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Dyspnea and orthopnea
5 Dyspnea and orthopnea Chapter Objectives 1. to discuss the causes of dyspnea and orthopnea; 2. to describe the etiology and symptoms of congestive heart failure and pulmonary edema; 3. to describe the complications associated with dyspnea; 4. to describe the complications associated with orthopnea; 5. to list the questions for patients for the inquiry; 6. to list diagnosing guides according to Chinese medicine and Western medicine for the physical examination; 7. to point out possible signs and symptoms and other guidance perspectives for diagnosis; 8. to list the types of treatments patients may undergo in Western medicine.
Causes Fluid retention in the legs and abdomen normally is redistributed to the chest while lying down flat; some of the fluid diffuses into the chest area. This redistribution of fluid is normal in all people; however, pathology is behind the accumulation of fluid in congestive heart failure, pulmonary edema, asthma, and sleep apnea.
Congestive heart failure and pulmonary edema In congestive heart failure, the heart is weak and cannot pump sufficient blood throughout the vessels, which affects the lungs as well. Two characteristic symptoms are palpitations and flash edema. The left ventricle pressure is elevated, causing the pressure to transmit backward through the pulmonary veins to the alveolar capillaries. Capillary pressure then becomes elevated, causing the leakage of excess fluids. Excess fluid can accumulate in the lower legs and in the lungs. Pulmonary edema is a life-threatening condition often seen in Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00005-8 Copyright © 2020 Elsevier Inc. All rights reserved.
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Chapter 5 Dyspnea and orthopnea
heart failure. Over time, with debilitation, the lungs collect fluid and the alveoli are damaged. Symptoms include difficulty in breathing while lying flat, with coughing and wheezing; waking up severely short of breath; weight gain due to fluid accumulation; fatigue; and swelling of the legs. The two common heart diseases associated with these symptoms are: • acute coronary syndrome; • acute stress cardiomyopathy. The three common pulmonary diseases associated with these symptoms are: • cardiac pulmonary edema; • noncardiac pulmonary edema; • asthma.
Dyspnea Dyspnea is a condition identified in heart failure. It is characterized by an uncomfortable sensation in the chest while breathing that occurs after lying down and is relieved with head elevation and two or three additional pillows.
Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea is a condition in patients with left and right ventricular heart failure and increased pulmonary fluid pressure. The patient is suddenly awakened while sleeping in a prone or supine position. It is characterized by: • a decrease in lung ventilation capacity, such as with pleural effusion in the interstitial spaces around the alveoli, causing stimulation of the J receptors of the vagus nerve and then activation of the HeringeBreuer reflex, causing rapid, shallow breathing; • an acidebase imbalance, hypoxia, anemia, and oxygen deficit; • complications such as asthma, chronic obstructive pulmonary disease (COPD), and congestive heart failure, which can cause airway resistance due to decreased bronchial flow or systemic edema.
Orthopnea Orthopnea is a symptom of congestive heart failure with failure of both ventricles and increased pressure from fluid through the pulmonary circulation. It is characterized by shortness of breath
Chapter 5 Dyspnea and orthopnea
during low-impact activities or at rest. If in a prone or supine lying position, the patient must sit up or stand up for relief. Two symptoms of orthopnea include: • platypnea, shortness of breath while standing; • trepopnea, shortness of breath while lying on the side. Three variations of orthopnea include: • cardiac orthopnea, left- and right-sided congestive heart failure; • gestational orthopnea, heart failure, cardiomyopathy, and edema due to red blood cell lysis during pregnancy; • pediatric orthopnea, sudden infant death syndrome or asthma due to sleeping position. Orthopnea causes include: • heart disease; • angina pectoris; • ascites; • upper respiratory tract infections; • fear and anxiety; • diaphragm paralysis; • obesity; • emphysema; • pneumonia; • COPD; • pulmonary edema; • pleural effusion.
Inquiry and examination of dyspnea and orthopnea in western medicine and traditional Chinese medicine Inquiry Questions should be nonleading. Breathing: 1. Have you experienced any difficulty in breathing? 2. What was happening at the onset of breathing difficulties the first time you noticed? 3. What activities do you do that make breathing difficult now? 4. Do you notice breathing difficulties when you stand, sit, lie down, or in slow/moderate/fast-moving activities? 5. Have you developed a cough with breathing difficulty? 6. What other symptoms do you notice with the breathing difficulty? Activities of daily living:
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Chapter 5 Dyspnea and orthopnea
1. Describe activities that you are limited in your ability to do right now? 2. Describe activities that are no longer possible to do right now? 3. Describe any activities that require assistance from others, to do for you or to assist in right now? 4. How many minutes of activity can you accomplish before your breathing becomes difficult? 5. Are eating and drinking habits affected because of breathing difficulties? Sleep quality: 1. How many hours per night is normal for you to spend sleeping? 2. How long has sleeping been difficult for you? 3. How many hours per night do you sleep now? 4. Are you ever abruptly awakened because of changes in breathing? 5. Are you able to sleep flat or do you need to sit up? 6. Do you need two or three pillows to elevate your head when sleeping flat or sitting up? 7. When you elevate with more pillows, do you feel better than without the pillows? 8. Are you using a breathing device while sleeping, such as CPAP, BiPAP, etc.? Physical appearance: 1. Have you noticed any rapid weight gain over a short period of time? 2. Have you noticed any areas of edema in the lower legs? 3. Have you noticed any distended neck veins?
Physical examination In Chinese medicine, dyspnea and orthopnea involve a difficulty in inhaling and both are classified as breathlessness. The pathology mainly involves difficulty in inhaling, most likely as a failure of the kidneys to grasp the qi. Tongue and pulse examination may be, but is usually not, a significant method to determine diagnosis. Pulse Lung qi Failure of kidney to grasp qi
Weak Deep and weak
Chapter 5 Dyspnea and orthopnea
• The differentiation is qi deficiency. • Tongue may be pale, often with tooth marks. Pulse: In Western medicine, the pulse is generally absent. In Chinese medicine, the pulse is generally empty and weak. Common: • Qi deficiency • Weak or absent pulse • Hyperactive kidney • Thread pulse • Dampness and phlegm • Rolling pulse Auscultation: • First palpate the apical impulse for left ventricular enlargement or hypertrophy. • Listen for an early sign of hypertension, the fourth heart sound (S4), which indicates left atrium overwork. • Listen for underlying sign of heart disease, the third heart sound (S3), which indicates left ventricular malfunction. Pathology: • Regurgitation may be heard at the aortic position in aortic dissection. • A pericardial friction rub may be heard in pericarditis. • A midsystolic click or late systolic murmur may be heard in mitral valve prolapse. Blood pressure: This is taken in sitting, standing, or supine position and readings indicate the stage of hypertension.
Diagnosis • Determine whether the patient can sleep while lying flat or needs to elevate the head and the nature of the shortness of breath. • Determine whether the patient can sleep with or without pillows. If pillows are needed, determine how many, usually up to two or three or more. The number of pillows used can be consistent with worsening heart failure and need for hospitalization. • Determine the cause or concomitant symptoms consistent with heart failure and respiratory symptoms, including sleep apnea, bronchitis, asthma, etc., through complete physical examination and diagnostic workup.
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Chapter 5 Dyspnea and orthopnea
• Gather results of any diagnostic workup results and make future plans for follow-up, including pulmonary function testing, sleep studies, and echocardiogram. Congestive heart failure signs: • Orthopnea • Dyspnea on exertion • Decreased exercise tolerance • Distended neck veins (RV sign) • Heartbeat uneven and pulse fast paced • Crackles on lung auscultation • Swelling over the liver area or abdomen Pulmonary edema signs: • Increased weight gain • Productive cough with expectoration of froth or bloody tinge • Chest discomfort with palpitations • Wheezing • Hemoptysis and dizziness • Exercise-induced dyspnea • Orthostatic dyspnea (dyspnea while lying down) Restrictive cardiomyopathy: • Distended neck veins • Abdominal distension around the liver • Lung crackles • Faint heart sounds • Lower leg edema • Paroxysmal nocturnal dyspnea with bed elevation and two or three pillows Pericardial effusion: • Right heart failure • Hypotension • Cardiac tamponade • Distended neck veins • Dyspnea on exertion • Breathing discomfort while lying down • Jugular venous pressure elevated to 8 cm • Respiration >25 • Pulse >120 • Blood pressure (BP) <100/<75 Pulmonary embolism signs with acute right ventricular dysfunction signs: • Tachycardia • Low arterial BP • Distended neck veins • Parasternal heave • Tricuspid regurgitation murmur
Chapter 5 Dyspnea and orthopnea
• Hemodynamic compromise • Accentuated pulmonic valve closure (P2) • Low arterial pressure (e.g., BP <80/<60) Superior vena cava syndrome: • Distended neck veins • Upper extremity edema • Dry cough • Chest pain • Dyspnea at rest Restrictive pericarditis (chronic): • Heart failure • Myocardial infarction history • Facial plethora (redness of face with Cushing’s syndrome) • Distended neck veins • Pleural effusion (right lobe) • Dyspnea • Ascites
Treatment • Oxygen therapy • Medications for heart failure: • Angiotensin-converting enzyme inhibitors: BP and left heart failure • Beta blockers: BP and left heart failure • Diuretics: edema and fluid retention • Medications for COPD, to relax the bronchus and alveoli and for lobular inflammation: • Inhaled steroids • Bronchodilators
Further reading Cox CA, Boudewijn IM, Vroegop SJ, et al. Associations of AMP and adenosine induced dyspnea sensation to large and small airways dysfunction in asthma. BMC Pulm Med. 2019;19(1):23. https://doi.org/10.1186/s12890-0190783-0. Published 2019 Jan 28. Damani A, Ghoshal A, Salins N, Muckaden MA, Deodhar J. High prevalence of dyspnea in lung cancer: an observational study. Indian J Palliat Care. 2019; 25(3):403e406. https://doi.org/10.4103/IJPC.IJPC_64_19. Finney LJ. Is it safe to prescribe benzodiazepines or opioids for dyspnoea in interstitial lung disease? Breathe (Sheff). 2019;15(2):137e139. https://doi.org/ 10.1183/20734735.0015-2019. Gaber HR, Mahmoud MI, Carnell J, et al. Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency
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Chapter 5 Dyspnea and orthopnea
department. Clin Exp Emerg Med. 2019;6(3):226e234. https://doi.org/ 10.15441/ceem.18.072. Hanania NA, O’Donnell DE. Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions. Int J Chron Obstruct Pulmon Dis. 2019;14:1127e1138. https://doi.org/10.2147/COPD.S188141. Published 2019 May 24. Mihaltan F, Adir Y, Antczak A, et al. Importance of the relationship between symptoms and self-reported physical activity level in stable COPD based on the results from the SPACE study. Respir Res. 2019;20(1):89. https://doi.org/ 10.1186/s12931-019-1053-7. Published 2019 May 14. Nielsen OW, Valeur N, Sajadieh A, Fabricius-Bjerre A, Carlsen CM, Kober L. Echocardiographic subtypes of heart failure in consecutive hospitalised patients with dyspnoea. Open Heart. 2019;6(1):e000928. https://doi.org/ 10.1136/openhrt-2018-000928. Published 2019 Jun 20. Nishimura K, Oga T, Nakayasu K, Ogasawara M, Hasegawa Y, Mitsuma S. How different are COPD-specific patient reported outcomes, health status, dyspnoea and respiratory symptoms? An observational study in a working population. BMJ Open. 2019;9(7):e025132. https://doi.org/10.1136/bmjopen2018-025132. Published 2019 Jul 24. Pesola GR, Terla V, Malik N, Ahsan H. Chronic dyspnoea: finding the cause to reduce mortality. J Thorac Dis. 2018;10(suppl 33):S4057eS4060. https:// doi.org/10.21037/jtd.2018.09.60. Senderovich H, Yendamuri A. Management of Breathlessness in Palliative Care: Inhalers and Dyspnea-A Literature Review. Rambam Maimonides Med J. 2019;10(1):e0006. https://doi.org/10.5041/RMMJ.10357. Published 2019 Jan 28. Sepehrvand N, Alemayehu W, Rowe BH, et al. High vs. low oxygen therapy in patients with acute heart failure: HiLo-HF pilot trial. ESC Heart Fail. 2019; 6(4):667e677. https://doi.org/10.1002/ehf2.12448. Shi J, Luo L, Chen J, Wang J, Zhao H, Wang W. Study on the differences between traditional chinese medicine syndromes in NYHA I-IV classification of chronic heart failure. Evid Based Complement Alternat Med. 2019;2019: 2543413. https://doi.org/10.1155/2019/2543413. Published 2019 Feb 3. Smithline HA, Donnino M, Blank FSJ, et al. Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial. BMC Complement Altern Med. 2019;19(1):96. https://doi.org/10.1186/s12906019-2506-8. Published 2019 May 6. ski R, et al. Patterns of dyspnoea onset in Sokolska JM, Sokolski M, Zymlin patients with acute heart failure: clinical and prognostic implications. ESC Heart Fail. 2019;6(1):16e26. https://doi.org/10.1002/ehf2.12371. Stefan MS, Priya A, Martin B, et al. How well do patients and providers agree on the severity of dyspnea? J Hosp Med. 2016;11(10):701e707. https://doi.org/ 10.1002/jhm.2600. Stevens JP, Dechen T, Schwartzstein R, et al. Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission. J Pain Symptom Manage. 2018;56(1):15e22. e2. https://doi.org/10.1016/j.jpainsymman.2018.02.013. Wang X, Zhao Z, Mao J, et al. Randomized, double-blinded, multicenter, placebo-controlled trial of shenfu injection for treatment of patients with chronic heart failure during the acute phase of symptom aggravation (Yang and Qi Deficiency Syndrome). Evid Based Complement Alternat Med. 2019; 2019:9297163. https://doi.org/10.1155/2019/9297163. Published 2019 Feb 25.
Chapter 5 Dyspnea and orthopnea
Wolters F, Peerdeman KJ, Evers AWM. Placebo and nocebo effects across symptoms: from pain to fatigue, dyspnea, nausea, and itch. Front Psychiatry. 2019;10:470. https://doi.org/10.3389/fpsyt.2019.00470. Published 2019 Jul 2. Yu M, Gao L, Kong Y, et al. Safety and efficacy of acupuncture for the treatment of chronic obstructive pulmonary disease: a systematic review protocol. Medicine (Baltimore). 2019;98(37):e17112. https://doi.org/10.1097/ MD.0000000000017112. Zhang W, Li J, Lu S, et al. Gut microbiota community characteristics and disease-related microorganism pattern in a population of healthy Chinese people. Sci Rep. 2019;9(1):1594. https://doi.org/10.1038/s41598-018-36318-y. Published 2019 Feb 7. Zhang XW, Liu W, Jiang HL, Mao B. Dissection of pharmacological mechanism of chinese herbal medicine yihuo huatan formula on chronic obstructive pulmonary disease: a systems pharmacology-based study. Sci Rep. 2019;9(1): 13431. https://doi.org/10.1038/s41598-019-50064-9. Published 2019 Sep 17.
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Causes Fluid retention in the legs and abdomen normally is redistributed to the chest while lying down flat; some of the fluid diffuses into the chest area. This redistribution of fluid is normal in all people; however, pathology is behind the accumulation of fluid in congestive heart failure, pulmonary edema, asthma, and sleep apnea.
Congestive heart failure and pulmonary edema In congestive heart failure, the heart is weak and cannot pump sufficient blood throughout the vessels, which affects the lungs as well. Two characteristic symptoms are palpitations and flash edema. The left ventricle pressure is elevated, causing the pressure to transmit backward through the pulmonary veins to the alveolar capillaries. Capillary pressure then becomes elevated, causing the leakage of excess fluids. Excess fluid can accumulate in the lower legs and in the lungs. Pulmonary edema is a life-threatening condition often seen in Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00005-8 Copyright © 2020 Elsevier Inc. All rights reserved.
43
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Chapter 5 Dyspnea and orthopnea
heart failure. Over time, with debilitation, the lungs collect fluid and the alveoli are damaged. Symptoms include difficulty in breathing while lying flat, with coughing and wheezing; waking up severely short of breath; weight gain due to fluid accumulation; fatigue; and swelling of the legs. The two common heart diseases associated with these symptoms are: • acute coronary syndrome; • acute stress cardiomyopathy. The three common pulmonary diseases associated with these symptoms are: • cardiac pulmonary edema; • noncardiac pulmonary edema; • asthma.
Dyspnea Dyspnea is a condition identified in heart failure. It is characterized by an uncomfortable sensation in the chest while breathing that occurs after lying down and is relieved with head elevation and two or three additional pillows.
Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea is a condition in patients with left and right ventricular heart failure and increased pulmonary fluid pressure. The patient is suddenly awakened while sleeping in a prone or supine position. It is characterized by: • a decrease in lung ventilation capacity, such as with pleural effusion in the interstitial spaces around the alveoli, causing stimulation of the J receptors of the vagus nerve and then activation of the HeringeBreuer reflex, causing rapid, shallow breathing; • an acidebase imbalance, hypoxia, anemia, and oxygen deficit; • complications such as asthma, chronic obstructive pulmonary disease (COPD), and congestive heart failure, which can cause airway resistance due to decreased bronchial flow or systemic edema.
Orthopnea Orthopnea is a symptom of congestive heart failure with failure of both ventricles and increased pressure from fluid through the pulmonary circulation. It is characterized by shortness of breath
Chapter 5 Dyspnea and orthopnea
during low-impact activities or at rest. If in a prone or supine lying position, the patient must sit up or stand up for relief. Two symptoms of orthopnea include: • platypnea, shortness of breath while standing; • trepopnea, shortness of breath while lying on the side. Three variations of orthopnea include: • cardiac orthopnea, left- and right-sided congestive heart failure; • gestational orthopnea, heart failure, cardiomyopathy, and edema due to red blood cell lysis during pregnancy; • pediatric orthopnea, sudden infant death syndrome or asthma due to sleeping position. Orthopnea causes include: • heart disease; • angina pectoris; • ascites; • upper respiratory tract infections; • fear and anxiety; • diaphragm paralysis; • obesity; • emphysema; • pneumonia; • COPD; • pulmonary edema; • pleural effusion.
Inquiry and examination of dyspnea and orthopnea in western medicine and traditional Chinese medicine Inquiry Questions should be nonleading. Breathing: 1. Have you experienced any difficulty in breathing? 2. What was happening at the onset of breathing difficulties the first time you noticed? 3. What activities do you do that make breathing difficult now? 4. Do you notice breathing difficulties when you stand, sit, lie down, or in slow/moderate/fast-moving activities? 5. Have you developed a cough with breathing difficulty? 6. What other symptoms do you notice with the breathing difficulty? Activities of daily living:
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Chapter 5 Dyspnea and orthopnea
1. Describe activities that you are limited in your ability to do right now? 2. Describe activities that are no longer possible to do right now? 3. Describe any activities that require assistance from others, to do for you or to assist in right now? 4. How many minutes of activity can you accomplish before your breathing becomes difficult? 5. Are eating and drinking habits affected because of breathing difficulties? Sleep quality: 1. How many hours per night is normal for you to spend sleeping? 2. How long has sleeping been difficult for you? 3. How many hours per night do you sleep now? 4. Are you ever abruptly awakened because of changes in breathing? 5. Are you able to sleep flat or do you need to sit up? 6. Do you need two or three pillows to elevate your head when sleeping flat or sitting up? 7. When you elevate with more pillows, do you feel better than without the pillows? 8. Are you using a breathing device while sleeping, such as CPAP, BiPAP, etc.? Physical appearance: 1. Have you noticed any rapid weight gain over a short period of time? 2. Have you noticed any areas of edema in the lower legs? 3. Have you noticed any distended neck veins?
Physical examination In Chinese medicine, dyspnea and orthopnea involve a difficulty in inhaling and both are classified as breathlessness. The pathology mainly involves difficulty in inhaling, most likely as a failure of the kidneys to grasp the qi. Tongue and pulse examination may be, but is usually not, a significant method to determine diagnosis. Pulse Lung qi Failure of kidney to grasp qi
Weak Deep and weak
Chapter 5 Dyspnea and orthopnea
• The differentiation is qi deficiency. • Tongue may be pale, often with tooth marks. Pulse: In Western medicine, the pulse is generally absent. In Chinese medicine, the pulse is generally empty and weak. Common: • Qi deficiency • Weak or absent pulse • Hyperactive kidney • Thread pulse • Dampness and phlegm • Rolling pulse Auscultation: • First palpate the apical impulse for left ventricular enlargement or hypertrophy. • Listen for an early sign of hypertension, the fourth heart sound (S4), which indicates left atrium overwork. • Listen for underlying sign of heart disease, the third heart sound (S3), which indicates left ventricular malfunction. Pathology: • Regurgitation may be heard at the aortic position in aortic dissection. • A pericardial friction rub may be heard in pericarditis. • A midsystolic click or late systolic murmur may be heard in mitral valve prolapse. Blood pressure: This is taken in sitting, standing, or supine position and readings indicate the stage of hypertension.
Diagnosis • Determine whether the patient can sleep while lying flat or needs to elevate the head and the nature of the shortness of breath. • Determine whether the patient can sleep with or without pillows. If pillows are needed, determine how many, usually up to two or three or more. The number of pillows used can be consistent with worsening heart failure and need for hospitalization. • Determine the cause or concomitant symptoms consistent with heart failure and respiratory symptoms, including sleep apnea, bronchitis, asthma, etc., through complete physical examination and diagnostic workup.
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Chapter 5 Dyspnea and orthopnea
• Gather results of any diagnostic workup results and make future plans for follow-up, including pulmonary function testing, sleep studies, and echocardiogram. Congestive heart failure signs: • Orthopnea • Dyspnea on exertion • Decreased exercise tolerance • Distended neck veins (RV sign) • Heartbeat uneven and pulse fast paced • Crackles on lung auscultation • Swelling over the liver area or abdomen Pulmonary edema signs: • Increased weight gain • Productive cough with expectoration of froth or bloody tinge • Chest discomfort with palpitations • Wheezing • Hemoptysis and dizziness • Exercise-induced dyspnea • Orthostatic dyspnea (dyspnea while lying down) Restrictive cardiomyopathy: • Distended neck veins • Abdominal distension around the liver • Lung crackles • Faint heart sounds • Lower leg edema • Paroxysmal nocturnal dyspnea with bed elevation and two or three pillows Pericardial effusion: • Right heart failure • Hypotension • Cardiac tamponade • Distended neck veins • Dyspnea on exertion • Breathing discomfort while lying down • Jugular venous pressure elevated to 8 cm • Respiration >25 • Pulse >120 • Blood pressure (BP) <100/<75 Pulmonary embolism signs with acute right ventricular dysfunction signs: • Tachycardia • Low arterial BP • Distended neck veins • Parasternal heave • Tricuspid regurgitation murmur
Chapter 5 Dyspnea and orthopnea
• Hemodynamic compromise • Accentuated pulmonic valve closure (P2) • Low arterial pressure (e.g., BP <80/<60) Superior vena cava syndrome: • Distended neck veins • Upper extremity edema • Dry cough • Chest pain • Dyspnea at rest Restrictive pericarditis (chronic): • Heart failure • Myocardial infarction history • Facial plethora (redness of face with Cushing’s syndrome) • Distended neck veins • Pleural effusion (right lobe) • Dyspnea • Ascites
Treatment • Oxygen therapy • Medications for heart failure: • Angiotensin-converting enzyme inhibitors: BP and left heart failure • Beta blockers: BP and left heart failure • Diuretics: edema and fluid retention • Medications for COPD, to relax the bronchus and alveoli and for lobular inflammation: • Inhaled steroids • Bronchodilators
Further reading Cox CA, Boudewijn IM, Vroegop SJ, et al. Associations of AMP and adenosine induced dyspnea sensation to large and small airways dysfunction in asthma. BMC Pulm Med. 2019;19(1):23. https://doi.org/10.1186/s12890-0190783-0. Published 2019 Jan 28. Damani A, Ghoshal A, Salins N, Muckaden MA, Deodhar J. High prevalence of dyspnea in lung cancer: an observational study. Indian J Palliat Care. 2019; 25(3):403e406. https://doi.org/10.4103/IJPC.IJPC_64_19. Finney LJ. Is it safe to prescribe benzodiazepines or opioids for dyspnoea in interstitial lung disease? Breathe (Sheff). 2019;15(2):137e139. https://doi.org/ 10.1183/20734735.0015-2019. Gaber HR, Mahmoud MI, Carnell J, et al. Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency
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Chapter 5 Dyspnea and orthopnea
department. Clin Exp Emerg Med. 2019;6(3):226e234. https://doi.org/ 10.15441/ceem.18.072. Hanania NA, O’Donnell DE. Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions. Int J Chron Obstruct Pulmon Dis. 2019;14:1127e1138. https://doi.org/10.2147/COPD.S188141. Published 2019 May 24. Mihaltan F, Adir Y, Antczak A, et al. Importance of the relationship between symptoms and self-reported physical activity level in stable COPD based on the results from the SPACE study. Respir Res. 2019;20(1):89. https://doi.org/ 10.1186/s12931-019-1053-7. Published 2019 May 14. Nielsen OW, Valeur N, Sajadieh A, Fabricius-Bjerre A, Carlsen CM, Kober L. Echocardiographic subtypes of heart failure in consecutive hospitalised patients with dyspnoea. Open Heart. 2019;6(1):e000928. https://doi.org/ 10.1136/openhrt-2018-000928. Published 2019 Jun 20. Nishimura K, Oga T, Nakayasu K, Ogasawara M, Hasegawa Y, Mitsuma S. How different are COPD-specific patient reported outcomes, health status, dyspnoea and respiratory symptoms? An observational study in a working population. BMJ Open. 2019;9(7):e025132. https://doi.org/10.1136/bmjopen2018-025132. Published 2019 Jul 24. Pesola GR, Terla V, Malik N, Ahsan H. Chronic dyspnoea: finding the cause to reduce mortality. J Thorac Dis. 2018;10(suppl 33):S4057eS4060. https:// doi.org/10.21037/jtd.2018.09.60. Senderovich H, Yendamuri A. Management of Breathlessness in Palliative Care: Inhalers and Dyspnea-A Literature Review. Rambam Maimonides Med J. 2019;10(1):e0006. https://doi.org/10.5041/RMMJ.10357. Published 2019 Jan 28. Sepehrvand N, Alemayehu W, Rowe BH, et al. High vs. low oxygen therapy in patients with acute heart failure: HiLo-HF pilot trial. ESC Heart Fail. 2019; 6(4):667e677. https://doi.org/10.1002/ehf2.12448. Shi J, Luo L, Chen J, Wang J, Zhao H, Wang W. Study on the differences between traditional chinese medicine syndromes in NYHA I-IV classification of chronic heart failure. Evid Based Complement Alternat Med. 2019;2019: 2543413. https://doi.org/10.1155/2019/2543413. Published 2019 Feb 3. Smithline HA, Donnino M, Blank FSJ, et al. Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial. BMC Complement Altern Med. 2019;19(1):96. https://doi.org/10.1186/s12906019-2506-8. Published 2019 May 6. ski R, et al. Patterns of dyspnoea onset in Sokolska JM, Sokolski M, Zymlin patients with acute heart failure: clinical and prognostic implications. ESC Heart Fail. 2019;6(1):16e26. https://doi.org/10.1002/ehf2.12371. Stefan MS, Priya A, Martin B, et al. How well do patients and providers agree on the severity of dyspnea? J Hosp Med. 2016;11(10):701e707. https://doi.org/ 10.1002/jhm.2600. Stevens JP, Dechen T, Schwartzstein R, et al. Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission. J Pain Symptom Manage. 2018;56(1):15e22. e2. https://doi.org/10.1016/j.jpainsymman.2018.02.013. Wang X, Zhao Z, Mao J, et al. Randomized, double-blinded, multicenter, placebo-controlled trial of shenfu injection for treatment of patients with chronic heart failure during the acute phase of symptom aggravation (Yang and Qi Deficiency Syndrome). Evid Based Complement Alternat Med. 2019; 2019:9297163. https://doi.org/10.1155/2019/9297163. Published 2019 Feb 25.
Chapter 5 Dyspnea and orthopnea
Wolters F, Peerdeman KJ, Evers AWM. Placebo and nocebo effects across symptoms: from pain to fatigue, dyspnea, nausea, and itch. Front Psychiatry. 2019;10:470. https://doi.org/10.3389/fpsyt.2019.00470. Published 2019 Jul 2. Yu M, Gao L, Kong Y, et al. Safety and efficacy of acupuncture for the treatment of chronic obstructive pulmonary disease: a systematic review protocol. Medicine (Baltimore). 2019;98(37):e17112. https://doi.org/10.1097/ MD.0000000000017112. Zhang W, Li J, Lu S, et al. Gut microbiota community characteristics and disease-related microorganism pattern in a population of healthy Chinese people. Sci Rep. 2019;9(1):1594. https://doi.org/10.1038/s41598-018-36318-y. Published 2019 Feb 7. Zhang XW, Liu W, Jiang HL, Mao B. Dissection of pharmacological mechanism of chinese herbal medicine yihuo huatan formula on chronic obstructive pulmonary disease: a systems pharmacology-based study. Sci Rep. 2019;9(1): 13431. https://doi.org/10.1038/s41598-019-50064-9. Published 2019 Sep 17.
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