False Shortness Of Breath (Pseudo-Dyspnea) / December 12

        Dyspnea, which means shortness of breath, has numerous causes.  The five major body systems that can cause dyspnea are the a) lungs, b) heart, c) muscles, d) blood, and e) circulation.  Disturbances of these five systems such as: a) lung asthma, b) heart failure, c) muscle weakness, d) blood anemia, e) and circulation dehydration all lead to shortness of breath, especially upon exertion.  True shortness of breath, therefore, is worsened by exertion (because exertion increases the demand for oxygen) and improves with rest (because rest reduces the demand for oxygen).

         Pseudo-dyspnea, which means false shortness of breath, is the opposite of true dyspnea.  It is improved by exertion and worsened by rest.  One of the best clinical tools that can differentiate between true and false shortness of breath is exertion.  Simply asking the patient who suffers from dyspnea if the shortness of breath is made worse or better by activity will clarify the diagnosis.  The three main causes of pseudo-dyspnea or the false shortness of breath are a) esophagitis, b) anxiety, and c) panic.

         a) Esophagitis, or inflammation of the esophagus, is mostly caused by acid reflux, which is the backlash of stomach acid into the esophagus.  Whereas the stomach is constituted like the mouth, the esophagus is constituted like the eye.  A drop of lemon juice in the mouth tastes good but the same drop in the eye causes a red eye.  Similarly, acid in the stomach is well tolerated because the stomach has a thick mucous coat whereas acid backlash into the esophagus burns and causes inflammation or esophagitis.

         Esophagitis is like an iceberg, silent in the majority but causes symptoms in a small minority.  Unaware, all of us backlash acid into the esophagus many times a day but anti-reflux defenses come to our rescue and wash the acid away.  When our anti-reflux defenses fail, we develop esophagitis and some of us develop symptoms.

         The common and well-known symptoms of esophagitis include heartburn, indigestion, abdominal pain, cough, chest pain, sore throat, and hoarse voice.  A less known but more worrisome symptom is the feeling of shortness of breath, which usually occurs without the other, more common symptoms.  Undiagnosed, this false shortness of breath or pseudo-dyspnea may lead to frequent heart and lung investigations and inappropriate treatments.

         There are sensory nerve endings in the esophagus that can send false messages to the brain.  When the esophagus is burned by refluxed acid, these nerve endings fool the brain into feeling short of breath, as though the lungs were not providing enough oxygen.  Reacting to this feeling, the individual takes in deep sighs in an attempt to alleviate the perceived shortness of breath.  But, the more and the deeper the sighs, the worse the perceived shortness of breath gets, rendering the individual restless and anxious.  This restless anxiety leads the individual to pace or exercise, which temporarily relieves the shortness of breath.  When motion ceases and the individual sits or lies down, the shortness of breath returns.

         Treatment of this false shortness of breath relies on suppressing stomach acid and coating the esophagus with acid protecting agents.  A combination of Omeprazole (or other acid suppressing medicines) plus Simethicone (or other acid protecting medicines) will give prompt relief and reassurance that there is nothing wrong with the heart or lungs.

         Esophageal pseudo-dyspnea cannot be diagnosed with tests, examinations, or procedures.  This diagnosis is entirely clinical, based on the history alone, and can only be confirmed with a therapeutic trial.  Obtaining relief with acid suppressing and acid neutralizing agents confirms the diagnosis and cures the condition.

         b) Anxiety or worry often lead to feelings of shortness of breath, and exercise is again helpful because it temporarily alleviates anxiety.  Specific anti-anxiety medicines given by experienced physicians or specific anti-anxiety psychological therapies are both effective in controlling these false symptoms.

         c) Panic attacks come on unexpectedly, cause sudden air hunger with feelings of choking or strangulation, and prompt the patient to run away into the open air.  Unlike esophageal pseudo-dyspnea and anxiety pseudo-dyspnea, they are self-limited, last no more than an hour, and leave the patient drained and dreading.  Like anxiety, treatment depends on both medications and psychological therapies.

         To conclude, in all varieties of pseudo-dyspnea, the feeling of shortness of breath leads to hyperventilation.  Hyperventilation leads to low carbon dioxide.  Low carbon dioxide leads to dizziness, numbness, worry, and restlessness.  The diagnoses are entirely clinical, tests and procedures are of little value, successful therapeutic trials confirm the diagnoses, and the prognoses are good.  A great deal of suffering occurs because, unlike true dyspnea, pseudo dyspnea is less known and often misdiagnosed and mistreated. 

This information is not intended to replace the personal physician, who should always be consulted before any treatment or action are taken.