Dyspnea

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Classification according to ICD-10
R06.0 Dyspnea
ICD-10 online (WHO version 2019)

As dyspnea (from ancient Greek δυσ dys ' difficult 'and πνοή pnoe , breathing'), German air hunger , shortness of breath , difficulty breathing , shortness of breath , is an uncomfortably difficult breathing activity referred that occurs when a "discrepancy between requirement for breathing and ability on the part of of the patient ”. This “feeling of exertion when breathing” is also referred to as the (subjective) “feeling of hunger for air” or “shortness of breath”. The term “breathing difficulties” comes closest. The causes, perceptions and consequences of this symptom can vary widely. If such symptoms only during exercise, it is an exertion (latent respiratory failure with respiratory restriction reserves and lung volumes in normal gas tension of the blood at rest), the breathlessness is already at rest, then by a resting dyspnea spoken. Difficulty breathing when speaking is called speech dyspnea . In the case of orthopnea , the existing dyspnea at rest can only be improved by sitting upright and using the auxiliary breathing muscles .

definition

The American Thoracic Society has defined shortness of breath ( dyspnea ) since 1999 as a subjective experience of breathing difficulties, consisting of qualitatively different sensations of varying intensity. Physiological, psychological, social and environmental factors work together. Shortness of breath can provoke further physical and behavioral reactions.

causes

The mechanisms that lead to the perception of dyspnea as an unpleasant sensation are not exactly known. Breathing is the only vital function of the organism that is controlled not only by the automatic centers in the brain stem ( Formatio reticularis ) but also by the cerebral cortex . The insular cortex could play an important role here, as its injury reduces shortness of breath and pain .

The respiratory drive is not normally oxygen deficiency, but by increase in Kohlenstoffdioxidgehaltes in arterial blood triggered. This makes sense because the carbon dioxide level in the blood increases faster than the oxygen level decreases. Patients who have a permanently increased carbon dioxide content in their blood, for example due to lung diseases, become accustomed to the fact that breathing is no longer controlled by an increase in the carbon dioxide content ( hypercapnia ), but rather by a decrease in the oxygen content ( hypoxia ). In such patients, when there is shortness of breath, the uncontrolled supply of medical oxygen can lead to a decrease in respiratory drive up to and including respiratory arrest .

Shortness of breath can arise as a reflex, for example through a blow on the solar plexus , or it can be an expression of diseases of the chest ( broken rib , pleural effusion ). Mentally induced hyperventilation is harmless, but subjectively can cause great difficulty in breathing. Serious causes of respiratory failure , hypercapnia and dyspnea are lung and heart diseases and obstructions of the airways , e.g. B .:

Other causes can be adverse drug effects , for example from levofloxacin or other drugs.

In addition, psychological reasons, for example fear or relationship conflicts (“bad air”), can also be considered as causes for subjectively felt shortness of breath with normal blood gas values . Conversely, shortness of breath can exacerbate existing fears. Around half of all tumor patients suffer from shortness of breath in the course of their illness. Fear of asphyxiation can be a concern of some palliative care patients or their relatives despite the absence of dyspnea or that cannot be somatically demonstrated; In addition, such fears can also occur during a falling asleep or waking phase, see also sleep paralysis .

Diagnosis

It makes sense to measure the severity of the shortness of breath on a scale. A standard tool for assessing the functional status of patients with heart and lung diseases is the MMRC , a modified NYHA classification . The Borg Dyspnea Scale can be used to try to classify the subjective dyspnea perception of patients during or immediately after a performance test. In palliative medicine , the Edmonton Symptom Assessment System (ESAS) is also increasingly being used for assessing dyspnea, although patient statements are probably still not taken into account.

Objective signs of dyspnea are: deeper breaths, increased breathing rate (tachypnea), retraction and the use of the auxiliary respiratory muscles while sitting, possibly standing. A cyanosis need not, but may be present as a sign of a lack of oxygen.

Other symptoms of acute dyspnea can include wheezing on exhalation , coughing, stridor on inhalation , chest pain and signs of right heart failure .

In palliative medicine , however, the focus is no longer on diagnostic clarifications and the treatment of the underlying disease, but on symptom-oriented therapy. Every newly occurring shortness of breath should therefore be clarified with the simplest possible examinations that do not stress the patient.

therapy

If possible, the cause should be identified and treated first, e.g. For example, a pleural effusion can be punctured, pneumonia can be treated with antibiotics , allergic asthma can be treated with corticoid inhalation , etc.

Difficulty breathing, which cannot be influenced in this way, is referred to as refractory and treated as a palliative (soothing). There are general measures, non-drug and drug interventions for this. The patient's initiative and self-control should be encouraged.

  • General measures are physical activity, changes in the daily rhythm, calming down the patient and relatives, rituals against shortness of breath. It is important to know that acute shortness of breath almost never leads to suffocation .
  • The simplest non-drug measure is a cool draft of air to the patient's face, for example through a small fan . The relief is proven with a high level of evidence. Physiotherapy and behavioral therapy can help learn conscious breathing control exercises and reduce panic . Oxygen is often administered, but this is only useful in the case of cyanosis , otherwise not more effective than normal room air. In COPD patients with restricted mobility, symptoms of shortness of breath could be relieved by regular and long-term neuromuscular electrical stimulation of the leg muscles.
  • The drugs of first choice for respiratory distress are orally or parenterally administered opioids (such as morphine , fentanyl and hydromorphone ). Opioids increase the tolerance of the respiratory center and reduce anxiety so that the patient breathes more slowly and more effectively. If the dosage is adequate to alleviate the symptoms, there is no risk of excessive respiratory depression from these preparations. Other useful substances include sedatives , antidepressants , corticoids, and promethazine .

See also

Web links

literature

Individual evidence

  1. ^ H. Benzer: Therapy of respiratory failure. In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid 1994, ISBN 3-540-57904-4 , pp. 215-278, here: p. 218.
  2. ↑ Hilmar Burchardi: Etiology and pathophysiology of acute respiratory failure (ARI). In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid 1994, ISBN 3-540-57904-4 , pp. 47–91, here: pp. 56–58.
  3. ^ H. Benzer: Therapy of respiratory failure. 1994, p. 218.
  4. ↑ Joachim Frey : Diseases of the respiratory organs. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 599-746, here: p. 616.
  5. ^ ATS Board of directors: AMERICAN THORACIC SOCIETY - Dyspnea: Mechanisms, Assessment, and Management: A Consensus Statement . In: Am. J. Respir. Crit. Care Med. Volume 159 , no. 1 , 1999, p. 321-340 , PMID 9872857 (English, full text ).
  6. ^ Daniela Schön, Michael Rosenkranz, Jan Regelsberger, Bernhard Dahme, Christian Büchel, Andreas von Leupoldt: Reduced Perception of Dyspnea and Pain after Right Insular Cortex Lesions . In: American Journal of Respiratory and Critical Care Medicine . tape 178 , 2008, p. 1173-1179 , doi : 10.1164 / rccm.200805-731OC , PMID 18776150 .
  7. ^ Claudia Bausewein , Susanne Roller, Raymond Voltz (eds.): Guide to Palliative Care. Palliative Medicine and Hospice Care Elsevier Munich, 5th edition 2015, p. 132.
  8. ↑ IGPTR: When there is no air
  9. ↑ Cheryl Nekolaichuk: The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991-2006) . In: Palliative Medicine . tape 22 , no. 2 , 2008, p. 111-122 , doi : 10.1177 / 0269216307087659 .
  10. ^ Jörg Braun: Lungs. In: Jörg Braun, Roland Preuss (Ed.): Clinic Guide Intensive Care Medicine. 9th edition. Elsevier, Munich 2016, ISBN 978-3-437-23763-8 , pp. 285-310, here: pp. 286-288 ( acute respiratory failure ).
  11. ↑ S. Husebø, E. Klaschik: palliative care . 4th edition. Springer, 2006, ISBN 3-540-29888-6 , pp. 276 ff .
  12. ^ Claudia Bausewein, Steffen T. Simon: Shortness of breath and cough in palliative patients. In: Deutsches Ärzteblatt, issue 33–34, 2013; accessed on November 29, 2018.
  13. ^ Bausewein / Simon 2013.
  14. ↑ E. Aulbert, F. Nauck, L. Radbruch (eds.): Textbook of Palliative Medicine . Schattauer, 2007, ISBN 978-3-7945-2361-0 , pp. 386 ff . ( limited preview in Google Book search).
  15. ↑ R. Viola, C. Kiteley, N. Lloyd, JA Mackay, J. Wilson, R. Wong, Supportive Care Guidelines Group: The management of dyspnea in cancer patients: a clinical practice guideline. ( Memento of January 17, 2009 in the Internet Archive ) Cancer Care Ontario (CCO), Toronto (ON) 2006 Nov 6. (Evidence-based series; no. 13-5).