Why is the patient breathless?

Breathlessness is an unpleasant awareness of the effort ofbreathing

. This sense of effort usually reflects an increasedventilatory load (e.g. bronchoconstriction), a reducedbreathing capacity (e.g. respiratory muscle weakness dueto motor neuron disease) or both (e.g. severe COPD, inwhich respiratory muscle function is impaired because ofhyperinflation and load is increased). The history shoulddocument severity: How far can the patient walk on theflat? How many steps can the patient climb without stopping?

The causes of breathlessness are multiple and poorly understood.Hypoxia and hypercapnia can contribute, but changes in blood gasesper se are often not of great importance. Breathlessness is an unpleasant awareness of the difficulty of breathing and is most commonly the consequence of disproportionate respiratory effort. Whenever the loadon the respiratory system is increased(e.g. lung fibrosis, airways obstruction) and/or ventilatory capacity is reduced (e.g. respiratory muscle weakness), neural respiratorydrive is increased and becomes a larger proportion of maximum available respiratory drive. Thus,breathing is perceived as being agreat effort.Pleural thickening encasing thelung, as in the present case,dramatically reduces chest wall compliance, imposes a high load onthe respiratory system, and makes ventilation difficult despite great efforts.

The marked reduction in ventilation of the lung. Perfusion of the lung is also reduced, but less so than ventilation,and such ventilation/perfusionmismatch contributes to hypoxia,especially on exercise.

Treatment for chronic pleuralthickening is limited. In selectedcases it is possible for a thoracicsurgeon to dissect the thickenedpleura off the lung. This is a difficultoperation, often only partially successful, and not appropriate inmost cases. In the present case thepatient was advised that surgery wasnot appropriate and he resolved toseek educational training for adifferent profession. The case emphasizes how important it is thatacute pleural disease (particularly empyema) is correctly managed toavoid whenever possible thedevelopment of chronic extensive pleural thickening.

Why is the patient breathless?

By: Dr Izharul Hasan

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