“Clinically important breathlessness …. was associated with depression, anxiety, and coexisting anxiety/depression. Poorer function that is associated with psychological morbidity in the general population requires further research.”

Breathlessness, Anxiety, Depression, and Function–The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults David C. Currow, BMed, MPH, PhD, FRACP, FAHMS Sungwon Chang, PhD Helen K. Reddel, MBBS, PhD, FRACP Irina Kinchin, MSc, PhD Miriam Johnson, MBChB(Hons), MD, MRCP, FRCP Magnus Ekström, MD, PhD JPSM  VOLUME 59, ISSUE 2, P197-205.E2, FEBRUARY 01, 2020

Why not ask a patient who is depressed if they are breathless? If they having difficulty breathing? Are they having difficulty speaking in full sentences? Has their voice changed recently?

It would have been so much easier for Paula if her doctor had asked her these questions. Paula was not able to remember to tell the doctor these things but she could answer yes or no to these questions; that was much easier for her to do.

Difficulty breathing [even with healthy lungs] is a likely cause of difficulty thinking or remembering.

The first symptom that Paula was aware of when her attack of [so called] depression started was dyspnea or difficulty breathing at rest. It was such an intense and unusual sensation that she did not recognize it , but had she been asked if she experienced distress from difficulty breathing she would have answered yes. This intense and unpleasant and distressing sensation lasted for over a year.

Am.Fam.Physician Jul 15, 2012 Issue

Causes and Evaluation of Chronic Dyspnea

“Chronic dyspnea is shortness of breath that lasts more than one month. The perception of dyspnea varies based on behavioral and physiologic responses. Dyspnea that is greater than expected with the degree of exertion is a symptom of disease. Most cases of dyspnea result from asthma, heart failure and myocardial ischemia, chronic obstructive pulmonary disease, interstitial lung disease, pneumonia, or psychogenic disorders. The etiology of dyspnea is multi-factorial in about one-third of patients. The clinical presentation alone is adequate to make a diagnosis in 66 percent of patients with dyspnea. Patients’ descriptions of the sensation of dyspnea may be helpful, but associated symptoms and risk factors, such as smoking, chemical exposures, and medication use, should also be considered. Examination findings (e.g., jugular venous distention, decreased breath sounds or wheezing, pleural rub, clubbing) may be helpful in making the diagnosis. Initial testing in patients with chronic dyspnea includes chest radiography, electrocardiography, spirometry, complete blood count, and basic metabolic panel. Measurement of brain natriuretic peptide levels may help exclude heart failure, and d-dimer testing may help rule out pulmonary emboli. Pulmonary function studies can be used to identify emphysema and interstitial lung diseases. Computed tomography of the chest is the most appropriate imaging study for diagnosing suspected pulmonary causes of chronic dyspnea. To diagnose pulmonary arterial hypertension or certain interstitial lung diseases, right heart catheterization or bronchoscopy may be needed. “

Chronic dyspnea has been defined as shortness of breath lasting longer than one month.1 A consensus statement from the American Thoracic Society defines dyspnea as a “subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”2 When shortness of breath is greater than expected for a given level of exertion, it is considered pathologic and a symptom of disease.3

 

SORT: KEY RECOMMENDATIONS FOR PRACTICE

CLINICAL RECOMMENDATION	EVIDENCE RATING	REFERENCES
Electrocardiography and measurement of brain natriuretic peptide levels should be ordered if heart failure is suspected.	C	1
In patients with dyspnea, spirometry should be performed to diagnose airflow obstruction.	C	24
Measurement of maximal inspiratory and expiratory pressures should be done when neuromuscular causes of dyspnea are suspected.	C	7
In chronic dyspnea likely due to diffuse pulmonary disease, when the diagnosis is unclear, high-resolution noncontrast computed tomography of the chest should be performed. [updated]	C	8
Ventilation/perfusion lung scanning should be done in patients with unexplained pulmonary hypertension to exclude chronic thromboembolic pulmonary hypertension.	C	31

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A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml.

Patients with chronic dyspnea present with stable, but not necessarily normal, vital signs. In addition to a history and physical examination, several diagnostic tests have been shown to be valuable in clarifying the underlying problem and planning appropriate treatment.

Paula had depressed breathing and made use of her abdominal muscles to exhale; at rest, and with every breathe. This was not at all normal and a sign that she was struggling to maintain normal homeostasis and arterial blood gases.

But no one asked her if she had difficulty breathing. No one asked if she was experiencing intense discomfort and distress as a result of difficulty breathing. No one looked to see if her breathing was abnormal [use of abdominal muscles at rest is abnormal] and no one measured her vitals, including respiratory rate.

So no one followed up with any tests.

They sent her for talking therapy; and she could barely talk or think or remember.

What a waste.