Shortness of breath in asthma

Breathlessness, shortness of breath, dyspnea, air hunger, whatever you want to call it, when you can’t breath, it can “feel” like you’re suffocating, but are you?

If you suffer from chronic asthma or COPD, then you’ve probably noticed that the severity of your shortness of breath can vary in immensely, from mildly annoying to sudden and severe. While all forms of breathlessness in asthma are very uncomfortable, not all are life threatening. That’s because not all the breathlessness you experience has the same cause.

As a person whos been short of breath his entire life, Ive come to realize that there is more than one cause of breathlessness in asthma. These various sources of breathlessness can occur separately or at the same time, making it difficult to distinguish the main cause and therefore the most appropriate treatment for it. In this post Ill share what I’ve learned over the years through self observation and experimentation on how to recognize which type is affecting me at any given time as well as how best to treat it.

There have been a many times when I thought I was suffocating to death from severe bronchospasm, only to realize later that my airways weren’t tightening up that much, and that the breathlessness that I was experiencing at the time was actually caused by something different.

Before we move on , it might be a good idea to define what breathlessness actually is. Just like pain, breathlessness is a symptom, which is totally subjective and which is perceived differently by different people. Likewise, everyone’s tolerance to breathlessness and respiratory discomfort can vary sharply from person to another. What I might perceive as mild shortness, you might perceive as a feeling of total suffocation. Whether it be prolonged physical exertion, breathlessness caused by heart problems or lung problems, or even shortness of breath from being overweight, breathlessness is a warning sign that something isn’t right and it shouldn’t be ignored.

From my personal experiences, I’ve been able to identify 4 distinct causes of shortness of breath that can affect people with chronic asthma and lung disease.
#1 Bronchospasm and/or airway inflammation
#2 Lung hyperinflation (air-trapping)
#3 Abdominal bloating
#4 Anxiety.
It’s important to note that while all of these conditions can cause shortness of breath and/or the sensation of shortness of breath (dyspnea), by far the most concerning of these, is bronchospasm and airway inflation. Especially if it doesn’t respond to bronchodilators and steroids.

First on the list, and the most common cause of breathlessness in asthma, is Bronchospasm and/or airway inflammation. I lump these two conditions together because they both result in narrowing of the airways. Basically what happens during an acute asthma flare, is that something triggers your airways to tighten and become narrow, either through bronchospasm, or through inflammation (swelling) on the inside of the airways, or the airways become blocked with mucus, or a combination of things. Any or all of these asthma flare components can obstruct air flow through the affected airways, resulting in shortness of breath. For example, you’re exposed to something that your airways are sensitive to like perfume or some other odor. The smooth muscle layer that surrounds your airways begins to constrict or spasm ( aka bronchospasm), which then literally squeezes the airways making them narrower. As you breath in and out, the air has to pass through those narrowed air passages. The more narrow the airway, the more difficult it is to breath through them, which also cause the familiar wheeze. You then take a hit off your inhaler, which relaxes the muscles that are the causing the bronchospasm around the airways. As the airway relaxes and dilates back to its original size, the wheezing subsides it becomes much easier to breath again. While this chain of events is the main cause of shortness of breath in asthma, there are other causes that can make you short of breath as well.

Number 2 on the list is Lung Hyperinflation, also referred to as “air-trapping“, which I’ve written about extensively. Though air trapping is the primary cause of breathlessness in people with COPD, which includes Emphysema and chronic bronchitis, it also occurs in people with severe and chronic asthma and other lung conditions such as cystic fibrosis. Essentially, air trapping is a state in which air can enter the small airways easily, but has a difficult time getting out. In asthma, air trapping is usually caused by tiny mucus plugs that act like little one-way valves where air can get in to the airways, but not out without a lot of effort. Air trapping can also be caused by inflammation on the inside the airway and/ or by airways that collapse prematurely when you exhale. Any of these conditions alone or in combination can obstruct or block the airway making it difficult to exhale easily. As a result, some of the air that’s inhaled into these plugged airways gets trapped, causing them to become slightly over-inflated. The brain interprets this over-inflation of the lungs and inability to easily and completely expel the air, as something out of whack with one’s breathing, which is then perceived as increased shortness of breath and respiratory discomfort. As counter intuitive as it sounds, when your lungs become over inflated with too much air,it can make you feel like you’re not getting enough air, hence you feel short of breath. Crazy huh?

Next up is Abdominal bloating. This one should be more obvious because it happens to everyone, asthmatic or not. Gas produced in the stomach and gut builds up and is perceived as excess pressure in the abdomen. Essentially you feel distended and bloated. If the bloating gets bad enough it can make it uncomfortable to breath and you find yourself loosening your belt or pants button. Well, when you have lung disease like severe asthma, this excess pressure or bloating in the GI tract can actually impede or interfere with the movement of the diaphragm, which is the main muscle the body uses in the act of breathing. So rather than just feeling bloated, uncomfortable and difficult to breath, it actually is difficult to breath because the diaphragm cant move freely. Treating breathlessness that’s caused by abdominal bloating with neb treatments or inhaler could actually make the bloating worse as you tend to swallow air when you inhaled meds, especially with neb treatments.

Last on the list is good old Anxiety. Ive written about the A word many times as well. Unless you’ve been diagnosed with a generalized anxiety disorder (GAD) where your anxious about everything all the time, it’s the breathlessness resulting from any of the above situations that’s probably causing the anxiety, not the other way around. Even though I rarely get panicky when my asthma flares, I find that if my air trapping gets really bad, that anxiety sometimes rears it’s ugly head and can make me feel like Im suffocating or about to pass out. Having said, lets be clear, it’s completely normal and expected that you’ll experience some degree of anxiety when your breathing feels labored or outta whack in someway. In fact, I would go as far as saying that it’s impossible not experience anxiety symptoms if your breathing gets bad enough.Of course stress can play a role in triggering or making your asthma symptoms worse, but it’s rarely the primary cause.

It’s not on my list, but there’s actually a 5th cause of breathlessness in people with lung disease. Low levels of oxygen in the blood can make you feel short of breath, but that pertains mostly to those with COPD and Emphysema. If you have asthma, with no history of COPD, and you’re having a difficult time breathing and your O2 sats are low, that’s a medical emergency and you should get to a hospital right away.

So now that you know the different causes of shortness of breath, how can you tell what’s causing what?

If you start experiencing symptoms that are vague and don’t seem to respond to your inhaled meds, the most useful tool to identity or rule out the primary cause of your breathlessness is your peak flow meter. When you’re feeling short of breath, check your peak flows and see if they jive with how you’re feeling. If your numbers are normal (ie, your green zone), but you feel short of breath, then you’re probably experiencing the symptoms of air- trapping or airway inflammation, but not acute bronchospasm.

But wait, how can my peak flows be normal if I’m short of breath? Well, that’s because when you blow into a peak flow meter, you’re actually measuring the output of your larger airways, not the smaller ones where inflammation and air trapping occur. If those smaller airways are block or air-trapped, it wont always be reflected in your peak flows. Additionally, the breathlessness associated with air trapping tends to be less acute or sudden in nature and less intense. It’s more of a subtle sensation of not being able to exhale easily, than of gasping for air. It feels like the proverbial elephant sitting on your chest, just enough to make you feel miserable. Nevertheless, air trapping can be very uncomfortable and unlike the breathlessness caused by bronchospasm, it doesn’t respond well to standard bronchodilators and can last several hours to several days at a time. Long acting anticholinergic drugs like Spiriva have been proven effective in quelling these symptoms in people with COPD, but its unclear if this is the case in asthma.

What if your peak flows are lower than usual( your yellow or red zone), then shortness of breath youre experiencing is almost always a direct result of your airways tightening up (bronchospasm) or from increasing inflammation or mucus in your airways.

If you find that your peak flows are variable from breath to breath, trying doing what I call a “huff test”. Take a normal size breath in and then gradually, but forceful blow it out with your mouth partly open. Kinda like a huff. When you forcefully exhale like this, does it produce a wheezing sound at the end? Does it feel like you have to push hard to get all the air out? Can you blow it all out within 1- 2 seconds or does it take several seconds and lots of effort to completely empty your lungs? If so, its probably air-trapping.

Now that you have an idea of who the main culprit is behind your breathlessness, what can you do about it?

Well, if you’ve pinned your breathlessness down to bronchospasm, inhaled bronchodilators like albuterol should help and should quickly reverse it. If it doesn’t help, you need get to a hospital.

If your shortness of breath is caused mostly by air trapping, then bronchodilators, purse lip and/or abdominal breathing will help a little, but generally the symptoms of air trapping will usually persist until the lungs decompress, which could be a matter of hours or even days.

If its GI bloating that’s worsening your shortness of breath, getting rid of the excess gas in your gut will reduce your breathlessness. Taking nebulizer treatments when you have GI bloating, could actually make your breathing worse, as you tend to swallow more air with a neb than with an inhaler. You can cut down on the abdominal bloating by adjusting your diet and preventing constipation. Though I don’t have an actual allergy to gluten, I do have a gluten sensitive. Ive found that by switching some of the wheat based products I consume to gluten free products, that I have fewer problems with abdominal bloating. Drinking more water and consuming less sugar can reduce bloating as well. Reducing stress and anxiety in all its forms can have a positive impact as well.

Last, but not least, on the list is Anxiety. This is a tough one, because not only does anxiety tend to make these other sources of breathlessness feel worse, anxiety itself can be caused by worsening breathlessness. Anti anxiety meds like Ativan can help, as well as stress reduction, mindfulness, distractions, slowing your breathing down, sitting in the fresh air, basically anything that helps you relax. I know, easier said than done when youre having a hard time, but you have to at least try.

In a nutshell, t’s bad enough when your airways are inflamed or start to narrow up and you’re already working to breathing, but when you pile on symptoms of air – trapping, abdominal bloating, and/or upper airway stenosis to the mix, it can be downright unbearable and cause more respiratory discomfort and distress, than a full-on life threatening asthma attack. This is the purgatory of severe asthma and COPD and where a lot of us live.Whatever the cause of your breathlessness, I hope my explanation helps you in someway and that you’re able to obtain relief.