Dyspnea
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.
Action stat!
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.
History and physical examination
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're increasing in severity. Can he 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.
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 (ARDS).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 (ALS).ALS causes the slow onset of dyspnea that worsens with time. Other features include dysphagia, dysarthria, muscle weakness and atrophy, fasciculations, shallow respirations, tachypnea, and emotional lability.
Anthrax (inhalation).Dyspnea is a symptom of the second stage of anthrax, along with a fever, stridor, and hypotension (the patient usually dies within 24 hours). Initial symptoms of this disorder, which are due to the inhalation of aerosolized spores (from infected animals or as a result of bioterrorism) from the bacterium Bacillus anthracis, are flulike and include a fever, chills, weakness, a cough, and chest pain.
Aspiration of a foreign body.Acute dyspnea marks this life-threatening condition, along with 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.Acute dyspneic attacks occur with asthma, along with audible wheezing, a 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.
Avian influenza.These potentially life-threatening viruses are spread to humans through contact with infected poultry or surfaces contaminated with infected bird excretions. Within 1 to 5 days of exposure to avian influenza, the patient typically develops flulike symptoms, such as fever, sore throat, cough, and muscle aches. Those with severe forms of the virus may develop dyspnea caused by acute respiratory distress or pneumonia.
Blast lung injury.The result of a forceful percussive wave following an explosive detonation, blast lung injury is commonly characterized by dyspnea and hypoxia. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause cyanosis, chest pain, wheezing, and hemoptysis. Chest X-ray, the primary diagnostic tool, reveals a characteristic “butterfly” pattern. Many of these patients suffer concomitant injuries and require complex management, usually in an intensive care setting.
Cor pulmonale.With 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 have a chronic productive cough, wheezing, tachypnea, jugular vein distention, dependent edema, and hepatomegaly. He may also experience increasing fatigue, weakness, and light-headedness.
Emphysema.Emphysema is a chronic disorder that gradually causes progressive exertional dyspnea. A history of smoking, an alpha1-antitrypsin deficiency, or exposure to an occupational or environmental irritant usually accompanies 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.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.
Heart failure.Dyspnea usually develops gradually in patients with heart failure. Chronic paroxysmal nocturnal dyspnea, orthopnea, tachypnea, tachycardia, palpitations, a ventricular gallop, fatigue, dependent peripheral edema, hepatomegaly, a 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 the inhalation of chemicals or hot gases. Increasing hoarseness, a 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.
Monkeypox.Dyspnea is one of the less common symptoms of this rare viral disease. Infected individuals may also experience fever, muscle aches, sore throat, chills, and lymphadenopathy. A papular rash appears 1 to 3 days after the fever begins. The virus is similar to smallpox; however, the symptoms are milder and the disease is rarely fatal in developed countries.
Myasthenia gravis.Myasthenia gravis causes bouts of dyspnea as the respiratory muscles weaken. With myasthenic crisis, acute respiratory distress may occur, with shallow respirations and tachypnea.
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(Yersinia pestis).Among the symptoms of the pneumonic form of plague are 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 myalgia. If untreated, plague is one of the most potentially lethal diseases known.
Pleural effusion.With pneumonia, yspnea 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 a 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, a fever may occur.
Pneumonia.With pneumonia, dyspnea occurs suddenly, usually accompanied by a fever, shaking chills, pleuritic chest pain that worsens with deep inspiration, and a productive cough. Fatigue, a 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 the pain. Sudden, stabbing chest pain may radiate to the arms, face, back, or abdomen. Other signs and symptoms include anxiety, restlessness, a 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.
Poliomyelitis (bulbar).Dyspnea develops gradually and progressively worsens. Additional signs and symptoms include a fever, facial weakness, dysphasia, hypoactive deep tendon reflexes, decreased mental acuity, dysphagia, nasal regurgitation, and hypopnea.
Pulmonary edema.Commonly preceded by signs of heart failure, such as jugular vein distention and orthopnea, pulmonary edema—a life-threatening disorder—causes acute dyspnea. Other features include tachycardia, tachypnea, crackles in both lung fields, a third heart sound (S3 gallop), oliguria, a 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, a low-grade fever, tachypnea, a nonproductive or productive cough with blood-tinged sputum, a 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.
Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a 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.
Shock.Dyspnea arises suddenly and worsens progressively 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.Dyspnea commonly occurs with chest pain, crackles, and a productive cough. Other findings are night sweats, a fever, anorexia and weight loss, vague dyspepsia, palpitations on mild exertion, and dullness on percussion.
Tularemia.Also known as rabbit fever, tularemia causes dyspnea along with a fever, chills, a headache, generalized myalgia, a nonproductive cough, pleuritic chest pain, and empyema.
Nursing considerations
▪ Monitor the patient with dyspnea closely.
▪ Be calm and reassuring to reduce the patient's anxiety.
▪ Position the patient comfortably, usually high Fowler's or the forward-leaning position.
▪ Administer oxygen if needed and monitor pulse oximetry.
▪ 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.
Patient teaching
▪ Teach the patient pursed-lip breathing, diaphragmatic breathing, and chest splinting.
▪ Instruct the patient to avoid chemical irritants, pollutants, and people with respiratory infections.
▪ Explain the underlying causes of his dyspnea and the treatment plan.
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Breathlessness on exertion
Read excerpts from these other book chapters related to Breathlessness on exertion:
Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Breathlessness on exertion
» Next page: Hyperpnea (Nursing: Interpreting Signs and Symptoms)
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