratory tract infection, Guillain-Barré syndrome causes slowly worsening dyspnea along with fatigue, ascending muscle weakness and, eventually, paralysis. Other clinical features include facial diplegia, dysphagia or dysarthria and, less commonly, weakness of the muscles supplied by cranial nerve XI.
Heart failure
Dyspnea usually develops gradually in patients with heart failure. Chronic paroxysmal nocturnal dyspnea, orthopnea, tachypnea, tachycardia, palpitations, ventricular gallop, fatigue, dependent peripheral edema, hepatomegaly, dry cough, weight gain, and loss of mental acuity may occur. With acute onset, heart failure may produce jugular vein distention, bibasilar rates, oliguria, and hypotension.
Inhalation injury
Dyspnea may develop suddenly or gradually over several hours after inhalation of chemicals or hot gases. Increasing hoarseness, persistent cough, sooty or bloody sputum, and oropharyngeal edema may also be present. The patient may also exhibit thermal burns, singed nasal hairs, and orofacial burns as well as crackles, rhonchi, wheezing, and signs of respiratory distress.
Lung cancer
Dyspnea that develops slowly and progressively worsens occurs with late-stage lung cancer. Other findings include fever, hemoptysis, productive cough, wheezing, clubbing, chest pain, and pleural friction rub. The patient may also report weight loss and anorexia.
CULTURAL CUE:Among indigenous Arctic populations, the incidence of lung cancer is growing faster than any other cancer. This may be a result of high smoking rates in Native Alaskan adults and children.
Myasthenia gravis
Myasthenia gravis is a neuromuscular disorder that causes bouts of dyspnea as the respiratory muscles weaken. The patient may have difficulty chewing and swallowing, which may lead to aspiration. With myasthenic crisis, acute respiratory distress may occur, with shallow respirations and tachypnea.
Myocardial infarction
With myocardial infarction, sudden dyspnea occurs with crushing substernal chest pain that may radiate to the back, neck, jaw, and arms. Other signs and symptoms include nausea, vomiting, diaphoresis, vertigo, hypertension or hypotension, tachycardia, anxiety, and pale, cool, clammy skin.
Plague
The pneumonic form of plague, caused by the bacterium Yersinia pestis, is characterized by dyspnea, a productive cough, chest pain, tachypnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency. The onset of this virulent infection is usually sudden and includes such signs and symptoms as chills, fever, headache, and myalgias. If untreated, plague is one of the most potentially lethal diseases known.
Pleural effusion
Dyspnea develops slowly and becomes progressively worse with pleural effusion. Initial findings include a pleural friction rub accompanied by pleuritic pain that worsens with coughing or deep breathing. Other findings include dry cough; dullness on percussion; egophony, bronchophony, and whispered pectoriloquy; tachycardia; tachypnea; weight loss; and decreased chest motion, tactile fremitus, and decreased breath sounds. With infection, fever may occur.
Pneumonia
With pneumonia, dyspnea occurs suddenly and is usually accompanied by fever, shaking chills, pleuritic chest pain that worsens with deep inspiration, and a productive cough. Fatigue, headache, myalgia, anorexia, abdominal pain, crackles, rhonchi, tachycardia, tachypnea, cyanosis, decreased breath sounds, and diaphoresis may also occur.
Pneumothorax
Pneumothorax is a life-threatening disorder that causes acute dyspnea unrelated to the severity of pain. Sudden, stabbing chest pain may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, dry cough, cyanosis, decreased vocal fremitus, tachypnea, tympany, decreased or absent breath sounds on the affected side, asymmetrical chest expansion, splinting, and accessory muscle use. In patients with tension pneumothorax, tracheal deviation occurs in addition to these typical findings. Decreased blood pressure and tachycardia may also occur.
Pulmonary edema
Commonly preceded by signs of heart failure, such as jugular vein distention and orthopnea, pulmonary edema causes acute dyspnea. Other features include tachycardia, tachypnea, crackles in both lung fields, a third heart sound (S3 gallop), oliguria, thready pulse, hypotension, diaphoresis, cyanosis, and marked anxiety. The patient’s cough may be dry or may produce copious amounts of pink, frothy sputum.
Pulmonary embolism
Acute dyspnea that’s usually accompanied by sudden pleuritic chest pain characterizes pulmonary embolism — a life-threatening disorder. Related findings include tachycardia, low-grade fever, tachypnea, nonproductive or productive cough with blood-tinged sputum, pleural friction rub, crackles, diffuse wheezing, dullness on percussion, decreased breath sounds, diaphoresis, restlessness, and acute anxiety. A massive embolism may cause signs of shock, such as hypotension and cool, clammy skin.
Sepsis
Sepsis, a potentially fatal disorder, gradually causes dyspnea along with chills and sudden fever. As dyspnea worsens, it may be accompanied by tachycardia, tachypnea, restlessness, anxiety, decreased mental acuity, and warm, flushed, dry skin. Late findings include hypotension; oliguria; cool, clammy skin; and rapid, thready pulse.
Severe acute respiratory syndrome
Severe acute respiratory syndrome (SARS) is an infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.
CULTURAL CUE:Although most reported SARS cases have been in Asia (particularly China, Vietnam, Singapore, and Thailand), some people in Europe and North America have also been diagnosed with SARS.
Shock
Dyspnea arises suddenly and worsens progressively in a patient with shock, a life-threatening disorder. Related findings include severe hypotension, tachypnea, tachycardia, decreased peripheral pulses, decreased mental acuity, restlessness, anxiety, and cool, clammy skin.
Tuberculosis
In a patient with tuberculosis, dyspnea is commonly accompanied by chest pain, crackles, and productive cough. Other findings include night sweats, fever, anorexia and weight loss, vague dyspepsia, palpitations on mild exertion, and dullness on percussion.
Tularemia
Also known as rabbit fever, tularemia is an infectious disease that causes dyspnea along with fever, chills, headache, generalized myalgia, a nonproductive cough, pleuritic chest pain, and empyema. Other signs and symptoms include diaphoresis, weight loss, and a red spot on the skin that ultimately enlarges to an ulcer.
Special considerations
Monitor the patient with dyspnea closely. Be as calm and reassuring as possible to reduce anxiety, and help him into a comfortable position — usually high Fowler’s or forward-leaning position. Support him with pillows, loosen his clothing, and administer oxygen if appropriate.
Prepare the patient for diagnostic studies, such as arterial blood gas analysis, chest X-rays, and pulmonary function tests. Administer a bronchodilator, an antiarrhythmic, a diuretic, and an analgesic as needed to dilate bronchioles, correct cardiac arrhythmias, promote fluid excretion, and relieve pain.
Pediatric pointers
Normally, an infant’s respirations are abdominal, gradually changing to costal by age 7. Suspect dyspnea in an infant who breathes costally, in an older child who breathes abdominally, or in any child who uses his neck or shoulder muscles to help him breathe.
Both acute epiglottiditis and laryngotracheobronchitis (croup) can cause severe dyspnea in a child and may even lead to respiratory or cardiovascular collapse. Expect to administer oxygen, using a hood or cool mist tent.
Geriatric pointers
Older patients with dyspnea related to chronic illness may not initially be aware of a significant change in their breathing pattern.
Patient counseling
Tell the patient that oxygen therapy isn’t necessarily indicated for dyspnea. Encourage a patient with chronic dyspnea to pace his daily activities. Teach the patient pursed-lip, diaphragmatic breathing and chest splinting, as indicated. Advise him to avoid exposure to chemical irritants and pollutants and to stay away from people with respiratory infections.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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