I am breathless!

By Dr. Muhammad Hafizullah

“I cannot enjoy a wink of sleep, the moment I put my head down, I have to sit up as I find it difficult to breath,” presented a sixty years old known patient of heart disease with severe obstructions in her coronary arteries - vessels supplying blood to heart.

"Sir, I can hardly walk a few steps, I become so breathless that I have to stop and take rest," complained forty years old banker. Naghma - mother of four kids presented with, "doctor, I am perfectly well at home but I get breathless when I have to walk a block or more - especially when I am carrying a few things or I have to walk uphill." 

Fareed, a student of second year complained bitterly of 'heart problem' and feeling out of breath after climbing 'five flights' of stairs which perhaps will tire out everyone except an accomplished athlete.

These four case histories may be the extremes of conditions, afflicting heart or lungs, in the scenario of breathlessness.

Most people come to a cardiologist or chest physician complaining of breathlessness. Some of them have severe heart problem and others may be absolutely normal - we have to chaff the normal from pathological patients.

"I cannot walk two steps," can be a presentation of a person presenting with heart failure or a person with low respiratory reserve with advanced lung disease. This may, also, be a presenting complaint of a perfectly fit person with no heart or lung disease. Many people become obsessed about breathing and feel 'breathless' but not actually breathless. "Can you walk a mile?" we ask and the response is, "Of course yes!" "Well, if you can walk a mile, then you cannot possibly be short of breath on walking two steps," is the response from our side.

We, as physicians, classify breathing problems due to heart ailments into four classes.

This is based on New York Heart Association (NYHA) classification adopted in 1928 with various modifications classifying patients into four classes from class one to four.

Class four depicts a patient who is breathless at rest without any effort, even while lying in bed. The person feels breathless on lying flat and has to sit up.

Normally gravity helps pushing blood into dependent parts like lower body and legs. The work of heart is made more difficult as the person lies flat, a weak heart cannot work efficiently as the person lies down, hence fluid accumulates in lungs and the person becomes breathless. Such patients experience breathlessness, palpitations or fatigue on any physical activity.

Class three is the stage when a person becomes breathless on little effort like going to bathroom or walking a few steps. 

They have marked limitation of activities and are only comfortable at rest. Class two denotes a stage when patient is breathless on moderate effort, they have mild limitation of activities and they are comfortable at rest or mild activities.

Class one is breathlessness experienced on severe effort like climbing stairs and walking a long distance. These persons do not suffer from any symptom from ordinary activities and they do not have any limitation of activities. We try to classify our patients according to the NYHA class and document accordingly. Those in classes three or four are labelled as serious and they need urgent medical attention for detailed testing and treatment.

Many of out patients believe that exaggeration of complaints may attract more attention and sympathy from doctors and kiths and kin.

Someone who has pain in chest once in three days will multiply it with six and complain of daily pain. If the pain lasts for ten minutes they find it justifiable to multiply with six and extend the duration of pain to one hour.

Those who can walk 200 yards will exaggerate by dividing this figure by twenty and report breathlessness on walking ten steps. One thing is absolutely sure, such tactics do not win any advantage.

As a matter of fact they throw everything to doubt! Classical cardiac pain is brought on by exertion and lasts for a few minutes.

When a person complaints of frequent pains lasting for hours, a doctor has to entertain different possibilities. Such complaints will attract all diagnostic possibilities but a cardiac ailment. In the same vain, when people exaggerate breathing complaints, they multiply their problems with a factor ranging from five to twenty.

Some people get preoccupied for not being able to take a deep breath in. "I cannot take a deep breath!" is the usual complaint of young ladies. They try to interpret it as feeling of suffocation and experiencing difficulty in breathing. They can go around town shopping and do their usual chores but complain bitterly about being unable to breath. Actually, the problem lies with deep breathing - deep sighs.

Many of them are depressed and culturally, in our part of the world, 'sadness' is expressed by tears and deep sighs. Though they can sigh, yet they never get a sigh of real relief! Deep sighs have nothing to do with 'breathlessness' - the person can breath quite normally but the feeling of inability to take a deep sigh troubles them incessantly. 

We receive many young ladies holding their chest or throat and screaming , "I cannot breathe, I cannot breathe" and exit clinic on their feet after proper reassurance.

"I feel very short of breath when I am confined to a room, especially when someone locks the door!" is a fairly common complaint, usually in younger age group. Patients suffering from 'claustrophobia' may not find appropriate words to describe their condition and instead they paint a different picture.

This condition is quite common in anxious young adults - males and females. Some people, otherwise normal, get panicky when their attention is drawn towards it.

People with advanced condition cannot travel by plane or train being locked in a close environment. Some of them find it difficult to travel by bus and as soon as the door closes they feel an irresistible urge to get out.

There are many who will avoid travelling even at the cost of their job or profession because of claustrophobia. This must not be misconstrued as breathlessness because the person normal heart and lungs.

The problem is psychological and should not be confused with heart ailment.

Breathlessness is one of the common symptoms patients present to their physicians with. It has to be assessed in proper context and should be taken seriously.

Two symptoms must be entertained properly as it may lead to serious consequences - chest pain and breathlessness.

These must not be ignored by relatives and friends. But then, because it is taken very seriously by medics and paramedics, many attendants over react.

Less than half of patients presenting with chest pain have genuine heart problem similarly those presenting with breathlessness more than half are perfectly normal. Whereas it should be entertained, common sense should prevail and it should not be a cause of panic and over reaction.