Managing Episodic Shortness of Breath [ESOB] in Chronic Respiratory Illnesses

Introduction:

Episodic shortness of breath [ESOB] is the symptom of chronic illness such as COPD and asthma, in which the patient experiences breathlessness due to severe inflammation inside the airways that reduces the oxygen flow to the alveoli. Palliative management of ESOB is concerned with determining the current breathing issues of patient who suffers from this symptom and implement effective as well as holistic care regimen to reduce the impacts of ESOB thereby promoting the holistic wellbeing of the patient. This study will present a critical discussion on the palliative management of episodic shortness of breath [ESOB] by using the appropriate literature. First, the study will present the background of episodic shortness of breath [ESOB]. In which a brief overview of COPD will be given. Then the study will critically discuss the palliative management of episodic shortness of breath [ESOB] by discussing how symptoms of this health condition can be managed through effective palliative strategies. Finally, the study will summarize the main aspects of the entire discussion.

Background:

Episodic Shortness of Breath [ESOB] is the common symptom of Chronic Obstructive Pulmonary Disease or COPD which is a chronic inflammatory illness that affects different parts of the lungs thereby reducing the capability of alveoli insides each lung to maintain normal inhalation and exhalation (Premathilake et al. 2018). This symptom is associated with additional health issues such as increased breathing rate, chest tightness, heavy cough with sputum, wheezing and chest pain. A patient who experiences episodic shortness of breath has a high risk of primary lung malignancy and heart stroke (Cheraghi, 2019). ESOB is associated with two health condition, emphysema and chronic bronchitis. A patient suffering from COPD often experiences Episodic Shortness of Breath (ESOB) in which a very low amount of oxygen reaches the lung alveoli. This worsening of breathing condition is known as exacerbation.

Pathophysiology of Episodic Shortness of Breath:

Pathophysiology of Episodic Shortness of Breath discusses the functional changes that occurs in the lungs as the outcomes of the disease. In normal condition after breathing, the air enters into the respiratory tract. From the nasopharynx, the air passes to the oropharynx (Broese et al. 2020). These upper airways consist of tiny hair-like projections which are called cilia, that are located in the inner walls. These cilia play important roles in removing different foreign particles and debris that enters with air into the airways thereby clearing passage insides the airways to let the air pass through it without facing any obstruction. From the upper respiratory tract, the airways then pass through the lower respiratory tract, in which the air passes through the larynx and then the trachea, from the trachea the air passes through the bronchioles and then goes to the alveoli (Linde et al. 2018). In the alveoli, the gaseous exchanges take places which let the oxygen from et air enters into the blood of the surrounding blood vessel through diffusion, and carbon dioxide enters from the blood into the alveoli. Then the CO2 is eliminated from the body

During advance stages of Episodic Shortness of Breath, the airways get inflamed that causes limited airflow through the airways (Duenk et al. 2017). The physiology of Episodic Shortness of Breath mentions that different airways irritants such as nicotine (smoking) causes the activation of the T lymphocytes, neutrophils and the other inflammatory cells that are then accumulated into the inner wall of airways. Immediate after the activation of these inflammatory cells, there occurs an inflammatory response that triggers the influx of molecules, that are called the inflammation mediator (Barnett et al. 2017). These mediators are then navigated to the site of the air flowing through the airways then destroy the foreign particles and debris. This immunes response is important for the normal person to maintain a clear and mucous free airway to let sufficient air passes through it. In the case of the COPD patient who experiences the Episodic Shortness of Breath the continuous exposures of the inflammatory cells to the airways irritants never shuts the inflammatory response off, therefore there is continuous activation of the inflammatory cells and formation of the influx of the inflammatory mediators that lead to physiological and structural changes inside the lungs (Ha and McKee, 2020). The continuous inflammation leads to excessive narrowing and construction of the airways thereby causing severe obstruction in the airflow through it. On the other hand, the continuous inflammation reduces the function and capability of cilia inside the upper respiratory airways to swipe the excessive mucinous from the airways. As a result, there is excessing mucous production insides the airways that also constrict the passage for airflow inside the airways (Iyer et al. 2020). If left untreated, this process continues thereby causing severe narrowing of the airways which causes high oxygen scarcity inside the body.

Palliative management of episodic shortness of breath:

Palliative management of ESOB is associated with the implementation of strategies that will not only assist COPD patient to reduce the impacts of the symptoms of this illness but also promote their holistic wellbeing to improves their quality of living (Schloesser et al. 2020). The palliative management strategies for ESOB include appropriate assessment of this symptom, promote lifestyles changes in patients, encourage smoking cessation and follow the prescribed medication process.

Assessment using PEPSI COLA tool:

Before starting the palliative treatment for ESOB, an effective assessment of the entire health condition is crucial (Lewthwaite et al. 2019). Through applying the appropriate assessment tool, care professionals can determine additional elements associated with ESOB such as the severity of the lung infection, percentage of lung blockage., the current oxygen saturation level of the patients, the breathing rate of the patients and the lung capacity. While managing ESOB condition under palliative care, care professionals can use the PEPSI COLA assessment model (Maddocks et al. 2017). This model consists of the following elements that care professionals must consider while assessing yeh health condition of patients experiencing ESOB.

• Physical
• Emotional
• Personal
• Social support
• Information and communication
• Control and autonomy
• Out of hours
• Living will illness
• Aftercare

Under this assessment tool, care professionals can determine the physical health condition of patients experiencing ESOB (Philip et al. 2018). Through carrying out HRCT (high resolution computed tomography) test, spirometry, chest x-ray and complete blood counts, care professionals can determine the oxygen saturation level, current breathing rate and function of lungs Under NMC (2015), care professionals must determine the personalised needs while providing palliative care to patients [NMC, 2015]. Though using the PEPSI COLA assessment process, care professionals can determine the emotional and social needs of patients suffering from ESOB (Scheerens et al. 2018). Under the palliative treatment process, the patients experiencing ESOB must be provided with proper emotional support by using friendly, polite and empathetic behaviour towards them. Nurses must encourage patients to promote healthy habits, positive thoughts and positive lifestyle behaviours in them. Under this assessment process, palliative care professionals can use empathetic and supportive communication with patients who experience ESOB which will provide mental and emotional strength to the patients (Siouta et al. 2021). Under NMC (2015), while carrying out the health assessment of patients suffering from the life-threatening illness, care professionals must ensure that the autonomy and rights of that patients are respected, after assessing the lung condition of patients, care professionals must promote health literacy and self-management skill in the patients thereby teaching them how to reduce as well as eliminate the risk of ESOB

Pharmacological intervention:

Following pharmacological process will be used for managing ESOB

Medications:

Bronchodilators:

SABA:

Short-acting β2-agonist or SABA which is also known as Salbutamol is widely used for palliative management of ESOB. Salbutamol acts as the bronchodilator by increasing the cyclic adenosine monophosphate in the smooth muscles cell of the airways which causes bronchodilation (Smallwood et al. 2018). Salbutamol plays crucial roles in reversing the dynamic hyperinflation of the lung by dilating the small airways. By causing bronchodilation, SABA leads to an increase in the amount of airflow through the airways thereby increasing the airflow into the lung alveoli (Tavares et al. 2017). As a result, the more oxygen enters into the blood from the alveoli which then supplied to different body parts thereby meeting the oxygen demand of the body, this by using SABA inhaler oxygen flow into the patient’s body can be increased.

LAMA:

A long-acting muscarinic antagonist or LAMA is used for the improving the breathing condition of the patient thereby managing the advanced stage ESOB. LAMA nebulised is highly useful in managing the symptoms of COPD. LAMA act against the bronchoconstrictor impacts of acetylcholine on activating the M3 muscarine receptors that are located on the smooth muscle cells of the airways (Weiss et al. 2020). In patients experiencing ESOB the interaction of the acetylcholine and the M3 receptors causes severe constriction of the bronchioles thereby narrowing the air passage. LAMA nebulised block the activity of the acetylcholine and thereby pose resistance in the further secretion of the acetylcholine thus leading to bronchodilation. This nebuliser poses the following impacts on patients experiencing ESOB

• Improve the breathing condition of patients by causing bronchodilation
• Increase lung capacity to receive more oxygen (Siouta et al. 2021)
• Reduces the overall frequency of the exacerbations

Antibiotics:

Generally antibiotic is not effective in long terms management of symptoms of chronic health condition like ESOB. This is because this health condition has long term impacts on the patient’s airways and lungs that can not be cured permanently through using antibiotics (Scheerens et al. 2018). However, the exacerbation of COPD is associated with risk of ESOB. The risk of ESOB can be reduced and managed through using relevant antibiotics, in the case of COPD the widely used antibiotics are azithromycin and moxifloxacin. These antibiotics are generally prescribed by the physician for the managing ESOB in thereby improving the overall breathing condition of the patients by improving the oxygen supply to different body parts.

Glucocorticosteroids:

These medicines are prescribed to COPD and asthmatic patients for effectives management of the ESOB for reducing the severe inflammation in the airways and infection. These medicines are Metaproterenol, Levalbuterol, Albuterol And Pirbuterol (Lewthwaite et al. 2019). Glucocorticosteroids play crucial roles in reducing the inflammatory response inside the airways thereby reducing the bronchoconstriction. As a result, bronchodilation occurs which increases the airflow to the lung thereby leading the more oxygen supply to the body.

Smoking cessation:

Smoking is considered the major cause of ESOB. Evidence suggests that, while nicotine and other airways irritants enter into the air passage after a person smokes, these irritants cause severe inflammation of the airways (Siouta et al. 2021). The inner wall of the airways has epithelial inning which consists of severe hair-like projections called cilia. These cilia play crucial roles in sweeping away all the foreign particles and mucous from the airways thereby making the air passage clean so that the air can pass through the passage without facing any obstruction. But the regular entry of nicotine into the airways causes damage to the cilia thereby reducing the capability of epithelial lining to remove the foreign particles and mucous (Ecenarro et al. 2018). As a result, mucous and other particles get accumulated into the inner lining of the airways thereby making the inner walls thick. This action causes the narrowing of the airways thus leading to poor oxygen supply to the lung.

Healthy lifestyle:

Although ESOB is associated with chronic health conditions such as asthma, COPD and acute bronchitis that cannot be cured permanently, by following a healthy lifestyle it is possible to manage the severity and impacts of this symptom. Patients experiencing ESOB need to follow a healthy lifestyle and healthy as well as nutritious diet (Lewthwaite et al. 2019). patients with high risk to breathing difficulties must follow the diet that is prescribed by the pulmonologist. For example, they must avoid foods that can cause allergies such as cold drinks, nuts and dried or frozen foods. Patients must be provided with food that will be enriched in proteins, healthy fats, carbohydrates and essential vitamins and minerals. They must consume sufficient water and fruit juice that can improve their blood flow into the lung thereby improving the oxygen supply. Patients with high risk of ESOB must follow a healthy lifestyle such as sufficient sleep at night, no skipping of meals, regular health check-up, taking inhalers and other prescribed medicines on times and do aerobic exercise regular wise. Aerobic exercise will improve the oxygen capacity of the lung and airways thereby improving the breathing ability of the patients.

Vaccination:

Vaccination is crucial for patients having high risk to ESOB to improve the breathing condition by increasing the lung efficiency to carry more oxygen (Broese et al. 2020). Under the guidelines of British Thoracic Society UK, patients who have high risk of ESOB such as asthmatic patients or COPD patients must be provided with all the up-to-date information regarding the vaccination such as the date and time when the vaccine will be administered, the duration of the two-dose of vaccine, precautions taken before vaccines administration and the associated risk and benefits of the vaccine.

Self-management skill:

Nurses will provide proper health education to people with high risk of ESOB in the hospital setting and home setting to improve self-management skill (Lewthwaite et al. 2019). In this context, nurses will improve patient’s knowledge about the cause and health outcomes of ESOB, the associated risk of this symptom and the process of safe management of this symptom. Effective self-management skill will help patients to :

• Check their oxygen saturation level and breathing rate at home
• Observe their health condition
• Inform doctors if there is any deterioration
• Keep the necessary arrangement at home that is needed to provide immediate oxygen support to the patients when needed such as oxygen, nebulised and inhalers
• Mage the stress level by using stress management techniques such as deep breathing
• Follow a healthy lifestyle, diet and medication process

Conclusion:

From the overall discussion, it can be summarised that ESOB is a symptom that is associated severe breathing difficulties with chest tightness due to airways become inflamed thereby causing limited oxygen supply to the lungs. This symptom has adverse impacts on the physical and mental wellbeing of people thereby affecting their overall quality of living. however this symptoms can easily be managed through following a healthy diet, systematic lifestyles and following the prescribed medication regimen.

Continue your journey with our comprehensive guide to Managing COVID-19 Infections in Cities.

Reference list:

Barnett, L.A., Prior, J.A., Kadam, U.T. and Jordan, K.P., 2017. Chest pain and shortness of breath in cardiovascular disease: a prospective cohort study in UK primary care. BMJ open, 7(5), p.e015857.

Bove, D.G., Jellington, M.O., Lavesen, M., Marså, K. and Herling, S.F., 2019. Assigned nurses and a professional relationship: a qualitative study of COPD patients’ perspective on a new palliative outpatient structure named CAPTAIN. BMC palliative care, 18(1), pp.1-9.

Broese, J.M., van der Kleij, R.M., Kerstjens, H.A., Verschuur, E.M., Engels, Y. and Chavannes, N.H., 2020. A cluster randomized controlled trial on a multifaceted implementation strategy to promote integrated palliative care in COPD: study protocol of the COMPASSION study. BMC Palliative Care, 19(1), pp.1-12.

Cheraghi, T., 2019. Shortness of Breath, Chest Tightness, and Wheezing. In Pediatric Allergy (pp. 191-198). Springer, Cham.

Duenk, R.G., Verhagen, C., Bronkhorst, E.M., Van Mierlo, P.J.W.B., Broeders, M.E.A.C., Collard, S.M., Dekhuijzen, P.N.R., Vissers, K.C.P., Heijdra, Y. and Engels, Y., 2017. Proactive palliative care for patients with COPD (PROLONG): a pragmatic cluster controlled trial. International journal of chronic obstructive pulmonary disease, 12, p.2795.

Duenk, R.G., Verhagen, C., Dekhuijzen, P.N.R., Vissers, K.C.P., Engels, Y. and Heijdra, Y., 2017. The view of pulmonologists on palliative care for patients with COPD: a survey study. International journal of chronic obstructive pulmonary disease, 12, p.299.

Ecenarro, P.S., Iguiñiz, M.I., Tejada, S.P., Malanda, N.M., Imizcoz, M.A., Marlasca, L.A. and Navarrete, B.A., 2018. Management of COPD in end-of-life care by Spanish pulmonologists. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(2), pp.171-176.

Ha, D. and McKee, S., 2020. A differential comes up short in a patient with shortness of breath. Respiratory Medicine Case Reports, 30, p.101089.

Halpin, D.M., 2018. Palliative care for people with COPD: effective but underused.

Harrington, S.E., Rogers, E. and Davis, M., 2017. Palliative care and chronic obstructive pulmonary disease: where the lines meet. Current opinion in pulmonary medicine, 23(2), pp.154-160.

Iyer, A.S., Dionne-Odom, J.N., Khateeb, D.M., O'Hare, L., Tucker, R.O., Brown, C.J., Dransfield, M.T. and Bakitas, M.A., 2020. A qualitative study of pulmonary and palliative care clinician perspectives on early palliative care in chronic obstructive pulmonary disease. Journal of palliative medicine, 23(4), pp.513-526.

Landers, A., Wiseman, R., Pitama, S. and Beckert, L., 2017. Severe COPD and the transition to a palliative approach. Breathe, 13(4), pp.310-316.

Lewthwaite, H., Williams, G., Baldock, K.L. and Williams, M.T., 2019, March. Systematic review of pain in clinical practice guidelines for management of COPD: a case for including chronic pain?. In Healthcare (Vol. 7, No. 1, p. 15). Multidisciplinary Digital Publishing Institute.

Linde, P., Hanke, G., Voltz, R. and Simon, S.T., 2018. Unpredictable episodic breathlessness in patients with advanced chronic obstructive pulmonary disease and lung cancer: a qualitative study. Supportive Care in Cancer, 26(4), pp.1097-1104.

Maddocks, M., Lovell, N., Booth, S., Man, W.D. and Higginson, I.J., 2017. Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease. The Lancet, 390(10098), pp.988-1002.

Philip, J., Crawford, G., Brand, C., Gold, M., Miller, B., Hudson, P., Smallwood, N., Lau, R. and Sundararajan, V., 2018. A conceptual model: redesigning how we provide palliative care for patients with chronic obstructive pulmonary disease. Palliative & supportive care, 16(4), pp.452-460.

Premathilake, N.S., Kularatne, K. and Senadhira, D., 2018. Giant Mature Teratoma of the Thorax–a rare cause of episodic shortness of breath. Journal of the Postgraduate Institute of Medicine, 5(2), pp.1-5.

Rajnoveanu, R.M., Rajnoveanu, A.G., Fildan, A.P., Todea, D.A., Man, M.A., Motoc, N.S. and Mosoiu, D., 2020. Palliative Care Initiation in Chronic Obstructive Pulmonary Disease: Prognosis-Based, Symptoms-Based or Needs-Based?. International Journal of Chronic Obstructive Pulmonary Disease, 15, p.1591.

Roy, B. and Chahin, N., 2017. Clinical Reasoning: A 14-year-old boy with fatigue and episodic worsening of weakness. Neurology, 88(11), pp.e96-e100.

Scheerens, C., Chambaere, K., Pardon, K., Derom, E., Van Belle, S., Joos, G., Pype, P. and Deliens, L., 2018. Development of a complex intervention for early integration of palliative home care into standard care for end-stage COPD patients: A Phase 0–I study. PloS one, 13(9), p.e0203326.

Scheerens, C., Pype, P., Van Cauwenberg, J., Vanbutsele, G., Eecloo, K., Derom, E., Van Belle, S., Joos, G., Deliens, L. and Chambaere, K., 2020. Early Integrated Palliative Home Care and Standard Care for End-Stage COPD (EPIC): a phase II pilot RCT testing feasibility, acceptability, and effectiveness. Journal of pain and symptom management, 59(2), pp.206-224.

Schloesser, K., Eisenmann, Y., Bergmann, A. and Simon, S.T., 2020. Development of a Brief Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness—A Delphi Survey With International Experts. Journal of Pain and Symptom Management.

Siouta, N., Heylen, A., Aertgeerts, B., Clement, P., Janssens, W., Van Cleemput, J. and Menten, J., 2021. Quality of Life and Quality of Care in patients with advanced Chronic Heart Failure (CHF) and advanced Chronic Obstructive Pulmonary Disease (COPD): Implication for Palliative Care from a prospective observational study. Progress in Palliative Care, pp.1-9.

Smallwood, N., Currow, D., Booth, S., Spathis, A., Irving, L. and Philip, J., 2018. Differing approaches to managing the chronic breathlessness syndrome in advanced COPD: a multi-national survey of specialists. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(3), pp.294-302.

Tavares, N., Jarrett, N., Hunt, K. and Wilkinson, T., 2017. Palliative and end-of-life care conversations in COPD: a systematic literature review. ERJ open research, 3(2).

Weiss, A., Porter, S., Rozenberg, D., O'Connor, E., Lee, T., Balter, M. and Wentlandt, K., 2020. Chronic obstructive pulmonary disease: a palliative medicine review of the disease, its therapies, and drug interactions. Journal of pain and symptom management, 60(1), pp.135-150.