Preventing Panic

Preventing Panic Attacks When Short of Breath

Do you ever get so short of breath that you panic? It is instinctive to breathe faster and harder when you try to relieve shortness of breath. Did you know this is the worst thing you can do if you have chronic obstructive pulmonary disease (COPD)? What you really should do is the exact opposite.

To breathe easier, you need to slow your breathing rate, forget about breathing in, and just concentrate on breathing out! Yes, this is counterintuitive. Keep reading and you will understand why this will help and why certain breathing techniques can relieve shortness of breath, increase the oxygen saturation in your blood and prevent panic. If you are interested in this explanation, or in learning other techniques that will help you enjoy a life free of the fear of shortness of breath or panic, keep reading.

Over and over, patients graduating from pulmonary rehabilitation classes have said breathing retraining is the most important thing learned in class. Once they had control over their breathing, they were able to become more active and learn all the other things offered in the classes. Who can think of starting an exercise program when they get short of breath even walking across the room?

Some Causes of Shortness of Breath

Of course, you have already discussed your shortness of breath (SOB) with your physician. Do you remember all the times you got short of breath as a child running around and thought nothing of it? Now your shortness of breath may be caused by something far less taxing than running during a game, and that is what is of concern. Your doctor probably has tested you for various problems that can cause shortness of breath besides age or being a couch potato, the first things you suspected. Other diseases can be a cause; common causes include heart disease, anemia, obesity, asthma and various types of respiratory conditions, as well as pregnancy. Maybe you are using prescriptions for medications or inhalers for COPD, and you’ve been tested for the need for supplemental oxygen. You might be surprised to learn that sometimes shortness of breath, even with pulmonary conditions, is not always due to a low oxygen level and can be helped with some easy-to-learn breathing techniques.

If you have a respiratory problem, your doctor may suggest a pulmonary rehabilitation class. This class helps you learn efficient breathing techniques, such as proper pursed-lip breathing (PLB). What if you don’t have a pulmonary rehabilitation program nearby to help you? It probably is a little harder to learn those techniques without a therapist to help, but it still can be done.

If you have been diagnosed with COPD and are taking all the medications, or even oxygen, as prescribed by your doctor, why are you still having attacks of shortness of breath or even panic? How do you handle that, and what causes it? Let’s start with a few basics.

How Does COPD Affect Breathing?

Many of you may feel that you “suddenly” developed a problem with your breathing after getting that last episode of flu or pneumonia. Actually, COPD is a disease that slowly progresses over a twenty or thirty-year period. The first thing that happens, maybe while you were still a teenage smoker, is that the elastic fibers in your lungs start to deteriorate, and lungs start losing their elastic recoil. Just like our skin gets less ‘springy’ with age, your lungs can also get less springy as a result of smoking or of simply getting older. This loss of elasticity causes the lungs to lose their ability to get air out efficiently. This may get worse age you get older, especially if you continued to smoke, and some people start to develop air trapping in their lungs. Air trapping describes areas of the lung where air gets in but can’t get out.

Everybody has some air in their lungs, even after they breathe out as much as they can. This is normal and prevents the alveoli, the little air sacks, from collapsing flat as an old balloon. The air left in the lungs after you breathe all the way out is called residual volume (RV). Patients with COPD who have air trapping may have an RV that is 200% or more compared to a healthy individual of the same age. Why does that matter? This trapped air can compress some of the undamaged alveoli (the good parts of your lungs) so that they don’t work efficiently. The other thing that happens is that those larger lungs, full of trapped air, start to push your chest outwards. Have you noticed that your chest size is larger, or that your bra size has increased?

Another effect of air trapping is that the diaphragm becomes flattened. The diaphragm, which does about 80% of the work of breathing, is normally dome-shaped – a bit like the shape of an old fashioned parachute. When you breathe in, the diaphragm contracts and flattens out, which helps to suck air into your lungs. But in a COPD patient, the diaphragm may be already flat to begin with (to make room for all that trapped air), which makes breathing in harder work. The mechanics of breathing are all thrown off. A flat diaphragm can be seen on your chest x-ray. In this position, you start to use accessory muscles of breathing, such as your shoulder and neck muscles. Normally these muscles are only meant for use in emergencies, like when running fast. These muscles are inefficient, and using them makes you feel more short of breath. If you think that you work harder on your breathing than other people do, you are absolutely right! Even at rest, you are probably working many times harder to breathe than a person without lung disease. What can you do about that?

Breathing Techniques for COPD

You can learn a more efficient way of breathing! You have been breathing ever since you entered this world, so why are you now supposed to learn a new way to breathe? Because there have been changes in your body. If you remember what is wrong, it will be easier to make sense of the new breathing techniques you will learn.

That loss of elasticity in your lungs is the first thing for you to remember. In practical terms, it means you now have to work to get air out of your lungs. Think of a balloon. You work to get air into a balloon, but when you let go of the neck of the balloon, elastic recoil shoots the air out of the balloon without any effort on your part. Healthy lungs do the same thing. However, lungs that have lost elastic recoil by years of smoking or simply by older age have to work to get the air out. It’s like blowing air into a paper bag. You have to squeeze the air out of the bag since it won’t flatten out by itself. Now you have to work to get the air out of your lungs so you can make room for the oxygen in that fresh air you need on the next breath in.

Forget about breathing in; that is automatic and is not your problem! Your problem now is getting air out of your lungs to make room for the next breath in. When you have COPD, to accomplish this, you may need to breathe out 2 or 3 times longer than you breathe in. If you panic and breathe too fast, or even if you quickly breathe in and out at the same rate, you may cause more air trapping, leaving less room for fresh air, and you could quickly get even more short of breath.

The other very important thing you need to do is… slow… down. Pace yourself! Walk across the room slowly instead of running to get across it before you get short of breath!

What about this pursed-lip breathing (PLB) that we keep talking about? Does it really help? Yes, it does! Correctly done, PLB can raise the oxygen level of your blood as much, and faster, than breathing with supplemental oxygen set to 2 liters per minute. We have demonstrated that in test after test.

Then why do some of you not feel much better when you use PLB? Why do you sometimes feel worse? Because you may not be doing it correctly! Done correctly, you breathe in deeply and slowly through your nose. You slowly breathe out about 2 to 3 times longer through slightly pursed lips; you should have just a small opening in the center of your lips. Think in terms of gently blowing air out, just hard enough to make a candle flame flicker, but not hard enough to blow out the candle completely. Remember, it is very important to slow your breathing and concentrate on breathing out. Pursing your lips is one of the techniques that helps you to do that.

Always remember, one of the biggest mistakes made is blowing the air in your lungs out too forcefully. If you use too much force, you can actually lower the oxygen level of your blood and make yourself become more short of breath! If you can be heard breathing out, or you start to wheeze, you are working at this too hard. If you feel light-headed, or uncomfortable doing PLB, you are also working too hard. Stop and rest a bit. Good PLB feels comfortable and natural. Another common mistake is gulping a little air in through the mouth before breathing out, or while trying to breathe out, so watch to make sure you are not doing that.

Using a pulse oximeter (see our other article on “oximetry” in this series) is one of the easiest ways of telling whether or not you are doing effective PLB. Borrow one to try if you can. Pulse oximeters also are now widely available to purchase and are relatively inexpensive. If your oxygen level is low, say 88%; with good PLB you can usually “blow the number up” to 93%. Practiced breathers can sometimes get their oxygen saturation all the way up to 98%, but 93% or higher is a good number to aim for. What happens if you breathe incorrectly? Maybe nothing, except that you don’t feel less short of breath. With the oximeter, you will see for yourself that your oxygen saturation levels will drop and continue to drop until you stop blowing out so hard. With the correct PLB technique, breathing will feel natural, your oxygen saturation numbers will increase, and you should feel less short of breath.

Breathing Techniques for Restrictive Lung Diseases

What about those who suffer from a restrictive pulmonary disease, such as idiopathic pulmonary fibrosis (IPF)? In IPF, unlike COPD, air trapping is not the main problem. Patients with IPF have stiffer lungs due to accumulation of scar tissue. This also makes them work much harder to breathe and suffer from shortness of breath. So, do PLB techniques also work for IPF patients? Yes, a variation of PLB can help. There are many kinds of restrictive disease. Each patient is different and needs to experiment more with breathing techniques than someone with COPD. Doing so with the aid of an oximeter makes it much easier to learn the best way to breathe.

Patients with COPD can slow their breathing rate down to 10 or 12 breaths a minute to control panic. However, patients with IPF who breathe very rapidly when they panic can rarely slow their breathing down to less than 16 breathes a minute. Since IPF patients do not have air trapping, this higher breathing rate is adequate. Again, PLB helps accomplish this. Always pacing themselves is even more important for those with IPF than for those with COPD. Just getting out of a chair too quickly can precipitate a drop in oxygen saturation levels and cause a marked increase in shortness of breath. Again, while pacing yourself is important for all respiratory patients, it is essential for those with a restrictive disease! This cannot be stressed often enough.

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