Home Health & Hospice. Easing Your Breathing

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1 Home Health & Hospice Easing Your Breathing

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3 Dyspnea: Defined as being hungry for air. It is manifested as rapid inhalations and expirations. Breathing is labored and difficult and may even be painful. It may feel like a smothering sensation or the inability to catch a good normal breath. Dyspnea is commonly associated with audible breath sounds without a medical instrument, an anxious or distressed facial expression, mouth breathing or gasping, dilated nostrils and obvious bluish discoloration around the oral mucosa and lips. Dyspnea is normal when due to vigorous work or athletic activity. The physical sensation and the emotional reaction to the sensation blend to create an episode of breathlessness that can be anywhere from annoying to frightening. People with chronic breathing trouble can experience: Chronic cough Numbness or tingling Upset stomach, nausea Chest pain Fatigue; tiredness in the legs; desire to lay down Congestion Yawning Unsteadiness; dizziness Thirst Anxiety; panic Eye strain; headache Impatience; anger Husky or soft voice Shoulder stiffness Decreased appetite Breathing can be tolerable one minute and rough the next. Episodes can be triggered by activity, odors, weather changes, moist air, fatigue, an illness or infection, depression, or an emotional upheaval. Mild dyspnea can stop you from doing some of the things you normally do like climbing stairs or exercising. Severe dyspnea can make you curtail many activities and make work out of fun activities such as talking and eating. 3

4 Causes of Dyspnea Breathing trouble can be a consequence of problems with the lungs, heart, kidneys, liver, nerves, or muscles. Dyspnea is often expected with lung disease, but it can be a part of many other diseases, such as stroke, dementia, cancer, or congestive heart failure. Emphysema The air sacs in the lungs lose their normal elastic nature. Fresh air can be breathed in, but the airways then tend to collapse and the fresh air is trapped in the lungs. This diminishes the room left for new fresh air. The muscles that help you breathe become weakened and tired by the steady work. Your body begins to use other muscles to help you breathe, such as neck and chest wall muscles, but this too becomes exhausting. There is no cure for emphysema, but symptoms can stabilize or improve. Pulmonary fibrosis The lungs and chest walls are stiff and don t allow for normal air exchange in and out of the lungs. Heart disease A heart that is weakened by disease isn t able to properly pump blood through the body and fluids tend to back up into the lungs. Cancer Some cancers affect the ability of the body to regulate the breathing or can interfere with the normal flow of air into and out of the lungs. Other cancers can diminish the ability of the body to carry the fresh, oxygen-rich blood around the body. Nerve or muscle diseases People who have had strokes, who have ALS (Amiotrophic Lateral Sclerosis), or dementia sometimes have trouble moving the muscles that assist with breathing. The cause of the dyspnea may not be fixable, but there are techniques and medicines that can ease your breathlessness, stop the panic, and help you catch your breath. 4

5 What Does COPD Mean? COPD is a lung disease. The airways that carry air to your lungs become narrowed and it becomes harder for you to breathe. There are tiny air sacs where the airways end in your lungs. These air sacs don t empty and your lungs feel full when you have COPD. Besides feeling short of breath, you may cough more often and cough up mucous. Shortness of breath may keep you from doing things you would like to do. 5

6 Assessing Your Dyspnea People with long-term dyspnea do not always complain of breathlessness they have high thresholds and they develop a new sense of normal breathing. The best way for your home care or hospice nurse and your caregivers to assess your breathing status is to ask you. The person who has trouble breathing is the only one who can rate the ease or difficulty of breathing. A breathing scale is helpful to let your caregivers know how much trouble you are having at rest and with activity. 0 = No difficulty breathing 1 = Very slight problem with breathing 2 = Slight problem with breathing 3 = Moderate problem with breathing 4 = Somewhat severe problem with breathing 5 = Severe problem with breathing 6-8 = Very severe problem with breathing 9-10 = Maximum difficulty with breathing These are some of the things that your nurse will ask you about or look at to get a complete picture of your breathing status. What is the position that is the most comfortable for you? What is your mood? Irritable, anxious, so restless that you can t sit or lie still? What are your able to do? How far can you walk without stopping to rest? How steady are you? Do you need a cane or walker? How easy or hard is it for you to talk? Can you do housework? Bathe? Dress? How do you sleep at night? Lying down? How many pillows do you use? Sitting up in a recliner or easy chair? 6

7 How tired are you during the day? Do you doze frequently? Do you feel like you use all your energy to breathe? Do you have any trouble thinking clearly? What is the color of your skin? A bluish tinge to your nose, fingertips, or ears? What is the temperature of your skin? Is it cool, clammy? How is your appetite? Does it feel like it is work to eat? What foods don t appeal any more? Do you feel full fast? Do you get a bloated or gassy feeling after eating? What does your chest look like? Is there a widening of spaces between the ribs? A barrel-shape from years of air-trapping? How do you look when you breathe? Do your shoulders raise up? Does your whole chest move? Does your abdomen pump? Is there a bulging or retraction between the ribs? Do you grimace with each breath? Do you purse your lips when you breathe out? What are your breaths like? Fast or slow? Deep or shallow? Relaxed or labored? What does your heart beat sound like? Fast or slow? Loud or soft? Regular or irregular? What can be heard when someone listens to your lungs? A crackle indicating fluid? A wheeze indicating narrowed air passages? A rub, snore, or rattle indicating a blockage of mucus, infection, or spasm in the airways? How many colds or lung infections have you had recently? Do you cough a lot? What do you bring up when you cough? Do you use oxygen to help you breathe more comfortably? Do you have chest pain? Is there swelling in your feet or legs? Do you get headaches? 7

8 Non-Medicine Ways to Treat Dyspnea People who have trouble breathing become the experts on their own dyspnea management. You should have maximum control over how to handle your breathing on a day-to-day basis and when you have an episode of breathlessness but here are some suggestions that might work for you. Guidelines for Everyday Stop smoking and avoid exposure to smoke. Avoid exposure to any sprays (hairspray, bug spray, perfume). Wear loose clothing. Use air conditioning and a dehumidifier. Avoid exposure to people with colds, respiratory infections. Conserve your energy. Find the easiest way to do things. Pace yourself (i.e., climb a few steps at a time only). Eliminate unnecessary tasks. Take rests between activities. Decrease the amount of talking you do (if talking is hard). Be wary of activities that involve movement of the arms (lifting, shampooing hair, dressing) - these activities tend to rob your breath. Sit on a chair or stool for as many activities as possible. Use a bath bench and hand sprayer for showering. Open the bathroom door or use the exhaust fan to decrease the warm, moist air in the bathroom. Keep frequently used items nearby to avoid unnecessary walking, bending, carrying, and lifting. Eat to breathe. We also point out how diet can affect lung capacity. We encourage patients to: Eat several small meals per day to cut down on the oxygen needed for digestion. Breath evenly, slowly while chewing. Take breaks during the meal to conserve energy. Use a liquid supplement for breakfast (rather than skip a meal) if your short of breath in the morning. Avoid gas-forming foods. Bloating in the abdomen can make breathing even harder. Include extra protein whenever possible to rebuild muscle mass. Many of the illnesses that cause Dyspnea can also cause weakness, and a vicious cycle of decline. Building up muscle tissue can help a patient recover some strength. Add high-potassium foods to diet. Diuretics can sap the body of fluids and potassium, which are critical for maintaining energy. Avoid stomach upset, which can compromise food intake, by taking bronchodilators at least one hour before meals. 8

9 Guidelines for Managing an Episode of Breathlessness Get in the best position possible to ease breathing and expand the lungs: If in bed put head of bed up or use several pillows. If seated lean forward with head lowered and feet wide apart on floor or stool. Fold arms across a table or support on pillows or rest elbows on knees. If walking lean hips against the wall with feet apart and shoulders relaxed but bent slightly forward. Open the window or blow a fan directly at your face or have someone put a cool cloth against your face. All of these things will decrease the sensation of breathlessness. Use pursed-lip breathing to slow rapid breathing and prevent the collapse of air passageways and consequent air-trapping. Breathe in slowly through your nose for 1 count. Purse your lips as though you were going to whistle. Breathe out gently through pursed lips for 2 slow counts. Let air naturally escape out don t force. Repeat this pattern until you are not short of breath. Have your caregivers help you achieve a quiet environment to help you reduce your anxiety by providing: A calm presence Quiet music Distraction 9

10 Diaphragmatic Breathing Diaphragmatic breathing helps the diaphragm move. The diaphragm is the large muscle underneath your lungs. This type of breathing technique is helpful for some patients. Use diaphragmatic breathing during exercise and when you feel short of breath. Inhale. Sit comfortably in a chair. Place one hand on your stomach and one hand on your chest. Breathe air in through your nose slowly. Fell your stomach grow larger. Exhale. Breathe out slowly through pursed lips. Feel your stomach muscles tighten. Continue diaphragmatic breathing until you feel calmer and less short of breath. Conserve Your Energy: Learn how to pace your activates or do them in an easier way. You will do m ore and be less short of breath. A few examples are: Walk at a slow and comfortable pace Do activities at a slow and comfortable pace Do things sitting down Put things that you need in one place that is easy to reach Use a bath stool or bench during bathing Consider sponge bathing Dress seating instead of standing Consider the use of bedside commode Rest after you eat Avoid shopping at busy times of the day Go to places that do not have a lot of stairs Prepare for activities by resting first and using breathing techniques Ask for help when you need it 10

11 Breathing Techniques Breathing exercises and techniques can help you when you have trouble breathing. They can help strengthen the muscles you need when breathing. Posture Leaning forward often makes it easier to breathe. Sit at a forward angle with your elbows resting on your knees or a table. Pursed-lip breathing Pursed-lip breathing helps you breathe the air out of your lungs better. This way you will be able to breathe in more air when you inhale. Use pursed-lip breathing during exercise and when you feel short of breath. Inhale slowly. Exhale slowly and gently for 4-6 seconds, while you pucker your lips (like blowing out a candle). 11

12 Using Medicine to Treat Dyspnea There are medicines that are available to help ease your breathing. These can be used in addition to using non-medicine techniques. Your home care or hospice nurse will keep in close touch with your physician about what medicines may be needed. Antibiotics may be used if your doctor suspects you may have a lung infection. Cough expectorants may be used to help you cough up mucus from your lungs. Cough suppressants may be used to help you stop the cough to allow you to rest. Diuretics or water pills may be used to help get rid of excess fluids which may build up in your lungs or legs or abdomen. Bronchodilators such as inhalers or updrafts may be used to help open up your air passages. To use an inhaler: Stand or sit up straight. Take off the inhaler cap and shake the inhaler. Breathe out. Put the inhaler in your mouth or just in front. As you start to breathe in, push down on the top of the inhaler and keep breathing in slowly. Hold your breath for 10 seconds. Breathe out. Repeat process if directed An aero chamber device attached to the inhaler may assist you if you have trouble breathing in all the medication. If you find it becomes too difficult to use an inhaler, your physician may have you switch to taking your bronchodilator medicine through an updraft machine called a nebulizer. The machine changes the liquid medicine into a mist which you can breathe in through a hand-held pipe or mouthpiece. A mask that can be strapped to your face may also be used this is often a good solution when it becomes too tiring to hold the mouthpiece for the 10 minutes it takes to breathe in all the medicine. Your home care or hospice nurse will teach you how to set up the updraft machine. 12

13 Steroids may be used to reduce inflammation. Anti-cholinergic medicines may be used to dry up secretions. Anti-anxiety medicines are often used to decrease anxiety, relax skeletal muscles, decrease restlessness, decrease irritability, help you relax, help you sleep. Opiods (usually thought of as pain medicines) are safe and effective for managing your dyspnea when the non-medicine techniques you ve been using and your previously used medicines aren t keeping your breathing at a comfortable level anymore. Opiods (such as hydrocodone, oxycodone, or morphine): Relax your breathing. Stop the anxiety and panic. Decrease the sensation of breathlessness. Decrease your awareness of muscle exertion. Ease the flow of blood from the heart so that fluid is less likely to back up into the lungs. Make the breathing muscles slow down so that each breath can be more effective and you don t get so exhausted. Opiods can be used to help you get through an episode of breathlessness. Opiods can be used before activities that you know cause you to be breathless (like showering, visiting, or eating) and can keep you more independent. Doses are started low and then increased to the point where you report relief of your breathlessness. If you are using the opiod frequently through the day, your physician may order a long acting pill that you can take 2 or 3 times a day to give you better relief. There is also an opiod skin patch that can be applied once every three days. You will still use a quick acting form of opiod (usually a concentrated liquid) that can give you relief within minutes. If you have pain and dyspnea together, you will need a higher dose of opiod to fight both symptoms. 13

14 Using Oxygen for Relief of Dyspnea Oxygen can reduce the workload on the heart, may allow you to do more, and it may make you feel less breathless. The decision of when to use oxygen should be based on your level of comfort. It can be used all the time or just when you feel breathless. Early in the process of a breathing problem, your physician may wish you to start at a low dose of oxygen. You may need to increase that dose as time goes on. Your home care or hospice nurse will coordinate this with the physician. Most people who need oxygen use a combination of delivery systems one for at home and one for traveling out of the home. Your oxygen provider and your home care or hospice nurse will show you how to use the equipment that is chosen for you. The most common stationery system is a concentrator an electrical device that pulls oxygen out of the air. It has to be plugged in to work, but you will never run out of oxygen. Small tanks of compressed oxygen will be made available for you to use when you leave your home or if there is a power outage. The cabinet of the concentrator should be wiped down with a damp cloth and dried occasionally. The air filter should be removed, washed with soap and water, and replaced into the cabinet weekly. Large liquid oxygen tanks can also be used to deliver your oxygen. Smaller portable tanks can be refilled from the large tank. A humidifier can be added to the oxygen source to keep the oxygen moist so that your air passageways do not dry out. You will be given a bottle of distilled water to use to keep the water level within the well-marked lines on the humidifier bottle. The humidifier bottle should be washed with soap and water and rinsed thoroughly when being refilled. 14

15 Oxygen is usually delivered through a nasal cannula a long, slender plastic tube that runs from the oxygen source to small prongs that fit into the nostrils (following the curve of the nostrils downward). The tubing should then be positioned behind each ear, and adjusted below the chin for a comfortable fit. A mask that straps around the head can also be used instead of the prongs. The nasal prongs or mask can be replaced weekly or if you wish, they can be washed with soap and water, rinsed and reused for several weeks. Refill supplies will be provided. Extension tubing up to 50 feet long can be used to allow you freedom to walk around the house while still getting an adequate flow of oxygen. Guard closely against tripping. Your home care or hospice nurse can help prevent skin irritation. A water-based moisturizer such as KY Jelly (not an oil-based moisturizer such as petroleum jelly) can be applied to the nostrils to ease dryness or to protect from rubbing. Gauze, lamb s wool, foam rollers or cotton balls can be wrapped around the tubing if your ears get irritated or sore. Some safety measures to remember: Store the oxygen away from heat or direct sunlight. Secure the oxygen tanks so that there is no accidental tipping. No smoking or open flames within 10 feet of the oxygen source. Keep oxygen equipment 5 feet away from electrical equipment. Don t use aerosol sprays (such as hair spray or furniture polish) near the equipment. Don t use an extension cord with an oxygen concentrator. The concentrator can be tucked out of the way to decrease noise and warmth, but make sure there is good air flow around it (i.e., not in a tight closet). The oxygen provider should periodically be checking your equipment to make sure it is working properly. Refills should be provided in a timely manner. Talk to your home care or hospice nurse if there is a problem. 15

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17 Rate your breathing discomfort at rest and with activity I I I I I I I I I I I No Moderate Severe Maximum Difficulty Difficulty Difficulty Difficulty Describe what problems you are having with your breathing: What activities are difficult for you? What symptoms do you notice? Current oxygen dose: Note weekly cleaning of concentrator filter and/or change of oxygen tubing: 17

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20 For additional copies of Easing Your Breathing Mayo Clinic Health System- Home Health & Hospice P.O. Box 2060 Eau Claire, WI Or you may print directly from our website mayoclinichealthsystem.org Wisconsin/Eau Claire/Home Health & Hospice Under Resources on the Hospice Services page 1033H. 4/12 20