Short of Breath?

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What is shortness of breath?

For most people "shortness of breath" or "having breathing difficulties" means a sensation of difficult or uncomfortable breathing, or a feeling of not getting enough air. Medically, this is referred to as dyspnea.

Does shortness of breath mean illness?

Shortness of breath can occur in both health and disease, and its significance varies accordingly. For example, when it occurs in a healthy person walking 100 feet at the top of a very high mountain, it may signify no disease. But if the same person had smoked a pack of cigarettes a day for 20 years, the same symptoms at lower altitude may be the first sign of progressive emphysema. In healthy individuals, shortness of breath may also occur at rest for no apparent physical reason.

Shortness of breath may be appropriate or inappropriate, real or perceived; and therefore, there is no standard lay person definition of shortness of breath. Physicians use the term dyspnea to describe "an abnormally uncomfortable awareness of breathing."

What causes dyspnea?

The issue of dyspnea comes up frequently when patients are seen in their physician's office for specific complaints, or for a periodic physical examination. It's the physician's task, not always an easy one, to determine whether the dyspnea is medically important, and to recommend a diagnostic plan and a course of therapy when needed.

Dyspnea can be acute, intermittent, or chronic, and can be caused by a heart or lung problem or physical de-conditioning; or it can be of psychogenic origin.

Common heart diseases causing dyspnea include coronary artery disease (the major cause of heart attacks), congestive heart failure, and conditions where heart valves malfunction. Lung problems include bronchial asthma, acute and chronic bronchitis, emphysema, and interstitial lung disease (diffuse scarring and stiffening of lung tissue). Exposure to allergens may precipitate an asthma attack, or dyspnea-producing post nasal drip; but the biggest undiagnosed culprit remains smoking.

Psychogenic dyspnea, precipitated by anxiety, panic or an irregular breathing pattern of frequent sighs ("sigh dyspnea"), is now diagnosed in increasing frequency. This is usually not dangerous, but it may be uncomfortable, and particularly hard to diagnose and treat.

Lack of conditioning is also a cause of dyspnea, especially seen in the "weekend warrior athlete." If you are short of breath playing basketball on Sunday afternoon, do you have a disease causing dyspnea, or is this lack of conditioning?

How is the diagnosis made?

Your account of the intensity, severity and frequency of dyspnea is very important.
This, combined with a physical examination and some basic testing, may rapidly establish the correct diagnosis.

Sometimes the diagnosis is elusive. Both asthma and heart disease can be "silent." Even lack of conditioning may be difficult to diagnose without meticulous testing. The diagnosis of psychogenic dyspnea, can be made on the basis of your symptoms, after medical causes of dyspnea have been ruled out.

For exercise-related dyspnea, we use cardio-pulmonary stress testing (CPST). This important, noninvasive test combines the familiar cardiac test with lung function testing during exercise (on a treadmill or exercise bicycle). With it, we can determine your level of cardiopulmonary fitness, and whether your shortness of breath is due to a heart problem, lung problem, de-conditioning, or "none of the above."

Treatment

Treatment of dyspnea, and its effectiveness, depends on the underlying cause. Frequently, medications are used, such as those needed to optimally control asthma, congestive heart disease and anxiety. Special lifestyle instructions may be given, such as smoking cessation and allergen avoidance. Reconditioning exercises and stress management may be advised, or you may be instructed in the proper performance of diaphragmatic breathing.

Working together with your physician, in the overwhelming majority of cases, shortness of breath can be controlled or completely resolved.

Most, if not all the tools necessary to establish the cause of dyspnea and treat dyspnea are available under one roof at our practice.

Prevent a heart attack

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Heart attacks continue to be the number one killer in the US. Heart attacks are also one of the major strains on the national and personal health budgets. It is essential that you know your risks for the development of heart disease and take the necessary steps to decrease the chance of a premature heart attack.

Heart attacks, the major manifestation of coronary heart disease (or atherosclerosis, plaque), continues to be the leading cause of mortality in the US, and will continue to be so as longevity increases, and as the number of senior citizens increases. And, yes, many of us feel that we know what puts us at risk for a heart attack, and what we have to do in order to decrease that risk. But do we really know enough? And do we do enough?

Most of us know the detrimental role of smoking, diabetes, obesity, lack of exercise, and hypertension. Many of us also know of the role of cholesterol, including the “good cholesterol” (HDL) and the “bad cholesterol” (LDL), or even triglycerides. Certainly we know that it’s better to be born with “good genes.”

But what about the more recently recognized risks factors and tests to better detect a potential heart problem early, when there’s still time to delay or prevent a heart attack?

Look at one cholesterol related example: We now can look not only at the total LDL and HDL, but also at their respective subclasses (These are not routinely done unless your physician specifically asks for them). There are at least two important LDL patterns, “predominantly small particles LDL,” also known as B Pattern, and “predominantly large particles LDL,” known as A Pattern. Pattern B is the dangerous one, and it’s the one that can usually be managed by lowering dietary fat intake. In contrast, Pattern A individuals may not benefit, or even become worse with severe dietary fat restriction. Similarly, there are other subclasses and markers, each of which has its own significance and therapeutic implications.

Inflammation of the coronary arteries accelerates the formation of coronary plaque. Cardio-CRP is one such marker of inflammation, and helps identify those at risk of a first and subsequent heart attack, even when the cholesterol risk is low.

Newer blood tests, such as the extensive profile offered by the Berkeley HeartLab, (partially on the basis of technology developed at Berkeley Unversity) or the VAP profile (by Atherotech, Inc.) go much further into analyzing inflammatory markers, cholesterol subclasses, and the benefit effect of certain drugs in the management of cardiac risk factors.

Early detection of plaque formation has become easier too. We’re all familiar with the common treadmill stress test, stress ECHO’s, nuclear Thallium or MIBI test, or even cardiac catheterization. But newer tools have evolved. A modern “fast cardiac CT scan” in experienced hands can show calcium in existing plaque, and thus estimate the degree of atherosclerosis. Computerized coronary angiography, which is only minimally invasive, can even better assess the extent of plaque formation. A carotid ultrasound, with particular attention to inflammation (usually reported as “intimal thickening”) may be useful in risk assessment.

Many other developments are just below the horizon. However, an important problem hindering the use of many new techniques is coverage by the health insurance companies as well as Medicare. They traditionally take years before paying for some of these very important tests.

Regardless, we’ve come a long way in our ability to identify the risk of coronary heart disease, and to detect it early. At our practice, early detection and prevention is a cornerstone. Information is a powerful tool, become informed! We’re here to help you live a longer, healthier life…

The many faces of asthma

Bronchial asthma, usually simply referred to as asthma, is a common condition, affecting well over 20 million Americans, increasing every year. The disease affects both children and adults, and its severity can vary from very mild to deadly. It account for more than 400,000 hospital admissions and more than 4,000 deaths every year.

While most people think of asthma as a disease of the lungs, in reality it’s a chronic condition of the bronchi, the airways that carry air in and out of your lungs. In asthma, the bronchial linings (mucosa) become inflamed, and become sensitive to a variety of irritants. The tiny muscles that surround the bronchi tighten and the mucus glands that are imbedded in the bronchial mucosa produce extra mucus.

Some people think of asthma as occasional wheezing. But in reality, asthma has many faces. It can indeed present as wheezing, mild and short lived, or as a chronic persistent condition, but it can also present in other forms such as a chronic or intermittent cough, excess mucus production, or shortness of breath at rest or associated with exercise.

The frequency and severity of asthma symptoms vary widely. Some people have infrequent “attacks,” or flare-ups, and are otherwise symptom-free, while others have severe, chronic symptoms. But no matter what your symptoms are, you must think of asthma as a chronic condition.

What triggers asthma or an asthma attack depends on how susceptible you are. Common triggers include allergens such as dust, molds, animal dander and cockroaches; tobacco smoke; viral respiratory infections; strenuous exercise; exposure to very cold temperatures; certain foods and food additives, and certain drugs such as the beta blockers used in the treatment of heart disease. Sometimes, psychological factors play a role. Hyperventilation, or excessive breathing, seen in some patients with anxiety, can lead to an asthma flare-up.

Asthma is usually easy to diagnose, but its severity should be thoroughly evaluated by a qualified physician. Occasionally, the diagnosis is elusive, and it has to be distinguished from other diseases that can masquerade as asthma.

Asthma is treatable. New research and an ever-increasing understanding of asthma have lead to better treatment. It is now clear that the overwhelming majority of flare-ups, hospitalizations and deaths can be prevented. But the success of treatment depends on the skill of the treating physician, and the patient’s compliance. Too frequently, especially in milder cases, there is a reluctance to treat or be treated, which may lead to disastrous outcomes.

Treatment depends on severity and triggers, and must be individualized. It ranges from the occasional use of bronchodilators (puffers), to long-term use of inhalers and oral plays a significant role, immunotherapy (allergy shots), or the use of a relatively new anti-allergy injectable medication (Xolair, omalizumab) may be appropriate. Relaxation methods, regular exercise and a thorough understanding of your condition are very helpful.

So if you have asthma, see to it that your needs are properly addressed, and take your treatment seriously; your mind and body will thank you for it. Need help? Contact us.

Don’t let fitness take a holiday

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The holidays are over; there's no need to let fitness take a holiday now.

Fitness is an elusive concept. According to the President's Council on Physical Fitness, it is "the ability to carry out daily tasks with vigor and alertness, without undue fatigue, with ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies." Yet physical fitness means different things to different people. One fact is clear: if fitness is the goal, exercise is the way to get there.

There are four basic elements of physical fitness: cardiovascular endurance, muscular strength, muscular endurance, and flexibility. Each can be measurably improved with regular exercise. But keep in mind that exercising to build physical fitness is not the same as working out to improve athletic performance. To be physically fit, you should develop all four elements, not just one or two.

While each element is a part of fitness, the most important one is cardiovascular endurance. Physiologically, cardiovascular endurance is the sustained ability of the heart, blood vessels, and blood to carry oxygen to the cells, the ability of the cells to process oxygen, and the ability of the blood, once again, to carry away waste products. Since every cell in the body requires oxygen to function, there is no more basic element of fitness than this, to see that the heart, lungs, and circulatory system do their job.
Cardiovascular endurance is built up through exercises that enhance the body's ability to deliver ever larger amounts of oxygen to working muscles. To achieve this, the exercise must include the large muscle groups (such as in the legs) and, most importantly, it must be sustained.

Muscular strength is the force a muscle produces in a single effort (a lift, a jump, a heave), as when you swing a mallet to ring a carnival bell. Muscular endurance is a measure of the ability to perform repeated muscular contractions in quick succession, as in doing twenty push-ups in a minute. Although muscular endurance requires strength, it is not a single all-out effort.

Muscular endurance and strength are interrelated, but are quite distinct. Endurance enables you to maintain a sustained effort, while strength will give extra force to your golf swing or tennis serve. Gains in strength come most quickly from exercising with the maximum amount of resistance, usually weights, that you can lift comfortably in a few repetitions, working at below your maximum level and gradually increasing the number of times you perform an exercise.

Flexibility refers to the ability of the joints to move through their full range of motion. It varies from person to person and from joint to joint. Good flexibility is thought to protect the muscles against pulls and tears, since short, tight muscles may be more likely to be overstretched. Some people find that stretching hamstring and lower-back muscles alleviates lower-back pain, and calf stretches help prevent leg cramps.
Developing strong, flexible muscles is important for everyone, not just for athletes and body builders. Well-conditioned muscles and joints help you perform better physically, assist you in maintaining good posture, and may help prevent injuries and chronic lower-back pain.

Most certified personal trainers are very good, but watch out for the overzealous ones, they may hurt you.

Need help? feel free to contact my office (contact information on the side bar).