Problem identification and respiratory management

Dyspnoea

• SOB

• results from: psychological, physiological, social and environmental factors

• Weakness/fatigue of respiratory muscles:

  • increased ventilatory requirements

  • low CO

  • gas asbnormalities

  • cardiovascular/ respiratory deconditioning

• measures of breathlessness = VAS or modified borg scale

• OBJ Ax

  • rate, depth, I:E ratio

  • altered breathing pattern

  • symmetry of thorax

  • exercise testing

Effects and causes of those effects of Dyspnoea

Resp muscle weakness/fatigue

• brainstem lesions

• neuromusc disorders

• malnutrition

• ↑ WOB

↑ ventilatory demand

• hypoxia

• ↑ metabolic demand (fever, exercise)

Low CO / ischaemia

• ↓ O₂ delivery to muscles

• reflex → ↑ ventilation

Blood gas abnormalities

• anaemia

• COHb (carbon monoxide)

• CO poisoning

CVS / resp deconditioning

• dyspnoea esp. on exertion

↑ pulm capillary permeability

• pulmonary oedema

Perfusion limitation

• V/Q mismatch or shunt

  • pulm. embolus

  • pulm infarction

  • cyanotic heart-disease

Psychosocial

• anxiety / depression

• ↑ perception of dyspnoea

Psychogenic

• hyperventilation disorders

Breathless positions

positions that:

• Optimise diaphragm length–tension → ↑ contraction → ↓ WOB

• Promote relaxation of upper chest & accessory muscles

Avoid:

• Gripping with hands → ↑ shoulder elevation → ↑ accessory muscle use → worsens breathing

breathless positions:

• high side lying (lying in bed, on side w/ elbow pushing you up)

• forward lean sitting (leaning on stack of pillows)

• relaxed sitting position (elbows on knees)

• relaxed standing (back on wall)

• forward lean standing (hands on rail)

Breathing control

• normal tide breathing

• relaxation of upper chest + shoulders using lower chest

• patient in well-supported + comfortable position (sitting/high side lying)

• insp. = active, exp. = passive

• pt. encouraged to relax upper chest, use lower chest

• paced breathing

• can be used with activities

• if severely breathless, may use walking frame

• can control paroxymal coughing (sudden, violent, uncontrollable coughing fit → ↓ breathing → gag/vomit/exhaustion)