Chronic dyspnea can have several causes, the most common being pulmonary or cardiac. In addition to a good medical history and clinical examination, targeted additional investigations can lead to the correct diagnosis. Pulmonary rehabilitation plays an important role in the treatment of dyspnea in COPD.
Prof. Dr. med. Silvia Ulrich Somaini, Zurich, spoke on the topic of unclear chronic dyspnea. By way of introduction, she recalled the definition of dyspnea according to the American Thoracic Society (ATS): dyspnea represents the subjective experience of respiratory distress, consisting of qualitatively different sensations of varying intensity. Physiological, psychological, social and environmental factors interact. The ATS also states that respiratory distress can elicit other physical and behavioral responses [1].
In the diagnostic workup of chronic dyspnea, the history is paramount. “A targeted medical history is still the decisive factor today,” the speaker emphasized. “During the clinical exam, remember to not only auscultate the lungs, but also look for leg edema, as seen in heart failure or cor pulmonale.” Differential diagnoses of dyspnea, in addition to heart and lung problems, include several other conditions (Fig. 1). Additional tests that can also be used in the primary care physician’s office to confirm a tentative diagnosis include a blood count, CRP, BNP, chest x-ray, ECG, spirometry, pulse oximetry, and certain exercise tests (e.g., stair climbing, 6-minute walk test, sit-to-stand test).
Pulmonary rehabilitation for chronic dyspnea.
Alexander Turk, MD, Horgen, Switzerland, highlighted the topic of pulmonary rehabilitation in patients suffering from dyspnea due to COPD. “We all know the vicious circle that, starting from the fear of respiratory distress, leads to avoidance of physical activity, which inevitably leads to a decrease in fitness and an increase in inactivity. As a result, confidence decreases and isolation increases,” he explained. Eventually, patients would just sit at home and spin in this breathing spiral. “The big task of pulmonary rehabilitation was and is to get patients out of that spiral,” he opined.
The ATS, together with the European Respiratory Society (ERS), defined pulmonary rehabilitation in 2013 as a comprehensive intervention based on careful patient selection and including multiple therapies tailored to the patient [2]. Essential elements include exercise therapy, education, and behavior modification. The aim of the measures is to improve the physical and psychological condition of the patients and to induce a long-term change in health behavior.
Positive effects of training and education
“The evidence for the benefits of pulmonary rehabilitation is enormous,” emphasized Dr. Turk [3]. “In addition to performance and respiratory distress, quality of life is also improved, and that’s really the bottom line for patients with chronic disease.” The heart of pulmonary rehabilitation, he says, is endurance and strength training, which can be done on an outpatient or inpatient basis (Overview 1). In addition, rehabilitation also includes measures that help patients, for example, to inhale properly, to cope better with everyday life, or to recognize an exacerbation at an early stage.
A Cochrane review examined the effect of pulmonary rehabilitation in patients with unstable COPD after an exacerbation [4]. The included studies were very heterogeneous but showed a positive effect of rehabilitation on the number of hospitalizations (odds ratio: 0.44). “If you look at the number-needed-to-treat, it’s well below 10,” Dr. Turk added. There were few interventions in pulmonology that achieved a better value, he said. The review further found good evidence that rehabilitation significantly and clinically relevantly improves quality of life. In addition, the 6-minute walk distance improved by an average of 62 meters. “That may sound like little, but it can make all the difference to patients.”
Non-causal forms of therapy
Non-causative therapies that can be used in COPD patients include oxygen and heliox [1]. “The effect of oxygen on dyspnea is not entirely clear. Only in hypoxemic patients could an effect be observed,” commented Dr. Turk. Heliox, a mixture of helium and oxygen, is an interesting therapeutic approach, but cannot be recommended at present. In contrast, one paper demonstrated a significant effect on dyspnea of a small handheld fan whose airflow was directed into the face [5]. The lip brake is also highly recommended [6]. “However, patients need to be shown the proper technique here,” Dr. Turk said. Further, he pointed out that opiates are highly valued in acute dyspnea [6,7].
Finally, as a tool for managing an acute dyspnea crisis, Dr. Turk recommended working with patients and family members to develop an action plan so that everyone involved knows the relevant measures to take in such a situation. The plan designated by the acronym COMFORT (Call, Observe, Medications, Fan, Oxygen, Reassure, Timing), which includes seven measures that can be adapted to the individual patient, can be used as a guide for this purpose [7].
Source: Dyspnea Symposium 2018. In search of clues – Dyspnea in the field of tension between heart and lungs. July 5, 2018, Rüschlikon.
Literature:
- Parshall MB, et al: An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. Am J Respir Crit Care Med 2012; 185: 435-452.
- Spruit MA, et al: An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13-64.
- From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available at www.goldcopd.org.
- Puhan MA, et al: Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016 Dec 8; 12: CD005305.
- Galbraith S, et al: Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage 2010; 39: 831-838.
- Marciniuk DD, et al: Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18: 69-78.
- Mahler DA, et al: Recent advances in dyspnea. Chest 2015; 147: 232-241.
- Mularski RA, et al: An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013; 10: S98-106.
HAUSARZT PRAXIS 2018; 13(6): 9-10
