Anxiety after a flight of stairs, difficulty breathing after a race to get to the bus stop on time or simply having the so-called “shortness of breath” after walking at sustained pace. All normal? Experimenting with what doctors call “breathlessness” does not necessarily mean that our body has something wrong. There may be various causes: some of these are warning signs for more serious illnesses, others indicate that we are out of training and that our lifestyle is perhaps a little too sedentary. In any case, it may be important to examine the situation with your doctor, who alone will be able to confirm that you are not dealing with a pathological symptomatology or to prescribe the necessary investigations. We talk about this topic with Dr. Massimo Crippa, a pulmonologist from Humanitas.
When dyspnea is a warning sign
“Dyspnea is the term used to define the unpleasant subjective sensation of respiratory difficulty not always related to the severity of the disease – explained the specialist. Patients describe it in different ways, most commonly as “breathlessness”. This symptom originates when there is a conscious awareness of a mismatch between what the brain expects and what it receives, in terms of information from the lungs, airways and receptors localized at the level of the tendons and muscles of the ribcage. We can say that feeling a respiratory fatigue is a “normal” or “abnormal” feeling depending on the situation in which it occurs; for example, during or after a walk at a steady pace, or a short run or the ascent of a flight of stairs, for a subject with a sedentary lifestyle, poor physical training and perhaps overweight, dyspnea can be considered normal and not associated with pathological events. However, it remains an essential fact that dyspnea is a symptom that is always a major concern for those who experience it and it is therefore one of the main reasons for seeking medical attention.
To understand if the difficulty to breathe can be the symptom of something more serious we must first ask ourselves if it is a sensation that happens regularly, if it is prolonged in time or on the contrary something extemporary and extremely fleeting. Dyspnea can be a general symptom of many diseases, especially of cardiac or pulmonary origin. It can accompany asthma, chronic obstructive broncopneumopathy, heart attack, pulmonary embolism, bronchitis and pneumonia, heart failure, pneumothorax, malignant and benign lung cancer, as well as neurological diseases such as multiple sclerosis.
Lack of regular exercise
Smoking habits and lack of physical activity are among the bad habits that lead to shortness of breath. When our heart is not sufficiently trained, the least effort leads to a reduction of oxygen parameters in the blood. So the frequency of breathing must increase, as it happens during the first ten minutes of running, to take in as much air as possible and rebalance the levels of oxygen necessary for the well being of all internal and external organs.
“Dyspnea occurring during daily activities or at rest is one of the most common manifestations of respiratory diseases although it is present in many other clinical situations such as cardiac, neurological, hematological, endocrinological – metabolic and psychiatric disorders. Therefore, the assessment of the patient who experiences dyspnea must always be very accurate and thorough – added the specialist. Through the anamnestic collection, the doctor investigates some aspects of the patient’s life and in particular risk factors such as smoking or exposure to harmful inhalants in the workplace are sought. If the symptom has arisen acutely or has been present for a long time and worsens over time, if it is perceived only during the effort you should try to quantify it, if it is associated with other symptoms such as cough, chest pain, closed nose, sneezing, itching or burning eyes and tearing.
Useful tests and examinations
If you experience dyspnea, depending on your general clinical condition, the specialist may ask you to undergo tests to measure your blood oxygen levels, an X-ray of your chest, an electrocardiogram or echocardiogram, blood tests to detect anemia, and a series of lung function tests such as spirometry. Finally, the psychological causes should not be underestimated, especially if the feeling of lack of air and the consequent hyperventilation is due to a state of anxiety or if, even worse, it leads to a real panic attack.
“The general objective examination is fundamental for the search of clinical signs of pathological significance for the various organs and apparatuses – concluded Dr. Crippa. In particular: detect the vital parameters (blood pressure, heart rate and respiratory in an adult subject at rest and again after 15 to 20 active minutes; oxygen saturation detectable by a saturated digital meter, reflects the percentage of hemoglobin saturated with oxygen. Normal values range between 95 – 100%). Check for labial cyanosis and extremities. Auscultation of the thorax may highlight findings that are either infectious (e.g. bronchitis exacerbation or bronchopneumonia) or chronic inflammatory causes, such as COPD (a very common disease in smokers) or asthma. Cardiac objectivity allows you to detect any changes in heart rhythm or the presence of puffs. The evidence of edema in the lower limbs is often due to heart failure that can manifest itself with breathlessness. The diagnostic path to start for the study of dyspnea can be varied and articulated. The first test, which can be carried out in any pulmonology clinic, is simple or basal spirometry: A quick and easy test that provides a first assessment of any respiratory deficit in real time. In particular, the spirometry test allows us to classify respiratory pathologies into 2 main classes: obstructive and restrictive pathologies. Obstructive damage is characteristic of the two major airway diseases, asthma and COPD. Restrictive damage is typical of more complex lung diseases that affect the crevice of the lung and are therefore referred to as pulmonary crevices. Simple spirometry can be complemented by global spirometry, which allows additional and more detailed information regarding respiratory function to be added.
Further information on possible causes of dyspnea may be provided by radiological examinations such as standard chest radiography and possibly a chest CT scan. With this last investigation, carried out with the administration of contrast agents, in addition to images of bronchial and lung pathologies, alterations in the pulmonary arterial circle can be highlighted, as happens in cases of pulmonary thrombus embolism.
Blood gas analysis is a blood collection from a radial artery that allows us to obtain accurate information about any alterations in gas exchange. Through blood gas analysis we can evaluate lung function by measuring pH, oxygen (O2) and carbon dioxide (CO2); to monitor the treatment of lung diseases; to determine the presence of an acid-base imbalance in the blood, which may indicate respiratory, metabolic or kidney diseases; to assess the effectiveness of oxygen therapy.
Correlation with other diseases
As mentioned earlier, breathlessness can be a symptom related to extra respiratory clinical conditions, such as heart diseases like rhythm changes (tachycardia and tachyarrhythmia), valve defects, and cardiac pump deficit (heart failure). For this reason, an electrocardiogram and echocardiogram can be fundamental checks to clarify the nature of the symptom.
It should not be forgotten that even a simple blood count could reveal anemia of such a magnitude that it can justify dyspnea.
“In conclusion, we can say that dyspnea is one of the predominant symptoms in most respiratory diseases (chronic bronchus pneumopathy, bronchial asthma, pneumonia, lung cancer, pleuritis, interstiziopathy, pneumothorax, pulmonary thrombus embolism) as well as disorders of other organs and apparatuses (alterations of the cardiac rhythm, cardiac pump deficit, valvulopathies, anemia) and can also be supported by conditions of a psychic nature (states of anxiety) – the specialist adds. The diagnostic procedure to be followed to trace the cause of a respiratory distress can be quite complex and articulated but it is important that it is managed in the most correct way based on the information provided and on the clinical conditions of the patient at the time of the visit”.
