George A. Sprecace M.D.,
J.D., F.A.C.P. and Allergy Associates of New London,
Severe Shortness of Breath...
HOW TO DEAL WITH IT
The following recommendations are based upon over
forty years of clinical experience with this subject, and also are based
in part on a recent medical article that appeared in the Journal of the
American Medical Association (Luce and Luce, JAMA, March 14, 2001).
Acute, severe shortness of breath is a medical emergency
which requires treatment ultimately dependent on its cause.
Chronic, worsening and ultimately severe shortness of breath, initially
only on exertion and eventually constant, will require more than
good medical management. It will usually require specialty
care, or at least the devoted and regular long-term care of a very
knowledgeable primary care physician. Such care becomes a partnership
between patient and physician, more than usual, in which a main component
is the constant availability of the physician to deal with questions and
problems - small and large.
The following are some issues which should be addressed
by both partners in this life-time relationship:
If done right by all concerned, this process should
be a comfortable and humane life transition to a better place. If
done wrong, it can be painful, cruel, disastrous.
Diagnose and treat the primary disease comprehensively. As noted
in my offering on “Chronic Bronchitis”, this means making sure not to overlook
a possible co-existent reversible condition; namely, bronchial asthma.
Treat all secondary, associated or accompanying conditions, including left
and/or right heart failure, acute and chronic infections (eg. pneumonia,
recurrent acute bronchitis, sinusitis...), Gastro-esophageal reflux disease,
Control secretions, with liquefying agents, mobilizing agents, postural
drainage and vibratory-percussive chest physiotherapy, suction catheterization
and ultimately tracheostomy if necessary.
Consider Oxygen in timely fashion. This means being more liberal
in its use than is reflected in the Medicare guidelines which - if
followed - will very likely lead to end-stage right heart failure.
Incorporate exercise in the regimen: aerobic exercises as tolerated,
in the form of walking and stationary bicycle-riding (see American
Lung Association programs);
and muscle-toning exercises involving mainly the arms, shoulder girdles,
the intercostal muscles and the diaphgram.
Deal effectively with Nutrition of these often mal-nourished patients,
Hydration, Depression - a common finding, Sleep Deprivation (including
possible obstructive sleep apnea), and the all-important Socialization
(with family and especially with friends) - an often over-looked asset.
Use Opiates judiciously to relieve the sensation of constant shortness
Consider the use of Non-Positive Pressure Breathing devices.
Ultimately, work co-operatively and openly to prepare the patient for Death.
This involves considerations which I addressed in my offering on “Physician-Patient
Spirituality”; and it involves the timely completion of Advanced
Directives reflecting the terminal wishes of the patient and the
acceptance of the family.