Helping Patients with COPD Manage Episodes of Acute Shortness of Breath

MedSurg Nursing, August, 2000 by Sandra Truesdell

Nurses working in a variety of settings frequently care for patients with dyspnea. Although there are several medical conditions in which dyspnea is a symptom, patients with moderate to severe chronic obstructive pulmonary disease (COPD) often suffer dyspnea as their major and most disabling symptom. Often medications prescribed for these patients do not completely relieve shortness of breath. Because patients who experience dyspnea frequently express feelings of anxiety, worry, anger, frustration, or panic (Janson-Bjerklie, Carrieri, & Hudos, 1986), they may require a significant amount of attention from those around them including family members and nurses. In addition to administering scheduled and PRN doses of bronchodilator therapy, many nurses are aware that breathing techniques such as pursed-lip and diaphragmatic breathing can help patients manage episodes of acute shortness of breath. Although nurses may be familiar with these techniques, helping patients use them while they are acutely short of breath and anxious is far more difficult than teaching them at rest when their dyspnea is under control.

Although difficult, helping patients to use breathing techniques during dyspneic episodes may be one of the most effective nursing interventions available to reduce shortness of breath. The purpose of this article is to present an effective method for teaching pursed-lip breathing to patients during acute episodes of dyspnea.

Factors Contributing to Dyspnea

Chronic obstructive pulmonary disease occurs when chronic bronchitis or emphysema causes airflow obstruction (American Thoracic Society, 1995). The obstruction is generally progressive. It can be accompanied by airway hyperreactivity, and may be partially reversible. Patients with chronic bronchitis experience a chronic, productive cough. Emphysema includes abnormal enlargement of the airspaces distal to the terminal bronchioles with destruction of their walls but without obvious fibrosis (American Thoracic Society, 1995). Hyperinflation often accompanies emphysema. Inflammation of the terminal bronchioles may occur prior to the development of other changes in emphysema (Corbridge & Irvin, 1993).

Patients with COPD demonstrate significant airflow obstruction on expiration which can be demonstrated by pulmonary function testing. To overcome chronic airway obstruction, patients with COPD must increase their work of breathing. Additional work is created when hyperinflation is present because with a greater amount of air remaining in the lungs after exhalation, the diaphragm is pushed downward and is unable to move the chest cage effectively on inspiration (Manning & Schwartzstein, 1995). Because the diaphragm cannot work effectively, patients begin to use accessory muscles of breathing including sternocleidomastoid, pectoralis, and external intercostal muscles (Breslin, 1996). An increase in respiratory rate and the use of accessory muscles by patients with COPD has been associated with perceptions of increased dyspnea (Breslin, 1992).

Model of Dyspnea

In planning care for the COPD patient, the nurse must consider not only these likely physiologic factors involved in the sensation of dyspnea, but recognize that dyspnea is a multidimensional symptom (Carrieri & Janson Bjerklie, 1984; Gift, 1990; Steele & Shaver, 1992). A recent statement of the American Thoracic Society (1999, p. 332) defined dyspnea "as a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavior responses."

Gift (1990) described a comprehensive model of dyspnea which includes five components: sensation, perception, distress, response, and reporting of dyspnea. Sensation includes the stimuli, receptors (mechanical and chemical), and nerve pathways involved in the transmission of impulses to and from the lungs, respiratory muscles, chest wall, respiratory circulation, and brain. Dyspnea may involve an imbalance in all of these sources of sensation. The perception of dyspnea involves the patient's interpretation of the sensation. Perception may be influenced by how long the patient has experienced dyspnea; his expectations of the situation, age, gender; and the presence of other diseases.

Psychological aspects of dyspnea are reflected in the patient's descriptions of distress. High levels of anxiety have been associated with high levels of dyspnea (Gift, 1990). The response that patients have to dyspnea reflects their coping style. Responses can be immediate or long-term as well as problem focused or emotion focused (Carrieri & Janson-Bjerklie, 1986). Immediate responses that COPD patients frequently demonstrate when they are short of breath include sitting quietly and isolating themselves from others. To cope with dyspnea over time, patients may respond by changing their patterns of performing activities of daily living, such as bathing only when others are home to help them, and avoiding social activities with family and friends. These responses affect not only the patient but their families and other caregivers.