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Breathing space

Diagnosing and managing the causes of breathlessness is a vital part of helping people to lead longer and healthier lives. This month, in parallel with the national breathlessness awareness campaign the British Lung Foundation, in conjunction with the London Respiratory Network, launched the Breathing SPACE framework. This is to make it easier for doctors to make the right diagnosis, and start the process of treatment – but also to encourage people to exercise when their breathlessness is due to a lack of fitness.

Breathing SPACE is a framework for the care of any breathless person and stands for Smoking, Pulmonary disease, Anxiety, Cardiac disease and Exercise level. If a patient comes for an appointment complaining of breathlessness, doctors should consider how all five factors may be contributing to their symptoms. It seems simple, but we do know that some patients with breathlessness are often not diagnosed until a late stage and that people with one diagnosed problem may not have others considered. Heart disease is often underdiagnosed and undertreated in people with COPD and vice versa. Factors like anxiety may also be overlooked although this is a major factor in people with heart and lung problems and can also itself present with breathlessness and hyperventilation. Asking the right questions about someone’s state of mind can help identify anxiety and other mental health or social issues.

It is always vital to find out if someone is a smoker. Smoking causes heart and lung disease of course, but smoking cessation is also the most effective treatment for people with heart and lung disease and should improve breathlessness cough and survival.

Patients struggling to get their breath may have pulmonary disease including COPD which often comes on gradually and may not be noticed in the early stages. Taking too little exercise and being overweight can also lead to breathlessness, which should be considered when anyone comes into surgery whether or not they already have heart and lung disease.

Once the cause is determined, there is plenty that can be done to improve outcomes for patients and reduce breathlessness, and the sooner the better. Smoking cessation has a huge benefit and all smokers should be offered support to quit the habit. Unfortunately smoking cessation services are being decommissioned up and down the country at the moment due to cuts in Public Health budgets.

Taking more exercise can reduce the problem of breathlessness caused by being unfit and carrying extra weight. It can also reduce the risks of problems later on in life like hypertension osteoporosis and diabetes. Exercise rehabilitation is a really effective approach for people with heart and lung disease and we would like more people with COPD to have access to it as it is still under provided at the moment by the NHS. This should be a preferred intervention for many people with early COPD rather than the tendency to prioritise medications which are often less effective. This high-value intervention, promoting good health and lifestyle changes, is relatively inexpensive compared to a lifetime of inhalers and drugs. Another approach that the British Lung Foundation has been promoting is taking part in singing classes as a way to develop better breath control.

Pulmonary disease should be considered on a par with stroke and heart disease as major contributors to ill health and mortality. Breathlessness should not be ignored and patients need to have a holistic approach to its management – the simple acronym SPACE covers all the bases and should be a help to doctors in primary care.

Dr Nicholas Hopkinson
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