Breathlessness – when to seek help

Dr Caroline Jolley

Senior Lecturer in Human Physiology, Faculty of Life Sciences & Medicine, King’s College London, and Honorary Consultant in Respiratory Medicine, King’s College Hospital

Professor Surinder Birring

Professor of Respiratory Medicine, King’s College Hospital

Public Health England advice to “Stay Alert” during the current coronavirus pandemic has heightened the nation’s vigilance for symptoms of respiratory disease. Together with fever and cough, breathlessness is one of the most feared symptoms today as the number of deaths from SARS-CoV-2 infection continues to increase worldwide.

Breathlessness, known medically as ‘dyspnoea’, is a common and distressing symptom, often described by patients as ‘difficulty breathing’, ‘chest tightness’, ‘shortness of breath’ or ‘a feeling of suffocation’. Indeed, there are few sensations more terrifying than not being able to breathe.

Breathlessness is one of the most common reasons that patients visit hospital accident and emergency departments but it can also develop gradually and persist, affecting about 10% of the general population.

For most people, getting out of breath from time to time is completely normal

Breathlessness, like pain, is a warning that the body’s state of internal balance, or “homeostasis”, is under threat.

Imagine running for a bus. The extra muscle activity demands more oxygen and releases waste products (carbon dioxide and lactic acid) that need to be eliminated. The diaphragm and other respiratory muscles need to work harder to pump more air in and out of the lungs. Once the brain becomes aware that we are needing to breathe more than usual, we feel short of breath, but that breathlessness should subside within a few of minutes of stopping.

So if breathlessness can be ‘normal’, when should I worry?

Difficulty with breathing that persists and increases over weeks to months, often termed ‘chronic breathlessness’, can be attributable to a number of important long-term health conditions. These include lung diseases such as asthma, chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis (lung scarring), but also non-respiratory conditions such as heart failure, obesity, anaemia, and cancer.

The key message remains the same: If you get out of breath doing things you used to be able to do, tell your doctor.

Breathlessness is also a common symptom of anxiety, and many people experience a vicious cycle of breathlessness and panic that can be difficult to break. Lifestyle is important. Cough and breathlessness are more common in smokers even in the absence of smoking-related heart and lung disease.

Exercise improves physical fitness and cardiovascular function, and exercise, along with weight loss, may decrease any contribution to shortness of breath by muscle deconditioning.

New or rapidly increasing breathlessness associated with high temperature, a new, continuous cough, or a loss or change to your sense of smell or taste, is highly suggestive of COVID-19 pneumonia in the context of the current SARS-CoV-2 pandemic. This should prompt urgent medical advice in accordance with current NHS guidance. Please do remember, however, that there are other common respiratory infections, such as bacterial pneumonia, which are potentially serious if left untreated, but readily treatable if diagnosed promptly.

When to seek medical attention

Seek medical attention if breathlessness is new, more difficult to control, or is occurring every day at rest or with minimal physical exertion. This is especially important if there are other red flag symptoms such as coughing up blood or chest pain.

Despite the impact that breathlessness has on their daily lives, people often compensate for their breathlessness and normalise it by reducing their physical activity. This can delay reporting their breathlessness to their GP, and thus delay examination, investigation, diagnosis and treatment.

There is good evidence that earlier diagnosis of chronic lung disorders such as COPD can reduce breathlessness and improve quality of life and prognosis. Lung cancer can be cured completely if diagnosed at an early stage. The initial investigation by the doctor may involve an X-ray of the chest, breathing tests and blood tests.

Don’t delay getting help if you are concerned about new or persistent breathlessness.

However, if breathlessness is the only symptom, without a cough or fever, something other than SARS-CoV-2 is likely to be the problem, and it is important to seek medical advice. The key message remains the same: “If you get out of breath doing things you used to be able to do, tell your doctor.”