Case-based learning: chronic breathlessness in adults

All individuals experience an element of breathlessness in their lives as part of normal activities, normally related to an element of exertion, such as running or walking uphill, which usually resolves quickly. However, for some individuals, breathlessness may be persistent, distressing and related to other underlying morbidities. Breathlessness is a subjective sensation or awareness of difficulty in breathing and is also known as dyspnoea​[1]​. 

Breathlessness is associated with high healthcare use, accounting for 5% of presentations to the emergency department, approximately 4% of GP consultations and is reported by patients in 12% of hospital admissions​[2]​.

Breathlessness has both physical and psychological effects on the person experiencing it (and their carers): it limits them in activities of daily living and diminishes confidence. This can lead to psychological and functional decline​[3]​. A negative cycle of inactivity is often seen in patients for fear of further breathlessness, which results in deconditioning and loss of muscle strength, which in turn can cause other issues, such as falls (as seen in chronic obstructive pulmonary disease [COPD], especially more progressed disease)​[4]​.

Breathlessness can be: 

• Sub-acute (developing over minutes/hours);
• Acute (developing over days);
• Chronic (developing over weeks/months and often persisting).

Acute breathlessness may warrant an emergency admission to hospital. It can be a sign of something severe or life threatening, such as anaphylaxis or pneumonia; hence early detection is vital, especially if there is any suspicion of associated sepsis, which carries a mortality risk. Acute breathlessness is beyond the scope of this article but see further resources for more information and actions to manage such situations, including early detection of sepsis​[5,6]​. 

Causes

There are various causes of breathlessness, often cardiopulmonary related, but mental health and some miscellaneous causes can also contribute. Some common causes are summarised in the Table​[7,8]​. 

Patients often initially present with breathlessness to primary care; breathlessness is considered chronic if it has been present for more than eight weeks. There is usually more than a single cause for breathlessness and there is no single diagnostic test. Therefore, a multi-pronged approach to investigation is required to enable holistic and appropriate treatment.

Diagnosis

Face-to-face, objective assessment is necessary (and advised by NHS England​[2]​). In-person assessment allows observation of any non-verbal signs, the breathing pattern and measurement of respiratory rate, and other relevant physical assessments — such as echocardiogram, auscultation, oxygen saturation and relevant blood tests — should be conducted as necessary. Mobilisation, including the activities of daily life, may temporarily increase dyspnoea and some patients may already be oxygen users or vulnerable and shielding, making it more challenging to attend in-person appointments.

Although breathlessness is experienced subjectively, validated scales are useful to quantify/grade the level of breathlessness. For instance, the Medical Research Council (MRC) scale was developed to grade the breathlessness of patients with chronic bronchitis and has been used in other respiratory and non-respiratory conditions​[9]​. It is a five-statement questionnaire and can be easily administered in any setting​[10]​. The modified MRC (mMRC) is similar to the original version and is widely used to rate breathlessness owing to exertion; however, the MRC’s website makes clear that it is unable to give permission for use of any modified version of the scale (including the mMRC scale). Use of the MRC questionnaire is free but should be acknowledged​[11]​.

Other scales include the Borg Dyspnoea Scale, which rates the perceived extent of breathlessness, and the Transitional Dyspnoea Index​[12]​. However, these are not as easy to administer as the MRC, requiring more time and personnel to complete (plus a baseline score to meaningfully understand any change in breathing)​[13,14]​. More detailed lung function testing can also be undertaken in hospital lung physiology units (including spirometry as well as specific lung tests to determine breathing pattern).

Breathing pattern disorder is a term used for a dysfunctional breathing pattern; this is a group of disorders in which there is a chronic change in breathing pattern. This manifests as dyspnoea but also has non-respiratory symptoms. It can occur independently and may be related to trauma or secondary to anxiety or other medical disease (e.g. asthma)​[15]​. 

The ‘Breathing SPACE’ mnemonic was developed by the London Respiratory Network in 2017 and comprises five themes: smoking; pulmonary disease; anxiety/psychosocial factors; cardiac disease and exercise/fitness. It was designed to enable a holistic approach to the diagnosis and management of breathlessness, as there may be underdiagnosis or undertreatment of underlying cardiorespiratory problems​[4]​. It is not to be confused with the ‘breathing space’ concept, which is used to describe the experience of living with breathlessness​[16]​.

Care pathway

The adult national breathlessness pathway for England was developed during the COVID-19 pandemic and maps out a pathway for primary care clinicians to make the appropriate investigations or referrals (see Figure 1). This is important to avoid misdiagnosis or delays in diagnosis. Investigations should be undertaken and diagnosis and a management plan should be in place within six months of presentation​[2]​. 

Figure 1: Diagnostic pathway for patient presenting with chronic persistent breathlessness (>8 weeks duration)

• Breathlessness is frequently multifactorial and without a single specific diagnosis.
• Anxiety, depression, low physical activity and deconditioning are commonly associated with breathlessness.

Click to expand for more detail on diagnosis and management

Clinical assessment ⬇

History and physical examination including:

• Smoking history and body mass index.

Initial investigations according to clinical judgement:

• FBC/TFTs/biochemistry;
• ECG;
• NT-proBNP;
• Chest x-ray;
• Spirometry ± reversibility with bronchodilators;
• Fractional exhaled nitric oxide (FeNO);
• Patient health questionnaire (PHQ4);
• MRC breathlessness scale;
• GP physical activity questionnaire (GPPAQ).

If diagnosis clear, undertake confirmatory investigations as appropriate and management of the condition:

• Reassess after appropriate timescale.

Management
Breathlessness self-management, smoking cessation, healthy lifestyle support, including maintaining activity and weight management.

Diagnosis unclear ⬇

Discuss and implement further investigative plan at unexplained breathlessness MDM utilising community diagnostic centres.

• Pulmonary function tests;
• CT thorax;
• Echocardiogram;
• Ambulatory ECG monitoring.

Identify and confirm suspected diagnoses.

Undertake appropriate management.

Management
Breathlessness self-management, structured exercise rehabilitation, physiotherapy for breathing control exercises, occupational therapy, psychological support.

Diagnosis remains unclear ⬇

Refer to respiratory physician or cardiologist for further investigations:

• Including cardiopulmonary excercise test.

For acute severe breathlessness

For acute breathlessness or red flags, consider urgent specialist assessment.

Clinical judgement to be used at all times.

Red flags include:

• Symptoms and signs including chest pain, haemoptysis, cyanosis, unable to speak in sentences, confusion, agitation, unilateral leg swelling, respiratory and expriratory stridor;
• Increased risk of VTE;
• Rapidly progressing symptoms;
• New low resting SpO2 or reduction during minimal exercise;
• Unexplained reduction in SpO2 and elevated respiratory rate.

Pharmacists may directly review patients in a clinical setting, such as primary care, and could undertake some diagnostic/supportive assessments such as 'Fraction of exhaled Nitric oxide' (FeNO). This is useful to ensure considered interpretation of results and patient/disease optimisation before onward referral, such as outlined in the ‘uncontrolled asthma pathway’​[17]​. Community pharmacy teams can also have an important role in history taking, the detection of red-flag symptoms, medicines optimisation and providing lifestyle advice. Working with their local multidisciplinary teams, pharmacists can help to escalate the patient for further investigations and clinical follow up and may well be involved in these services in a hospital or specialist setting.

The 'Breathing-Thinking-Functioning' (BTF) model is a useful tool to use with patients (see Figure 2). It can be helpful if dysfunctional breathing pattern is present, as there is often a strong emotive element influencing breathing​[18]​. More information and resources can be found at the BTF website. 

The Pharmaceutical Journal

Management

The underlying cause of breathlessness should be established to ensure early, timely and accurate diagnosis or specialist referral (e.g. in cases of potential interstitial lung disease). This is also important to exclude differential diagnoses (such as vocal cord dysfunction, which is sometimes mistaken for asthma) and to initiate appropriate treatment. 

Oxygen should not be routinely prescribed for breathlessness. It has utility in an emergency setting or for longer term use, such as in COPD or palliative care, but also carries risks. Therefore, it should be prescribed as per national guidelines to ensure safe, clinically appropriate use​[19]​. European Respiratory Society (ERS) guidance points out that there is little reliable evidence that oxygen positively affects health-related quality of life or breathlessness scores in daily life​[20]​.

A combination of pharmacological and non-pharmacological approaches to treatment is often beneficial. For example, the use of a hand-held fan is established as part of COPD care to ease the feeling of breathlessness, alongside inhaled COPD treatments​[20,21]​.

Pharmacists are well placed to undertake medication reviews and discuss side effects and benefits of therapy with patients, giving reassurance supported by decision-making aids. Medication review can identify medicines that cause bronchospasm (e.g. non-steroidal anti-inflammatory drugs) or increase anxiety (e.g. short-acting beta agonists). Beta-blockers are often under-utilised owing to concerns about bronchospasm, but they are generally well tolerated in patients with lung disease and their benefits outweigh the risks, especially if there is concurrent cardiac disease​[22]​. However, this should be reviewed on a case-by-case basis in individuals particularly affected by breathlessness. Over-reliance on short-acting beta agonists may also owe to non-adherence with inhaled maintenance therapy, which pharmacists will be able to identify and optimise.

The smoking status of all patients should be checked and cessation support offered when a patient is amenable. National Institute for Health and Care Excellence (NICE) guidelines outline an evidence-based approach that includes both behavioural support and pharmacological treatment, such as nicotine replacement therapy aligned to the level of tobacco dependence​[23]​. ‘Very brief advice’ is a 30-second smoking intervention (‘ask, advise and act’) that can be used by any healthcare staff​[24]​. Pharmacy teams can apply this in any setting and also signpost patients to further information if they are not ready to quit yet.

If depression and/or anxiety is triggering breathlessness, the BTF model mentioned previously can be very useful (see Figure 2)​[18]​. Pharmacy teams can discuss mindfulness, sleep hygiene and stress management techniques as part of lifestyle advice. A referral for psychological intervention, such as cognitive behavioural therapy or talking therapy, is often useful and may be an adjunct or alternative to antidepressants. For some patients, breathlessness may be related to previous trauma and manifest as a post-traumatic stress disorder symptom. If anxiety-related breathlessness is adversely affecting quality of life, a low-dose benzodiazepine (e.g. lorazepam 0.5 mg) is used in practice, but it can cause its own side effects so should not be used routinely​[25]​. 

Patients with more advanced lung disease may be prescribed low-dose morphine (1.25–2.5mg orally). This is an unlicensed use of opioids but is used, although the evidence of benefit is variable and the ERS management guideline recommends against opioid use​[20]​. There may be a role for morphine in palliation of refractory breathlessness in advanced or terminal illness​[26]​. 

A Cochrane review found there is no evidence for or against benzodiazepines for the relief of breathlessness in people with advanced cancer and COPD​[27]​. There is a non-significant beneficial effect but the overall effect size was small. Benzodiazepines caused more drowsiness as an adverse effect compared with placebo, but less compared with morphine​[27]​. 

Other interventions that may help include breathing exercises (such as Buteyko technique for asthma), positions of ease, mindfulness techniques, stress management, yoga, psychological support for trauma and weight loss where appropriate​[28–33]​. Recognition and management of a panic attack versus other, such as asthma attack, is useful.

Case examples

The following cases demonstrate common scenarios that a pharmacist may encounter in primary care and community settings.

Case 1: A patient with suspected heart failure

A 60-year-old man, Jack, attends a structured medication review with the practice pharmacist. The patient regularly experiences breathlessness and is seeking advice on how best to manage this at home.

The pharmacist asks about the onset and duration of his breathlessness. When did it first start? How often do you experience it? Are there any triggers or patterns associated with it? Is there any pain anywhere?

The pharmacist takes a medical history (personal and family), remembering to specifically check for COPD, asthma, heart failure and anxiety or depression. They ask Jack about the number of pillows he uses to sleep, check for any swelling in the ankles and lower body and check his medication history, looking especially for new or changed medicines and anything over the counter. They also ask about social history (smoking/alcohol) and weight changes/BMI (finding an activity questionnaire useful for this), measure blood pressure and pulse rate, and listen to his chest with stethoscope (if competent to do this) for crackles.

Jack has hypertension in the family, is an occasional smoker when stressed and inactivity has made him put on weight recently. The breathlessness had a gradual onset over the past month; he can think of no obvious triggers but has needed to sleep more upright than usual, and his ankles are a bit puffy.

Discussion

After considering the information available, and in view of the hypertension, ankle oedema and inability to sleep laying flat, the pharmacist’s initial impression is that heart failure could be an underlying cause for breathlessness. They offer nicotine replacement therapy alongside referral to the local smoking cessation service as this will also be beneficial to the cardiovascular system. The pharmacist gives lifestyle advice for weight loss and activity, including chair-based exercises, and recommends mindfulness/relaxation techniques for stress management that will help normalise breathing and blood pressure. Jack is signposted to the NHS website for more information and it is explained that further tests are required to ascertain the underlying cause of his breathlessness. The pharmacist refers Jack to his GP for further blood tests and cardiac investigations.

Case 2: A patient with a misdiagnosis of COPD

A 55-year-old man, Arjun, presents to his local pharmacy seeking advice on how to use his new inhaler for COPD. He experiences breathlessness going upstairs and does not think the current inhaler is working well.

The pharmacist asks about the onset and duration of the breathlessness, his smoking status and if the patient has had a formal diagnosis via spirometry testing. They also ask about symptoms and any breathing flare ups, family history and occupational exposure, night sweats, coughing up of blood and recent infections. They have the patient demonstrate his inhaler technique, ask about treatment adherence, and check his BMI and MRC score. 

Arjun is an ex-smoker who used to smoke socially in his 20s. He has not been able to get spirometry testing because of long waiting lists, but has been given an ipratropium inhaler. He uses this as needed (and demonstrates a good technique), but feels it is not beneficial. Arjun had a cousin with a ‘breathing problem’. Arjun feels tired a lot and has had a dry cough for at least seven weeks. He has lost some weight, but thinks it might be a result of acid reflux affecting food intake. He also has round swollen fingertips, but puts this down to his manual work in a wood workshop, which is making him increasingly out of breath.

Discussion

As the patient’s COPD medication has not been effective despite good inhaler technique, it is appropriate to revisit the original diagnosis and gather additional information. Various things should be considered here: there was no spirometry testing to formalise a COPD diagnosis and the ‘social smoking’ might not have been sufficient to cause COPD. A change in inhaled therapy to longer-acting agents may be necessary (as per usual national guidance) for maintenance if it truly is COPD, but further review is required. Additionally, there’s a family history of respiratory disease. it is unclear exactly what kind Arjun’s cousin has, but it is relevant and could be affecting Arjun. The pharmacist suggests that Arjun keep a symptom diary to help identify any symptom patterns. 

Arjun is given one week’s worth of over-the-counter (OTC) antacid in view of his reported acid reflux, which can cause cough and irritate the lungs. Nocturnal cough is also a sign of uncontrolled asthma. The pharmacist advises Arjun that increasing hydration, plus using cough syrups as lubricant/antitussive, may give some cough symptom relief but are not a long-term solution. 

The pharmacist refers Arjun back to his GP for review of symptoms and rounded swollen fingers (clubbing), noting that the weight loss and persistent cough are red-flag symptoms. Imaging, such as a CT scan, may be necessary to enable timely accurate diagnosis if it is another condition. It is important that the pharmacist request the GP revisit the COPD diagnosis with formal spirometry (to be undertaken in a lung-function lab that also checks gas transfer). Many patients are misdiagnosed with COPD when they actually have idiopathy pulmonary fibrosis​[2]​. The pharmacist can advise Arjun to trial the OTC therapies above in interim while booking GP follow up.

Case 3: A patient with poorly controlled asthma

A 40-year-old woman, Kari, rings her GP surgery to request salbutamol for breathlessness and a cough. The receptionist routes the call to the practice pharmacist for a telephone review. 

Kari reports that she has asthma and uses salbutamol for cough symptoms that are worse at night. Over the phone, it is harder for the pharmacist to observe any physical signs/symptoms and they cannot observe inhaler technique. They can, however, listen for audible wheezing and have access to the patient’s GP records.

The pharmacist asks Kari to describe her symptoms. Is there any chest tightness, cough, wheeze or breathlessness? They must ensure there is no suggestion of an acute or life-threatening asthma attack. If Kari were unable to complete her sentence because of dyspnoea, it would indicate a need for urgent escalation to the emergency department. 

The pharmacist asks about any recent infections or exposures to triggers, smoking history, weight and physical activity, if she has a peak flow meter at home (if so, are there any recent readings she can share?) and if she has a personalised asthma action plan (PAAP) and if she knows how to use this.

The pharmacist checks treatment adherence by asking Kari about how frequently she uses her inhaler and checks her prescription record to calculate the medicines possession ratio, checking how many short-acting beta-agonist inhalers have been issued over the past year (>6 inhalers indicates SABA overreliance and poor asthma control). They also ask about inhaled corticosteroids: ‘How are you getting on with your inhalers? Can you explain how you usually use them? Do you ever forget to take your medicines (e.g. how many times in the week do you forget)?’

Kari describes her symptoms as being worse at night and admits to not using her steroid inhaler regularly. She usually feels her asthma is manageable but has had a recent cold and nocturnal cough has worsened. She does not have a PAAP in place. She is a non-smoker and is overweight. 

Discussion

By asking effective questions over the phone and accessing the information available, the pharmacist is satisfied that Kari doesn’t have immediately life-threatening symptoms (which would require urgent escalation if suspected). But they are able to establish that the patient scores 15/25 on the Asthma Control Test (ACT), indicating poorly controlled asthma​[34]​.

The pharmacist explains the ACT score to Kari and expresses concern that the score and her symptoms mean her asthma is not currently well managed, which is increasing the risk of an attack. The pharmacist emphasises the need to use inhaled steroid regularly as the main treatment for airway inflammation. Relying on salbutamol can mask symptoms and it comes with its own side effects. In further conversation, the pharmacist and Kari explore and address reasons for non-adherence. 

The pharmacist invites the patient into surgery for a FeNo test, a more in-depth, face-to-face asthma review, an inhaler technique/device review and the development of a PAAP. The inhaler device and/or regime can be adjusted according to her ability and preferences. The pharmacist should also discuss healthy weight management strategies and consult the pathway for uncontrolled asthma for this patient because current symptoms suggest she may need further escalation in future if not controlled by the optimisation interventions​[17]​.

Conclusion

There is no single diagnostic test or treatment for breathlessness, which is multifactorial and affects patients in many ways. A combination of pharmacological and non-pharmacological interventions enables a holistic, multidisciplinary approach to breathlessness management, including supported self-management.

Although benzodiazepines and opioids are used in clinical practice, there is limited high-quality evidence for their benefit and other interventions should be tried in preference, but they may serve as a last-line option in advanced disease.