Shortness of breath, labored breathing — what might be behind it?

Few things are more frightening than the feeling that you cannot breathe. Even a healthy person can experience shortness of breath with very strenuous exercise, extreme temperatures, obesity, or at high altitude. Outside of these, labored breathing is likely a sign of a medical problem. Shortness of breath — medically called dyspnea — is most commonly described by patients as a strong chest tightness, air hunger, breathing difficulty, or a choking sensation. If you experience labored breathing for the first time, seek medical attention immediately. The required treatment depends on the findings of the evaluation. With recurrent shortness of breath, follow your doctor's instructions (for example, take medication, perform breathing exercises, or receive supplemental oxygen).

Shortness of breath can occur suddenly (acute shortness of breath) or be recurrent, repeated, or persistent (chronic shortness of breath). In most cases, labored breathing is due to heart or lung disease. The heart and lungs participate in delivering oxygen to the tissues and removing carbon dioxide, and problems in any of these processes affect breathing.

Labored breathing can be a symptom or a component of many diseases and conditions; its causes are varied.

Possible causes of acute (sudden) shortness of breath

Anaphylaxis

A severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes after exposure to an allergen, such as eating peanuts or being stung by a bee.

The immune system releases substances that cause blood vessels to dilate, blood pressure to drop suddenly, and the airways to constrict, obstructing breathing. Symptoms include a rapid, weak pulse, skin rash, nausea, and vomiting. Common triggers include certain foods, some medications, insect venoms, and latex.

It can be fatal if not treated immediately.

Paramedics or an emergency physician can stop anaphylaxis with a life-saving injection (epinephrine), but the patient still needs immediate transfer to an emergency department.

Asthma

A condition in which the airways narrow, the inner walls of the lung airways become inflamed and swollen, and excess mucus is produced and accumulates. It can make breathing difficult and trigger coughing. It may cause a wheezing sound on exhalation and lead to shortness of breath.

Symptoms range from relatively mild in some people to severe in others. It can interfere with daily activities and lead to a life-threatening asthma attack.

Asthma is not curable, but its symptoms can be controlled. Because asthma often changes over time, it is important to monitor symptoms together with your treating physician and adjust treatment as needed.

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Carbon monoxide (CO) poisoning

Occurs when carbon monoxide accumulates in the bloodstream. When too much carbon monoxide is present in the air, it enters the lungs and binds to red blood cells, which then cannot carry oxygen. This leads to severe tissue oxygen deprivation, cell death, and can result in death.

Carbon monoxide is a colorless, odorless, and tasteless gas produced by burning petrol, wood, propane, charcoal, or other fuels. In enclosed spaces with poor ventilation, such as when a heater or vehicle engine is running indoors, carbon monoxide can build up.

If CO poisoning is suspected, open windows immediately or move the affected person to fresh air. Seek emergency medical care as soon as possible.

COPD exacerbation

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that obstructs airflow into the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production, and wheezing. It is usually caused by long-term exposure to irritating gases or particles, most commonly cigarette smoke. COPD increases the risk of heart disease, lung cancer, and many other conditions.

Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD. These two conditions often occur together with varying degrees of severity.

Chronic bronchitis involves inflammation of the inner walls of the bronchi that carry air to the lung alveoli. It is characterized by persistent cough and mucus production (sputum).

Emphysema is a condition in which the small air sacs (alveoli) at the ends of the smallest airways in the lungs are destroyed and merge together, reducing the surface area available for oxygen uptake.

Although COPD is progressive, it is treatable. With appropriate therapy, most people can achieve good symptom control and quality of life, and reduce the risk of associated diseases.

Upper airway obstruction

Occurs when something gets into the airways and blocks them. In mild cases, the cough reflex expels the object (as with a swallowed bite), but accidental ingestion of a larger object can be fatal.

Sudden, significant blood loss

Coronavirus disease 2019 (COVID-19)

Coronaviruses are a family of viruses that can cause respiratory illnesses such as the common cold, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS).

The virus is known as SARS-CoV-2, and the illness it causes is called coronavirus disease 2019 (COVID-19). The World Health Organization (WHO) declared COVID-19 a pandemic in March 2020.

Public health organizations, including Hungary's National Public Health Center and the WHO, monitor the COVID-19 pandemic and publish updated information on their websites. These groups have also issued recommendations for preventing and treating the disease caused by the virus.

Croup

Commonly occurs in young children. It is a viral infection of the upper airways that obstructs breathing and causes the characteristic barking cough.

The cough and other signs of croup result from swelling around the vocal cords (larynx), trachea, and bronchi. When the cough forces air through the narrowed airway, the swollen vocal cords produce a barking sound like a seal. Breathing often produces a high-pitched wheeze (stridor).

It typically affects younger children. Although it looks scary, it is usually not severe. See a doctor the first time it happens; afterwards you will learn how to prevent it and in most cases manage it at home.

Pneumothorax (collapsed lung)

Occurs when the lung somehow "punctures" and air leaks into the space between the lung and the chest wall (the pleural space). This air gradually compresses the lung, causing it to collapse, either partially or completely.

It can be caused by blunt chest trauma or penetrating injury, certain medical procedures, or damage from underlying lung disease (e.g., tumor). It can also occur spontaneously without an obvious cause. Symptoms usually include sudden chest pain and shortness of breath. In some cases, a collapsed lung can be life-threatening.

Treatment usually involves inserting a needle or chest tube between the ribs to remove the excess air. A small pneumothorax can sometimes heal on its own.

Heart failure

Also known as congestive heart failure, this occurs when the heart muscle cannot pump blood effectively. Blood can back up and fluid may collect in the lungs (pulmonary edema), causing shortness of breath.

Certain heart conditions, such as coronary artery disease or high blood pressure, can gradually weaken the heart muscle.

Appropriate (often medication) treatment can improve the signs and symptoms of heart failure, and some people can live longer. Lifestyle changes — for example, weight loss, exercise, reducing dietary sodium, and stress management — can improve quality of life. However, heart failure can be life-threatening. People with severe symptoms may need a heart transplant.

Prevention includes addressing underlying conditions such as coronary artery disease, high blood pressure, diabetes, and obesity.

Myocardial infarction (heart attack)

Occurs when the arteries supplying the heart become blocked. Most often caused by buildup of fat, cholesterol, and other substances that form a blockage in the coronary arteries.

A blood clot can form and completely obstruct blood flow. The resulting oxygen deprivation can damage or destroy part of the heart muscle. This is a heart attack (myocardial infarction).

It can be fatal, but treatments have advanced greatly over the years. Call emergency services if you think you may be having a heart attack.

Arrhythmia

An irregular heartbeat. It occurs when the group of cells that trigger the heartbeat does not function properly. As a result, the heart may beat too fast (tachycardia), too slow (bradycardia), or irregularly.

Heart contractions begin in a small group of cells in the sinus node, which sends an electrical impulse. This causes the atria and ventricles to contract in sequence, pumping blood out of the heart.

An arrhythmia can feel like a fluttering or racing heartbeat and is usually harmless. Some types, however, can cause unpleasant or even life-threatening symptoms.

A fast or slow heartbeat can also be normal, for example during exercise or sleep.

Treatment is usually with medication; in more serious cases catheter procedures or implanted devices (e.g., a pacemaker) may be used to control or eliminate the arrhythmia. A heart-healthy lifestyle can help prevent heart damage and consequent arrhythmias.

Cardiac tamponade

A life-threatening condition in which blood or fluid accumulates in the sac around the heart (pericardial space), compressing the heart. It prevents the chambers from fully relaxing and filling with blood, so they pump less blood.

Requires medical attention.

Pneumonia (and other lung infections)

Pneumonia is an infection that can affect one or both lungs' air sacs. The air sacs can fill with fluid or pus, causing cough, fever, chills, and difficulty breathing. Various organisms, including bacteria, viruses, and fungi, can cause pneumonia.

Most pneumonia occurs when a weakened immune system allows bacteria to invade and multiply in the lungs. White blood cells accumulate rapidly and, along with bacteria and fungi, fill the alveoli, making breathing difficult.

Bacterial pneumonia classically produces a cough with thick, bloody, or yellow-green sputum.

Severity ranges from mild to life-threatening. Infants and young children, people over 65, and those with other health problems or weakened immune systems are at greatest risk.

Pulmonary embolism

A blood clot travels to the lung artery and blocks blood flow. In most cases, pulmonary embolism is caused by clots that form in the deep veins of the legs (deep vein thrombosis) or, less commonly, elsewhere in the body and travel to the lungs.

Because the clot blocks blood flow in the lungs, pulmonary embolism can be life-threatening. Immediate treatment greatly reduces the risk of death. Measures to prevent thrombosis (regular exercise, avoiding prolonged sitting) also help protect against pulmonary embolism.

Causes of chronic (long‑standing) shortness of breath

The most common causes of breathlessness that has persisted for weeks or longer include the following:

Asthma

COPD (chronic obstructive pulmonary disease) severe form

Obesity

A complex disease characterized by excessive accumulation of body fat. It is far from being just a cosmetic problem. It is a condition that increases the risk of other diseases and health problems such as heart disease, diabetes, high blood pressure, and certain cancers.

There are many reasons why some people find it hard to lose weight. Obesity is usually the result of inherited, physiological, and environmental factors combined with dietary and physical activity choices. These interacting factors can have a complex effect on your life that is often hard to change.

The good news is that even modest weight loss can improve or prevent health problems related to obesity. A healthier diet, more exercise, and gradual changes to bad habits can help with weight loss.

Pleural effusion

Accumulation of fluid in the chest around the lungs.

Heart dysfunction

Interstitial lung disease

A broad group of disorders that commonly cause progressive scarring of lung tissue. This scarring affects breathing at rest and thus the amount of oxygen entering the bloodstream.

It can be caused by long-term exposure to hazardous substances such as asbestos. Certain autoimmune diseases, such as rheumatoid arthritis, can also cause interstitial lung disease. In many cases the cause remains unknown.

Once lung scarring develops, it is usually irreversible. Medications can slow the progression of interstitial damage, but lung capacity is rarely restored. For some patients, lung transplantation may be an option.

Other causes

Many other health conditions can make it hard to get enough air. These include:

Inhaled foreign object

A typical example is "choking" on food. A bite can enter the airway during eating, or a child may inhale a small toy into the trachea. Act quickly if you see someone choking on an inhaled object.

Call for medical help immediately. Learn and practice first aid techniques so you can assist. If the person is able to communicate and cooperate, ask them to cough forcefully until the airway clears.

Epiglottitis

A potentially life-threatening condition. The epiglottis is a small flap of cartilage that protects the start of the windpipe. When it becomes inflamed it swells and can partially or completely block airflow to the lungs.

Swelling of the epiglottis can result from various causes: burns from swallowing hot liquids, direct throat injury, or different infections. Epiglottitis can occur at any age.

Guillain‑Barré syndrome

A rare autoimmune disease in which the immune system attacks the nerves.

The demyelinating form destroys the protective covering (myelin sheath) of peripheral nerves, preventing nerve signals from reaching the brain. Early symptoms typically include limb weakness and tingling. These sensations can spread rapidly and may eventually paralyze the entire body.

In its most severe form it is a medical emergency. Most patients require hospital treatment.

The exact cause is unknown, but two-thirds of patients reported symptoms of an infection in the six weeks prior, such as a respiratory or gastrointestinal infection or Zika virus exposure.

There is no known cure for Guillain‑Barré syndrome, but several treatments can ease symptoms and shorten the course of the illness. Although most recover, the mortality rate is 4–7%. Some patients may have long-term effects such as weakness, numbness, or fatigue.

Cardiomyopathy

A disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body and can lead to heart failure. Main types include dilated, hypertrophic, and restrictive cardiomyopathy.

Treatment is mainly medication, but a heart transplant may be necessary depending on the type and severity of the cardiomyopathy.

Chest wall deformity (pectus deformity)

The deformity of the chest wall makes it difficult for the lungs to expand during inhalation, so not enough fresh air and oxygen reach the lungs.

Pleuritis (pleurisy)

Inflammation of the membrane surrounding the lungs. The pleura consists of two thin tissue layers that separate the lungs from the chest wall. Pleuritis means inflammation of this membrane and causes sharp chest pain that worsens with breathing.

One layer of the pleura surrounds the lung, the other lines the inner chest wall. Between them is a hair‑thin space filled with a very small amount of fluid. In health, the layers slide smoothly over each other with each breath, allowing the lungs to expand and contract. The small amount of fluid reduces friction between the pleural layers.

With pleurisy, the layers become swollen and rub together like two sheets of sandpaper, causing pain on both inhalation and exhalation.

Myasthenia gravis

A disease characterized by weakness and rapid fatigue of voluntary muscles. It is caused by a disruption in normal communication between nerves and muscles.

It is not curable, but treatment can relieve signs and symptoms such as weakness of the arms or legs, double vision, drooping eyelids, and difficulty with speech, chewing, swallowing, and breathing.

Although it can affect people of any age, it is more common in women under 40 and men over 60.

Pericarditis

Inflammation of the pericardium, the thin sac-like tissue surrounding the heart. It often causes sharp chest pain and sometimes other symptoms. Chest pain occurs when the inflamed layers of the pericardium rub against each other.

It is usually mild and resolves without treatment. In more severe cases, medication and rarely surgery may be required. Early diagnosis and treatment can reduce the risk of long-term complications of pericarditis.

Pulmonary fibrosis

A condition in which lung tissue — the tissues around and between the lung air sacs (alveoli) — becomes damaged and replaced by scar tissue. The increasingly thick, inelastic connective tissue makes proper lung expansion difficult. As it progresses, breathing efficiency declines and less oxygen reaches the body's cells.

Many factors can cause the scarring that leads to pulmonary fibrosis, but in most cases the cause cannot be determined. When no cause is found, the condition is called idiopathic pulmonary fibrosis.

The established lung damage cannot be reversed. Treatment can help relieve symptoms and improve quality of life. For some, lung transplantation may be considered.

Pulmonary hypertension

A type of high blood pressure that affects the arteries in the lungs and the right side of the heart.

In one form, pulmonary arterial hypertension (PAH), blood vessels in the lungs narrow or block, slowing blood flow and raising blood pressure in the pulmonary arteries. The heart must work harder to pump blood through the lungs. Over time this extra strain weakens the heart muscle and can cause it to fail.

It worsens over time and can become life-threatening. While some forms have no cure, treatment can help relieve symptoms and improve quality of life.

Pulmonary edema

Fluid accumulates in the lung tissues. Over time it can enter the air sacs and smaller airways, making breathing difficult.

Most cases are due to a heart problem. Other causes include pneumonia, certain toxins and medication side effects, or chest trauma (blow, kick). It can also occur in mountain climbers if ascent is too rapid.

Sudden pulmonary edema is a medical emergency requiring immediate care and can be fatal. Rapid treatment improves outlook. Therapy depends on the cause; it generally includes supplemental oxygen and medications to treat the underlying condition.

Lung cancer

A malignant tumor arising from lung cells. The lungs consist of two halves. When you inhale you take in oxygen-rich air, and when you exhale you expel carbon dioxide-rich air. Your cells need oxygen to function and produce energy; carbon dioxide is a waste product of these processes.

Lung cancer is the leading cause of cancer death worldwide.

Smoking is the greatest risk factor for lung cancer, though it can also occur in people who have never smoked. The longer and more you smoke, the higher your risk. Quitting all forms of tobacco significantly reduces the chance of developing lung cancer.

Sarcoidosis

A disease in which inflammatory cell clusters (granulomas) form in the body and may grow and multiply. It can affect any part of the body but most commonly the lungs and lymph nodes; it can also appear in the eyes, skin, heart, and other organs.

The cause is unknown. It may be an abnormal immune response to an unknown substance. Some research suggests infectious agents, chemicals, dust, or an abnormal reaction to the body's own proteins may play a role in people who are genetically predisposed.

There is no cure, but most people do well without treatment or with only mild therapy. In some cases sarcoidosis resolves on its own; in others it can persist for years and cause organ damage.

Heart failure

Anxiety disorders

Occasional anxiety is a normal part of life. People with anxiety disorders, however, often worry intensely, excessively, and persistently about everyday situations. They frequently experience repeated episodes of sudden intense anxiety, fear, or terror that peak within minutes (panic attacks). Some experience a choking sensation or chest pain during these attacks.

These feelings of anxiety and panic interfere with daily activities, are hard to control, are disproportionate to actual danger, and can last a long time.

People may deliberately avoid places or situations to prevent panic. Symptoms can begin in childhood or adolescence and continue into adulthood.

Anxiety disorders include social phobia, specific phobias, and separation anxiety disorder. More than one type of anxiety disorder can occur at the same time. Sometimes they are the result of another treatable medical condition.

Whatever form anxiety takes, treatment can help.

Broken ribs

A rib fracture is a common injury. The most frequent causes are chest trauma such as a fall, vehicle accident, or collision during contact sports.

Many rib fractures are simple cracks. A cracked rib hurts just as much, but it is not as potentially dangerous as a rib broken into separate pieces. Jagged bone edges can damage major blood vessels or puncture the lung.

They usually heal on their own in 1–2 months. Adequate pain relief is important so you can continue to breathe deeply and avoid lung complications such as pneumonia.

Tuberculosis (TB)

A potentially serious infectious disease that affects the lungs. It is caused by bacteria and is spread by people. The pathogen is released into the air by coughing and sneezing and is inhaled by others in small droplets.

In developed countries, tuberculosis infections began to rise again in 1985 partly due to the emergence of the HIV virus that causes AIDS. HIV weakens the immune system so it cannot fight TB bacteria. In Hungary, tuberculosis was a widespread disease in the early 20th century; in 1901 it caused 25% of deaths, and as late as 1953 nearly 50,000 cases were reported. Since 1954 every newborn has received BCG vaccination. Thanks to vaccinations and strict public health measures in the past century, as well as the establishment of lung screening systems, the number of cases has significantly decreased.

Poor housing conditions, inadequate hygiene, and diseases that cause immunodeficiency promote the development and spread of TB. In addition to vaccination, annual chest screening and proper hygiene are essential for prevention.

Many TB strains are resistant to the drugs most commonly used to treat the disease. People with active tuberculosis must take medication for months to eradicate the infection and prevent antibiotic resistance.

Anemia

There are not enough healthy red blood cells to carry adequate oxygen to the tissues. Because of anemia, or low hemoglobin, you may feel tired and weak.

There are many forms and causes. It can be temporary or long-term, and symptoms range from mild to severe. Often anemia has more than one cause. See your doctor if you suspect you have anemia, as it may be a sign of a serious condition.

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The diseases and conditions described here are often associated with shortness of breath and labored breathing. For an accurate diagnosis, always see a doctor and request the appropriate evaluation.

When to see a doctor?

Seek emergency medical care if you experience sudden, severe shortness of breath that affects your ability to function. Also seek care if your shortness of breath is accompanied by chest pain, fainting, nausea, bluish discoloration of the lips or nails, or changes in mental alertness — since these may be signs of a heart attack or pulmonary embolism.

Make an appointment for evaluation and see your doctor within a reasonable time if your labored breathing is accompanied by any of the following:

• Swollen feet and ankles
• Difficulty breathing while lying down
• High fever, chills, and cough
• Wheezing
• Worsening of already existing shortness of breath

Self-care measures for breathing difficulties

To help prevent worsening of chronic shortness of breath:

• Stop smoking: or even better, don’t start. Smoking is the leading cause of COPD. If you have COPD, quitting can slow disease progression and prevent complications.
• Avoid exposure to pollutants: as much as possible, avoid inhaling allergens and environmental toxins such as chemical fumes or secondhand smoke.
• Avoid extreme temperatures: very hot, humid, or very cold conditions can worsen breathlessness from chronic lung disease.
• Have an action plan: if you have a condition that causes breathlessness, agree with your doctor in advance what to do when your symptoms worsen.
• Be cautious with altitude: if you travel to high altitudes, allow time to acclimatize. Avoid exertion and gradually adapt to the altitude.
• Exercise regularly: physical activity can improve fitness and activity tolerance. Combined with weight loss when appropriate, exercise can reduce breathlessness caused by deconditioning. Always discuss an exercise program with your treating physician before starting.
• Take your medications: skipping medications for chronic lung and heart conditions can worsen control of breathlessness.
• Check your equipment regularly: if you rely on supplemental oxygen, make sure the flow is correct and the equipment is functioning properly.