Clinical Management of Dyspnoea

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Table of Contents

Patients Report
Dyspnoea
Literature review
Management
Conclusion
References

Patients Report

Mr. Y, a ninety-year-old man was admitted in the Intensive Care Unit with a diagnosis of severe chronic obstructive pulmonary disease. The presenting complains at the time of admission were dyspnoea at rest, difficulty in feeding, productive cough and inability to perform activities of the daily living. He was diagnosed with the aforementioned condition five years ago and has been on treatment. He has been hospitalized severally for the management of dyspnoea on exertion. He has never undergone any surgical operation. He stays with his son. He used to work at the quarry where he was mining stones. He smokes more than three rolls of cigarettes per day.

Dyspnoea

The main symptom of Mr. X is dyspnoea. On inspection, Mr. X appeared anxious and cyanotic. He had difficulties in breathing and talking. On auscultation, coarse crackles were present. On percussion, a dull sound was produced. On palpation, slight peripheral edema was detected.

Arterial blood gas analysis revealed a high partial pressure of carbon dioxide. The bronchodilator reversibility test was used to rule out asthma. According to the spirometry results, the FEV1/FVC ratio was 53%. Although the heart rate of Mr. X was high, the blood pressure, temperature, respiration and pulse rate were within the normal range.

Literature review

Introduction

Dyspnoea is the core manifestation of chronic pulmonary obstructive disease (COPD). As COPD progresses, the severity as well as the extent of dyspnoea increases. If the health care professionals do not manage dyspnoea well, the patient’s quality of life deteriorates and he can even die. Although it is difficult to manage dyspnoea in the advanced stages of COPD, health care professionals should work collaboratively and attempt to improve the patient’s condition. Therefore, this paper will provide a literature review of the management of dyspnoea in a patient with COPD.

Management

Drugs therapy

Although clinicians recommended the use of corticosteroids in acute dyspnoea in a patient with COPD, some researchers are against it. Barr et al., (2009) reported that corticosteroids especially the inhaled formulations predispose a person to dermatological conditions, cataracts and pneumonia while inhaled can cause diabetes as well as adrenal insufficiency. On the contrary, Ambrosino & Simonds (2007) reported that corticosteroids cause inflammation when used for a long period and should only be prescribed in the absence of other treatment modalities and avoided in patients with stable COPD.

Opiods have been used for a period to treat dyspnoea. Rocker et al., (2009) reviewed secondary data and found out that many health care practitioners prefer using opiods for the management of dyspnoea because it modulates dyspnoea by reducing the response of ventilation to hypoxemia and dilating the bronchi. On the other hand, Ambrosino & Simonds (2007) conducted a retrospective study and found out that morphine is effective in patients with stable COPD and not the advanced stages.

According to a research done, Baraniak & Sheffield (2011) reported that a patient with dyspnoea is usually anxious. Hill et al., (2008) recommended that, in order to manage dyspnoea, the nurse should give the patient anxiolytic like buspirone.

Medicatiions like bronchodilatora ans antibiotics are effective in the management of patients with COPD who present with dyspnoea. Salbutamol and broad-spectrum antibiotics are imperative in the management of dyspnoea (Jung, 2009). Lewis et al., (2011) reported that nebulization of patients with salbutamol decrease dyspnoea by dilating the bronchi and the bronchioles. On the contrary, Barr et al., (2009) reported that bronchodilators could cause dysrhythmias. In another study, Ahmedzai et al., (2012) found out that antibiotics are effective in managing dyspnoea when the patient is presenting with purulent sputum. Additionally, when the cause of COPD is infection, health care professionals should prescribe an antibiotic after a culture and sensitivity test (Smeltzer et al., 2010).

Oxygen therapy

Although many health care professionals usually find it hard to manage dyspnoea, Cranston et al., (2008) reported that oxygen therapy is one of the treatment of choice. Nishino (2011) stated that a patient with dyspnoea presents with air hunger. This means that the patient with dyspnoea require air in order to survive. This is because air has oxygen, which is essential for energy production. In another study, Clemens et al., (2012) reviewed the management of breathlessness. They recommended that oxygen therapy could be combined with other treatment modalities like opioids, anxiolytics as well as corticosteroids.

Abernethy et al., (2010) conducted a study about the difference in oxygen therapy and room air for relieving dyspnoea. They realized that both therapies have some side effects on the patients. For instance, they all cause drowsiness and nasal irritation. Additionally, oxygen therapy can cause nose bleeding. Abernethy et al., (2010) recommended that health care professionals should assess the patient’s need for oxygen and chose a method that does not injure the patient..

According to Marciniuk et al., (2011) long-term oxygen therapy is effective in the management of COPD patients who present with severe hypoxemia. In their study, Marciniuk et al., (2011) reported that, COPD patients with moderate hypoxemia do not benefit from long-term oxygen therapy. On the other hand, Marciniuk et al., (2011) reviewed other studies and found out that although short-term supplemental oxygen can reduce dyspnoea in COPD, other researchers are against it. They concluded that short-term supplemental oxygen could be beneficial to a patient with COPD who present with dyspnoea. Long-term therapy is important when the patient has severe hypoxemia and the nurse administers oxygen continuously for fifteen hours per day while short burst is for patients who become dyspnoeic after a little exertion and are on other treatment regimen.

The use of a ventilator

Scichilone et al., (2008) stated that dyspnoea which is common in COPD is pathology of demand of ventilation, muscles of respiration, the pattern of breathing and blood gases. Health care professionals have been using non-invasive ventilators to control dyspnoea in patients with severe COPD. Non-invasive ventilator is recommended as a palliative management of dyspnoea (Ambrosino & Simonds, 2007). Horton & Rocker (2010) conducted a study about management of dyspnoea in advanced COPD and recommended the use of non-invasive ventilation technique as palliative care. Horton, R., & Rocker, G. (2010) recommended that in order to improve the management of dyspnoea, health care professionals should understand the nature of dyspnoea and importance of ventilation technique in patients with advanced COPD.

Clearing secretions

According to the current literature, when a patient with dyspnoea becomes stable, health care professional should teach him how to clear secretions. Accumulation of secretions in the respiratory tract of patients with dyspnoea is associated with inactivity and it blocks the airway and exacerbates breathlessness Smeltzer et al., (2010). Ahmedzai et al., (2012) recommended that nurses should teach patients how to cough and breathe effectively so that the accumulated sputum can come out.

Dyspnoea in patients with COPD worsens in the morning because during the night, the parasympathetic system is active and as a result, there is production of too much secretion Smeltzer et al., (2010). Besides, the secretions accumulate because the patient is asleep and can neither cough nor move. Smeltzer et al., (2010) suggested that nurses should suction secretions every morning so that the airway of the patient become clear and the dyspnoea reduce.

Ahmedzai et al., (2012) reviewed COPD patients with dyspnoea and realized that approximately ninety eight percent of them had many secretions in the air way because they had fatigue and could not move the chest muscles. Such patients can benefit from chest physiotherapy and balanced diet. The nurse should call a physiotherapist to assist the patient exercise. Additionally, the nurse should provide a balanced diet through the oral or intravenous route. Diet gives the patient the energy to partially move or cough thus, clearing the secretions from the airway (Scichilone et al., 2008).

Breathing techniques

Breathing exercises are effective in the management of breathless (Booth et al., 2011). Therefore, health care professionals should assist COPD patients with dyspnoea to acquire the necessary skills.

Zhao & Yates (2008) stated that pulmonary rehabilitation is effective in the management of dyspnoea in patients with COPD. According to their research, patients who were trained about exercise reported a decrease in the level of anxiety, hence, a good respiratory function. Hill et al., (2008) suggested that health care professionals should include exercise training in the rehabilitation program.

Roberts et al., (2009) reviewed literature about the effect of lips breathing on dyspnoea in patients with COPD. They found out that lip breathing is an imperative technique in the management of dyspnoea especially in patients with moderate and chronic COPD. This is because lip breathing increases the saturation of oxygen as well as tidal volume while at the same time it reduces the rate of respiration and the recovery time to pre-exersise (Roberts al., 2009).Halth care professionals should teach patients with moderate and severe COPD lip breathing.

Relaxation techniques and positioning

Donesky (2012) conducted a study about the effect of complementary and substitute therapy in the management of COPD. She found that relaxation techniques like massage and body movements like acupuncture and yoga are imperative in alleviating symptoms of COPD like dyspnoea. In her study, many patients with COPD reported that they benefited from the yoga and the massage. Donesky (2012) recommended that health care professionals should train COPD patients with dyspnoea about relaxation technique and follow them up to ensure that they are doing it in the right way.

Anxiety is a common presentation in patients with COPD and it usually worsens dyspnoea. Baraniak & Sheffield (2011) conducted a study about the effect of psychological therapy on anxiety and found that patients with COPD benefited from it. Although cognitive behavioural therapy and psychotherapy had little impact on anxiety, Baraniak & Sheffield (2011) advocated for them and urged other health care professionals to explore the issue further as they focus on quality of life. Additionally, muscles relaxation technique is also imperative in alleviating dyspnoea in patients with COPD (Baraniak & Sheffield, 2011).

Booth et al., (2011) conducted a research about non-pharmacological interventions for patients with dyspnoea. They found out that positioning is imperative in alleviating breathlessness. Additionally, Booth et al., (2011) also realized that anxiety is one of the causes of dyspnoea and they advocated for relaxation techniques. They suggested that a COPD patients presenting with dyspnoea could benefit from facial cooling and electrical stimulation of the muscles. Anxious patients presenting with dyspnoea should learn the relaxation techniques.

According to Hill et al., (2008), muscle relaxation is a therapy that reduces tension in a patient with COPD thus, alleviating dyspnoea. In their research, patients who received muscle relaxation technique had improved respiratory frequency than their counterparts who did not receive that therapy.

Conclusion

According to the review of literature, management of dyspnoea in patients with COPD is difficult and it requires collaborative efforts of all the health care professionals. The management includes drug therapy, oxygen therapy, the use of a ventilator, clearing secretions, breathing technique and the use of relaxation techniques as well as positioning.

References

Abernethy, A. P., McDonald, C. F., Frith, P. A., Clark, K., & Herndon, J. E. (2010). Effect of palliative oxygen versus medical (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind randomized controlled trial. Lancet, 376(9743), 784.

Ahmedzai, S. H., David. C. C.,& Baldwin, D. R. (2012). Supportive Care in Respiratory Disease.Oxford: Oxford Publishers.

Ambrosino, N., & Simonds, A. (2007). The clinical management in extremely severe COPD. Respiratory medicine, 101(8), 1613–1624.

Baraniak, A., & Sheffield, D. (2011). The efficacy of psychologically based interventions to improve anxiety, depression and quality of life in COPD: A systematic review and meta-analysis. Patient education and counseling, 83(1), 29–36.

Barr, R. G., Celli, B. R., Mannino, D. M., Petty, T., Rennard, S. I., Sciurba, F. C., Stoller, J. K., et al. (2009). Comorbidities, patient knowledge, and disease management in a national sample of patients with COPD. The American journal of medicine, 122(4), 348–355.

Booth, S., Moffat, C., Burkin, J., Galbraith, S., & Bausewein, C. (2011). Nonpharmacological interventions for breathlessness. Current opinion in supportive and palliative care, 5(2), 77.

Clemens, K. E., Faust, M., & Bruera, E. (2012). Update on combined modalities for the management of breathlessness. Current Opinion in Supportive and Palliative Care, 6(2), 163.

Cranston, J. M., Crockett, A., & Currow, D. (2008). Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev, 3. Web.

Donesky, D. A. M. (2012). Integrative Therapies for People with Chronic Obstructive Pulmonary Disease. Integrative Therapies in Lung Health and Sleep, 63–101.

Hill, K., Geist, R., Goldstein, R. S., & Lacasse, Y. (2008). Anxiety and depression in end-stage COPD. European Respiratory Journal, 31(3), 667–677.

Horton, R., & Rocker, G. (2010). Contemporary issues in refractory dyspnoea in advanced chronic obstructive pulmonary disease. Current Opinion in Supportive and Palliative Care, 4(2), 56.

Jung, K. S. (2009). Management of COPD. Korean Journal of Medicine, 77(4), 422–428.

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2011). Clinical Companion to Medical-Surgical Nursing – E-Book. Australia: Elsevier Health Sciences.

Marciniuk, D. D., Goodridge, D., Hernandez, P., Rocker, G., Balter, M., Bailey, P., Ford, G., et al. (2011). Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Canadian respiratory journal: journal of the Canadian Thoracic Society, 18(2), 69.

Nishino, T. (2011). Dyspnoea: underlying mechanisms and treatment. British journal of anaesthesia, 106(4), 463–474.

Roberts, S. E., Stern, M., Schreuder, F. M., & Watson, T. (2009). The use of pursed lips breathing in stable chronic obstructive pulmonary disease: a systematic review of the evidence. Physical Therapy Reviews, 14(4), 240–246.

Rocker, G., Horton, R., Currow, D., Goodridge, D., Young, J., & Booth, S. (2009). Palliation of dyspnoea in advanced COPD: revisiting a role for opioids. Thorax, 64(10), 910–915.

Scichilone, N., Paglino, G., Battaglia, S., Martino, L., Interrante, A., & Bellia, V. (2008). The mini nutritional assessment is associated with the perception of dyspnoea in older subjects with advanced COPD. Age and ageing, 37(2), 214–217.

Smeltzer, S. C. O., Bare, B. G., Ph.D, J. L. H., & Ph.D, K. H. C. (2010). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing: In One Volume. Baltimore: Lippincott Williams & Wilkins.

Zhao, I., & Yates, P. (2008). Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliative medicine, 22(6), 693–701.

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