Mixed dyspnea

If a patient has a combination of inspiratory (during inhalation) and inspiratory (during exhalation) breathing difficulties, specialists use such a term as mixed dyspnea. Such a condition - often complex and dangerous, can appear under the influence of several causes simultaneously, so it requires complex and diverse diagnostic measures. Treatment depends on the initial root cause of the disorder.

What is mixed dyspnea and how does it manifest itself?

Mixed dyspnea is a feeling of lack of air with difficulty in taking a full breath in and out. The range of pathologies and pathological conditions that often accompany this phenomenon is quite extensive. It includes many life-threatening conditions, such as pulmonary embolism or myocardial infarction, and relatively "mild" disorders, such as hyperventilation syndrome or anemia. Each case of mixed dyspnea in a patient must be treated individually to properly identify the cause and make a definitive diagnosis, which directly affects the prognosis of the disorder.

Mixed dyspnea may be accompanied by various cardiac and pulmonary diseases, bronchial asthma, chronic pulmonary obstruction, congestive heart failure, malignant (including metastatic) lesions of the respiratory system. The magnitude and clinical significance of this symptom are obvious.

Mixed dyspnea can be characterized as subjective discomfort during the respiratory act. Such discomfort is expressed to a lesser or greater degree, and the most intense respiratory disturbance is called choking.

Different terms are often used to better characterize labored inhalation and exhalation, which also has important diagnostic implications. In a healthy adult, respiratory rate usually ranges from 16-20 respiratory movements per minute. In the case of abnormalities, both the frequency, depth and periodicity of respiratory movements are altered.

Rapid breathing (up to 60 movements or more) is called tachypnea, and infrequent breathing (less than 12 movements per minute) is called bradypnea. There is also the concept of "apnea", which means stopping breathing. Directly shortness of breath, lack of air and the resulting need to increase (deepen) respiratory activity is dyspnea.

Shortness of breath, not having enough air when breathing in is called inspiratory difficulty and expiratory difficulty when breathing out. Mixed dyspnea combines both inhalation and exhalation difficulties.

A respiratory problem that occurs only when the patient is lying down is orthopnea. In addition, there is paroxysmal nocturnal dyspnea, most often caused by pulmonary venous stasis or bronchial obstruction.

Other topical terms:

• Platypnea - difficulty breathing in a sitting position (usually associated with thoracic neuromuscular pathology or intrapulmonary or intracardiac blood shunting);
• trepopnea - difficulty breathing in the position lying on the side (often accompanies congestive heart failure).

Mixed dyspnea can be suspected if wheezing is heard at a distance, intercostal and periclavicular spaces are retracted, cervical muscles are tense during inhalation and exhalation, and the wings of the nose are inflated. Other additional symptoms include shin edema, decreased ejection fraction, etc.

Breathlessness happens:

• sudden (lasts a few seconds/minutes, noted in pulmonary edema, thromboembolism, pneumothorax, anaphylactic shock, chest trauma, foreign body in the respiratory tract);
• acute (lasts several hours/day, observed in bronchial asthma, pneumonia, tumor processes, presence of pleural effusion, and metabolic acidosis);
• chronic (lasts several months/years and accompanies heart failure, bronchial asthma, pulmonary fibrosis, anemia, heart defects, neuromuscular pathologies, pulmonary hypertension, etc.).

Clinically, the lack of air is manifested by these signs:

• directly mixed-type dyspnea;
• Diffuse (central) form of cyanosis;
• activation of the respiratory muscles;
• increase in blood circulation (increased heart rate, increased minute volume);
• changes in respiratory capacity and volume.

Mixed dyspnea of unknown origin may indicate the presence of a serious pathology. If there are additional symptoms in the form of dizziness, chest pain, it is important to seek medical help as soon as possible. The presence of cough often indicates the development of such pulmonary pathologies as chronic obstructive pulmonary disease, bronchial asthma, pneumonia. Since difficulty in inhaling and exhaling is not a disease in itself, but only a symptom (main or additional), in general, the character of the clinical picture will depend on the initial disease.

What factors can trigger mixed dyspnea?

Mixed dyspnea can be provoked by the following factors:

• Factors of central character (pathologies of the nervous system with lesions of the respiratory center, neuroses).
• Cardiac factors (heart failure, myocardial infarction, myocarditis, cardiomyopathy, heart defect, etc.).
• Pulmonary factors (lung pathologies such as pneumonia, chronic obstructive pulmonary disease, bronchial asthma, pulmonary fibrosis, chest lesions).
• Hematogenic factors (anemia, changes in blood acidity, intoxication - in particular, in liver failure, decompensation of diabetes mellitus, etc.).

The occurrence of mixed dyspnea may be due to disorders of external (pulmonary oxygen entry) or internal (tissue) respiratory function. Possible causes include:

• influence on the respiratory center of toxic substances, metabolic products - for example, against the background of severe infections;
• traumatic lesions of the chest with violation of cavity tightness, pressure on the lungs hydro or pneumothorax;
• obstruction of the lumen of the respiratory tract by thick secretions (e.g., in patients with bronchial asthma or bronchitis), tumor process, foreign object (including vomit or food particles);
• Heart failure with blood stasis in the small circulation circle, effusion into the pulmonary alveoli, decreased vital capacity of the lungs and peripheral blood flow;
• Anemia associated with a drop in hemoglobin and red blood cell count, with massive blood loss, with chemical poisoning with compounds capable of binding hemoglobin;
• High degree of obesity, complete lack of physical activity;
• ischemic heart disease;
• swelling, bronchial coarsening, spasm of bronchial muscles due to inflammation or allergies;
• neurological disorders due to myasthenia gravis, neurasthenia gravis, multiple sclerosis, etc;
• chemical intoxication.

Acute respiratory failure

The clinical picture of acute respiratory failure is characterized by an increase in respiratory rate exceeding 24 movements per minute, with severe deficiency may be noted up to 30-35 movements per minute, with extremely severe - more than 35 movements per minute. If extremely severe respiratory failure is replaced by a significant reduction in respiratory movements, it often indicates a possible rapid respiratory arrest.

Hypercapnic respiratory insufficiency is often caused by functional disorders of the relevant musculature, which can be compared with an overdose of drugs that inhibit the respiratory reflex or diaphragmatic paralysis. As for hypoxemia, it develops in pathologies associated with alveolar damage (e.g., pulmonary edema, acute lung pathology), severe ventilation-perfusion disorders (chronic obstruction, bronchial asthma), reduction of the functional surface of the capillary-alveolar membrane (vasculitis, pulmonary emphysema, pulmonary embolism, thromboembolism, etc.).

Mixed-type dyspnea on exercise in patients with bronchopulmonary disease is the result of either markedly increased ventilation or moderate increased ventilation with limited threshold ventilation (e.g., inadequate chest wall mobility, etc.).

In addition to difficulty breathing, symptoms such as wheezing, coughing, chest pain, blueing of the extremities and nasolabial triangle, hemoptysis are often present.

Restriction is referred to as respiratory failure, provoked by a decrease in ventilation and perfusion of the lung surface. This condition is caused by parenchymal pathologies (lung inflammation, atelectasis, granulomatosis, pneumoconiosis, diffuse pneumosclerosis, etc.) and non-parenchymal pathologies (pneumothorax, effusion, kyphosis/scoliosis, etc.).

In obstruction, there is an increase in resistance to airflow: during inhalation and exhalation, this occurs in patients with bronchial and/or bronchiolar stenosis, e.g., bronchial asthma, chronic bronchitis, pulmonary edema, emphysema, bronchiolitis.

What symptoms accompany mixed dyspnea?

Mixed dyspnea itself is a symptom of various pathological conditions and is characterized by difficulty in both inhalation and exhalation at the same time. Other associated clinical manifestations are also possible, but they can be very diverse, due to the large number of probable causes of the disorder.

The most common accompanying signs are coughing and respiratory failure, either at rest or during vigorous physical activity.

The clinical picture may be represented by the following manifestations:

• severe weakness, sudden fatigue;
• sudden lack of air;
• varying degrees of dizziness;
• changes in heart rhythm, tachycardia, arrhythmias;
• blueing of fingers and toes, nasolabial triangle;
• wheezing;
• lower leg swelling;
• hemoptysis;
• pain sensations and a feeling of squeezing in the chest (in case of cardiac factor).

The patient often feels agitated, restlessness and irritability are noted. Problems with oxygen intake, respiratory failure negatively affect speech capabilities: the patient begins to avoid long phrases, tries to speak intermittently, short.

The extreme degree of mixed breathing difficulties is an attack of shortness of breath, in which there is an acute lack of air, increased heart rate, a sudden feeling of fear. This is a rather dangerous condition that may indicate the presence of a serious disease accompanied by impaired respiratory tract patency, malfunction of the cardiovascular and/or nervous system.

With the development of bronchial obstruction (reduction in the internal diameter of small bronchi, which may be due to edema or bronchospasm), the attack develops abruptly, sometimes - after precursors, such as a feeling of compression in the chest, unreasonable anxiety, numbness of the extremities. Dyspnea gradually progresses, a person feels a shortage of air, breathing becomes more rapid, exhalation becomes longer. Sometimes it is possible to slightly relieve the feeling by changing the position of the body - for example, rest your hands on the back of a chair or table, sit or lie on the side. The attack is often accompanied by strong wheezing, blueing of the skin, protrusion of venous vessels. The duration of the attack varies from a few minutes to 2-4 hours. After its completion, a cough occurs, a small amount of clear sputum is expelled.

Asphyxiation occurs due to pulmonary edema, which accompanies many cardiovascular diseases. Congestion in the thoracic circulatory system is formed due to impaired cardiac pump function: as a result, lung tissue swells, fluid penetrates into the respiratory passages, obstructing airflow and causing asphyxiation.

Pulmonary edema often occurs against the background of myocardial infarction.

In children, this condition is in most cases associated with inhalation of foreign objects: food particles, toy parts, buttons and so on. For adults and elderly people, dental implants, vomit (which often happens with strong alcohol intoxication) can be dangerous in this regard.

In early childhood, mixed dyspnea often reveals itself in an attack of false croup. As a result of the inflammatory process there is edema of the larynx, the bronchial lumen decreases. This condition is manifested by sharp heavy breathing, hoarseness, barking cough, crying and severe anxiety of the child.

Bronchospasm (spasmodic constriction of the bronchi) develops when the respiratory system is exposed to thermal or chemical damage. This condition can also occur in other pathologies:

• obstructive disease;
• bronchial asthma;
• ingress of air into the pleural cavity (pneumothorax);
• acute form of stenotic laryngotracheitis (false croup);
• inflammation of the epiglottis (epiglottitis);
• panic attack;
• burns to the upper respiratory tract;
• anaphylaxis;
• pulmonary embolism;
• An overdose of narcotic drugs or certain medications.

Mixed dyspnea, occurring against the background of physical activity, is more characteristic of asthma or pneumonia, and dyspnea and shortness of breath at rest (when the patient is lying, sitting, not being physically active) are more often observed in acute heart failure.

How is mixed dyspnea diagnosed?

When mixed dyspnea appears, it is important to quickly orient and find out the cause of this disorder. Diagnostic measures include a history of associated pathologies.

Among the most common methods of diagnosis are the following:

• chest X-ray;
• blood tests (general, biochemical);
• echocardiography;
• bronchoscopy.

Ultrasound examination allows you to assess the condition of the lungs (pleura, parenchyma), heart (contractility, valve performance, the presence of fluid in the pericardium), as well as the deep veins of the legs (especially indicative of the presence of blood clots).

In complex cases, if there are additional questions when making a diagnosis, a CT scan is prescribed.

Mixed dyspnea in pathologies of respiratory muscles more often appears with problems with the diaphragm. We should not forget about such an infrequent pathological condition as congenital weakness of the diaphragm. The diaphragmatic musculature is atrophied, the thoracic abdominal barrier is inflated. Diaphragm movements are irregular (paradoxical).

High diaphragm standing and concurrent limited respiratory reserve is common in obese patients and people on corticosteroid therapy.

Bilateral diaphragmatic palsy in acute form can cause the development of severe respiratory deficit and life-threateningly low ventilation. Paresis is possible in patients with poliomyelitis, cervical spine injuries with spinal cord injury, myopathy, myasthenia gravis. Paralysis of the diaphragm can occur as a result of damage to the diaphragmatic nerve, which happens with mediastinitis, tuberculosis, tumor processes. Symptomatically, diaphragmatic paresis is manifested by retraction of the upper abdominal zone on inhalation.

Mixed dyspnea at low oxygen concentration in the air is explained by the so-called altitude deficit, which is noted starting at an altitude of 3,000 meters above sea level. This condition is more characteristic of people who are not adapted to staying in such conditions.

Mixed dyspnea with too high oxygen intake manifests as dyspnea of exertion. For example, this can occur in untrained people during intense physical activity, when oxygen consumption for respiratory function exceeds oxygen consumption for muscular activity. A similar condition, but with little exercise, is characteristic of people with hyperthyroidism.

Mixed dyspnea in patients with anemia occurs primarily in moments of physical exertion, which is associated with a deterioration in the ability to transport oxygen by blood against the background of adequate regulation of the CNS and normal pulmonary function. The acute form of anemia is accompanied by insufficient oxygen supply to the tissues, hypovolemia. Chronic form of anemia is characterized by a deficit of oxygen transport and, as a consequence, compensatory hyperventilation.

Mixed dyspnea with increased blood acidity is manifested by deepening and rapidity of respiratory movements, which is explained by excitation of the respiratory center in acidosis and is accompanied by alveolar hyperventilation. Therefore, practitioners consider deep, often rapid breathing as a symptom of increasing acidosis. Among the most common causes of this condition: failure of renal function, diabetic coma. Relatively rare causes: overdose of salicylic acid preparations, methanol intoxication.

Analyzing the complaints and collecting anamnesis, it is important to listen to the patient, assess his sensations, the rate of increase in breathing difficulty and its dependence on body position, the possible influence of ambient temperature and degree of humidity. Sudden onset and intensification of mixed dyspnea may indicate the progression of the underlying disease, or the accession of additional pathologic process.

How to treat mixed dyspnea?

Mixed dyspnea is not an independent disease, but only a symptom of another, initial pathology, signaling a malfunction in the work of one or another organ. Therefore, treatment is prescribed individually, directed mainly at the underlying problem, which provokes the appearance of shortness of breath.

If the patient is diagnosed with bronchitis with difficult expectoration of sputum, the doctor may prescribe expectorants and thinners, and bronchodilators (bronchodilators) are indicated in case of bronchial obstruction.

In heart failure, treatment measures are complex, prescribed by doctors of cardiology.

In mixed dyspnea of hematogenous etiology, correction of blood picture, elimination of anemia is indicated.

Psychogenic (stress) form of mixed dyspnea, occurring with panic attacks or other neurotic disorders, requires the intervention of a psychotherapist.

If a large amount of fluid builds up in the pleural cavity, compressing the lung, it may be necessary to perform a puncture. The procedure is performed by a thoracic surgeon.

Acute conditions with severe life-threatening mixed dyspnea require urgent hospitalization of the patient in the hospital, often in the intensive care unit, where all necessary resuscitative measures are carried out, including artificial ventilation.

What should I do if it's hard to breathe?

To reduce the discomfort of mixed dyspnea and restore normal respiratory function, doctors advise:

• in moments of physical activity - calm down, stop, and if possible, sit down;
• When indoors, get fresh air, or if this is not possible, go outside;
• sit at a table and rest your hands on it (helps to expand the chest);
• breathe slowly through the nose and exhale even more slowly through the lips gathered in a "tube".

In addition, you can connect breathing exercises, if there are no contraindications. As an emergency, you can try to perform the following exercise: press your chin to your chest, inhale 10 times sharply, but shallowly, inhale with your mouth, then make three inhalations and exhalations through the lips gathered in a "tube". Then inhale with the nose, and after 5 seconds slowly exhale with the mouth. Perform about 4 complete repetitions.

If mixed dyspnea occurs during physical activity, such as walking or climbing stairs, the following measures can be taken:

• try to breathe in and out evenly;
• It is better to inhale through the nose, and exhale through the lips gathered in a "tube".

In general, it is possible to reduce the manifestations of mixed dyspnea only by identifying and treating the underlying pathology. In the vast majority of cases it is necessary to involve drug therapy. According to indications, drugs are used to stabilize the heart, normalize blood pressure, removal of excess fluid from tissues, etc. Therapeutic measures are always selected individually.

What possible complications can occur with mixed dyspnea?

Regular or prolonged mixed dyspnea sooner or later leads to a disorder of gas exchange in the lungs. In turn, this causes a number of problems:

• lowering blood pressure readings;
• decreased oxygen levels in the blood, increased carbon dioxide levels;
• tissue hypoxia, oxygen deficiency in the organs and brain;
• asphyxiation, even fatal.

Mixed dyspnea, if it occurs from time to time, should not be ignored. Appearing at first against the background of physical exertion, in most cases, respiratory distress gradually begins to bother and at rest, even during night rest.

Among the most common complications:

• heart and respiratory failure;
• pulmonary edema;
• pulmonary emphysema;
• apnea.

Mixed dyspnea is often a dangerous signal of the body, indicating the appearance of a serious problem. It is important to detect and neutralize it as soon as possible to restore normal breathing and circulation.

If the patient timely consults with a doctor, it is enough for him to undergo the necessary diagnostic therapeutic measures aimed at eliminating the detected cause of impaired respiratory function. It is impossible to completely get rid of dyspnea without the intervention of a specialist and systemic examination.

If respiratory problems arise against the background of chronic pathologies of the cardiovascular or respiratory system, then in some cases a positive effect has a competent correction of lifestyle, regular intake of supportive medications, exclusion of provoking factors.

What are some methods of preventing mixed dyspnea?

If the patient regularly visits doctors, timely undergoes diagnostics and treats existing diseases, but mixed dyspnea still appears from time to time (for example, in moments of motor activity), then he should pay attention to the following recommendations:

• Body weight. Being overweight is a burden even for relatively healthy people, especially when it comes to physical activity. It is important to keep body weight within normal limits, but at the same time, weight loss should be gradual, without drastic and drastic measures.
• Active lifestyle. The optimal dosed load for people with recurrent mixed dyspnea (if the attending physician permits) is swimming and walking. It should be understood that one-time exercise will not lead to any significant effect. Exercise should be regular, dosed, and periodically consulted with specialists.
• Avoidance of excessive load. Physical training should be feasible, dosed, without sudden overloads and jumps.
• Development of stress resistance. It is necessary to work on yourself, avoid factors that contribute to the formation of stress and strong emotional states. Overstrain in the form of quarrels, scandals, excessive worries can also lead to the appearance of mixed dyspnea.
• Strengthening immunity. Weakened body is often exposed to various infectious processes and other unfavorable factors. It is necessary to eat a full diet, avoid hypothermia and potential sources of infection, maintain physical activity, harden yourself.
• Elimination of bad habits. If you eliminate smoking and other harmful habits from your life, you can gradually restore immunity, improve the condition of the respiratory system, raise to a new level of endurance, eliminate systematic coughing and shortness of breath.

In case of occurrence (first or repeated) of mixed dyspnea during motor activity or at rest, it is necessary to visit a general practitioner or cardiologist, undergo a complete examination to exclude diseases (including serious ones), or undergo treatment in the early stages of their development, which significantly improves the prognosis.

What precautions can help improve health with mixed dyspnea?

To ensure that attacks of mixed dyspnea occur as rarely as possible, doctors recommend:

• regularly visit and follow up with relevant specialists, monitor health status, and have check-ups;
• to carry out the prescribed treatment in a timely manner, to comply with individual recommendations;
• sleep with the head of the bed elevated, using a high pillow (especially if breathing difficulties are noted when lying down or resting at night);
• adhere to a healthy lifestyle;
• daily practice breathing exercises, avoid hypodynamia and physical overload (physical activity in general should be coordinated with the attending physician);
• eat a good quality, well-balanced diet;
• avoid both active and passive smoking;
• reduce the likelihood of exposure to potential allergens;
• maintain adequate humidity and ventilation of the premises.

What is the prognosis for life with mixed dyspnea?

Patients who periodically suffer from mixed dyspnea are often limited in terms of social activity, which negatively affects self-confidence, contributes to the emergence of anxiety, isolation. Many patients have disturbed sleep, develop depressive states. A special danger lies in the possible development of chronic heart failure.

As a result of metabolic abnormalities and, in particular, improper gas exchange, the following complications may occur in mixed dyspnea:

• change in blood pressure;
• pulmonary edema;
• cardiac asthma.

Of particular concern should be such symptoms as blueing of the hands, feet and nasolabial triangle, a cloche sensation in the chest, attacks of choking and severe coughing, profuse cold sweat, the appearance of sputum with blood.

With prolonged insufficient oxygen levels in the blood, hypoxia develops, which often causes confusion and loss of consciousness, and if the process is chronic, the breathing problem leads to impaired memory and concentration.

Mixed dyspnea is sometimes a serious and life-threatening symptom, so if it occurs, you should always visit a doctor and be examined. Only early diagnostic measures can guarantee further favorable outcome, as the problem can only be cured by treating the underlying, underlying disease.

Can exercise help with mixed dyspnea, and which exercises are most effective?

Before starting physical exercises, it is necessary to consult with the attending physician beforehand, because the causes of mixed dyspnea can be many, and not all patients are shown this or that load. If during exercise the condition worsened, and the discomfort changed to painful sensations, you should stop exercising and seek medical help.

Among the possible contraindications to exercise and breathing exercises:

• acute thrombophlebitis;
• polyneuropathy;
• mental disorders;
• injuries to the head and neck, spine and thorax;
• disc disorders, cartilage diseases of the spinal column;
• sudden fluctuations in blood pressure;
• post-infarction;
• internal bleeding.

The main effective exercises for mixed dyspnea are to strengthen the diaphragm, chest and abdominal wall muscles, which should help to facilitate respiratory movements. The easiest way to train the diaphragm is to take very deep breaths, while the muscles of the chest and abdominal wall can be strengthened by exhaling intensively through the lips gathered in a "tube" (as when playing a piper).

Other recommended exercises:

• Any workout should begin with a warm-up. You should sit as comfortably as possible or lie on your back (you can lie on a bed), relax your limbs, and stretch your arms along your body. Move the shoulders in a circular motion to the front, up, back and down, as if kneading them. Rotation should be done by the maximum possible amplitude, simultaneously with the left and right shoulder. If you feel pressure in the chest, you can reduce the amplitude, increasing it gradually.
• To improve the process of diaphragmatic breathing, lie on your back or sit on a comfortable chair with a backrest. Place your hands on the abdomen, slowly and deeply inhale with your nose, noting the movements of the abdomen. The chest should not move, staying in a relaxed state. Then slowly exhale, folding the lips "tube", simultaneously pulling the abdomen towards the spinal column. Repeat the exercise 5-10 times.
• To widen the intercostal spaces and spread the ribs for a deeper breath, perform the following exercise. Sit on a chair with a backrest or lie on your back (on the floor or bed). Arms are stretched along the body, palms up, relaxed as much as possible. Gently bring the shoulder blades together and lower them down, sticking out the chest "wheel". Inhale through the nose, exhale through the lips gathered in a "tube". Perform 5-10 repetitions.
• The following exercise is suitable for relaxing the thoracic musculature and ensuring the free entrance and exit of air from the lungs, increasing the level of oxygen in the body. Sit on a chair with a backrest or lie on your back. Gently bring the shoulder blades together and lower them down. Having joined hands in a "lock", slowly raise them above the head, as high as possible, while performing a deep breath. Lowering the arms, exhale. Do 5-10 repetitions.
• To strengthen the diaphragm and optimize lung volume, also sit on a chair with a backrest or lie on your back, inhale deeply with your nose, then take 3-5 more short breaths (without exhaling). After that, slowly exhale through the lips gathered in a "tube". Repeat 3-5 times.
• To quickly increase the level of oxygen in the tissues of the body, this exercise is suitable. The starting position is sitting on a chair with a backrest, or lying on your back. Inhale through the nose for 4 seconds, hold the breath for 8 seconds, slowly exhale through the lips gathered in a "tube" for 8 seconds. Perform 3-5 repetitions.

Breathing exercises, if done correctly, can help reduce discomfort. However, it is important to remember other ways to restore health. Mixed dyspnea is an urgent reason to think about your health: do daily exercise and walk in the fresh air, harden yourself (at first a contrast shower in the morning will work well), eat right and get rid of bad habits forever.