The following recommendations are based upon over forty years of clinical experience with this subject, and also are based in part on a recent medical article that appeared in the Journal of the American Medical Association (Luce and Luce, JAMA, March 14, 2001).

    Acute, severe shortness of breath is a medical emergency which requires treatment ultimately  dependent on its cause.
Chronic, worsening and ultimately severe shortness of breath, initially only on exertion and eventually constant,  will require more than good  medical management.  It will usually require specialty care,  or at least the devoted and regular long-term care of a very knowledgeable primary care physician.  Such care becomes a partnership between patient and physician, more than usual, in which a main component  is the constant availability of the physician to deal with questions and problems - small and large.

    The following are some issues which should be addressed by both partners in this life-time relationship:

1. Diagnose and treat the primary disease comprehensively.  As noted in my offering on “Chronic Bronchitis”, this means making sure not to overlook a possible co-existent reversible condition;  namely, bronchial asthma.
2. Treat all secondary, associated or accompanying conditions, including left and/or right heart failure, acute and chronic infections (eg. pneumonia, recurrent acute bronchitis, sinusitis...), Gastro-esophageal reflux disease, Diabetes, Cancer....
3. Control secretions, with liquefying agents, mobilizing agents,  postural drainage and vibratory-percussive chest physiotherapy, suction catheterization and ultimately tracheostomy if necessary.
4. Consider Oxygen in timely fashion.  This means being more liberal in its use than is reflected in the Medicare guidelines which  - if followed - will very likely lead to end-stage right heart failure.
5. Incorporate exercise in the regimen:  aerobic exercises as tolerated, in the form of walking and stationary bicycle-riding  (see American Lung Association programs);
6. and muscle-toning exercises involving mainly the arms, shoulder girdles, the intercostal muscles and the diaphgram.
7. Deal effectively with Nutrition of these often mal-nourished patients, Hydration, Depression - a common finding, Sleep Deprivation  (including possible obstructive sleep apnea), and the all-important Socialization (with family and especially with friends) - an often over-looked asset.
8. Use Opiates judiciously to relieve the sensation of constant shortness of breath.
9. Consider the use of Non-Positive Pressure Breathing  devices.
10. Ultimately, work co-operatively and openly to prepare the patient for Death.
11. This involves considerations which I addressed in my offering on “Physician-Patient Spirituality”; and it involves the timely completion of Advanced  Directives reflecting the terminal wishes of the patient  and the acceptance of the family.

GS