Management of Chronic Dyspnea #376

Background

Dyspnea is the sensation of breathing discomfort or an uncomfortable awareness of breathing (see Fast Fact #27 on acute dyspnea at the end of life). Chronic dyspnea usually refers to breathlessness lasting more than four to eight weeks and is prevalent in progressive illnesses such as chronic obstructive pulmonary disease (COPD) (56%–98%), heart failure (88%), cancer (77%), and end-stage renal disease (11%–82%). ¹ The aim of this Fast Fact is to review management options for chronic dyspnea.

Pathophysiology

When dyspnea becomes chronic, sensory input from chemoreceptors and mechanoreceptors become integrated into the neural processing of the brain making it challenging to fully eradicate. ² Although indirect corollary measures such as tachypnea or hypoxemia are often measured, patient self-report is the only reliable indicator of dyspnea. ² Breathlessness often triggers anxiety, which in turn can compromise respiratory mechanics through rapid breathing, hyperinflation, increased dead space, and diaphragmatic flattening. ³ Reduced physical activity and deconditioning often follows. Even though diagnosing a dyspneic patient with anxiety disorder is not accurate and can be stigmatizing, controlling the dyspnea–anxiety cycle is a key therapeutic goal in chronic dyspnea. Patient acknowledgement that breathlessness triggers anxiety and, that anxiety can worsen breathlessness, can provide insight and improve adherence with recommended therapeutic strategies. ⁴

Management of Chronic Dyspnea

The initial evaluation of chronic dyspnea should address the underlying etiology/chronic illness and correct hypoxemia if appropriate. Clinicians should consider whether disease-modifying therapies may improve the patient's quality of life (e.g., optimization of COPD, drainage of a malignant effusion) and refer to appropriate specialists if indicated. For many patients, further optimization of the underlying illness is not achievable, and the therapeutic goal must shift to reducing symptom burden and improving the patient's capacity to cope with chronic dyspnea. The following measures should be considered at any stage of disease, not just when life expectancy is short.

Nonpharmacological Management

Multidisciplinary regimens that integrate disease management, anxiety reduction, emergency contingent planning, self-mastery of breathing mechanics, and exercise training are most effective for chronic dyspnea.^5–7 Components of these regimens usually include the following:

Pulmonary rehabilitation: a structured four- to eight-week program involving physical and/or occupational therapists to provide education, exercise training, and counseling. For patients able to tolerate exercise training, pulmonary rehabilitation has the strongest supporting evidence for reducing chronic dyspnea. ⁸ Its value is unclear for severely debilitated patients in the last months of life.