EpistemisBreathing with pursed lips
Specialty: Respiratory.
Why it occurs
- Severe chronic obstructive pulmonary disease (COPD) or advanced pulmonary emphysema (unconscious adaptive maneuver performed by the patient to generate auto-PEEP, that is, a positive pressure at the end of expiration that prevents premature collapse of the small and intrathoracic airways during expiration, optimizing alveolar emptying)
- Severe bronchial asthma with significant dynamic air trapping
- Advanced cystic fibrosis (diffuse obstruction due to dense mucus that requires increased expiratory pressure to maintain bronchial patency)
- Decompensated congestive heart failure with passive pulmonary congestion.
Initial workup
Pre- and post-bronchodilator forced spirometry (evaluate severity of obstruction and air trapping through plethysmography if available); Baseline arterial blood gas (to evaluate the presence of chronic hypoxemia or compensated hypercapnia); Chest x-ray (search for signs of hyperinflation such as diaphragmatic flattening and increased retrosternal space).
red flags
Use of pursed-lip breathing at rest associated with obvious intercostal indrawing, inability to respond to simple questions, central cyanosis, cold sweats, or extreme psychomotor agitation indicating imminent fatigue of the respiratory muscles and need for intubation.
Standard management
- Tiotropium — long-acting muscarinic antagonist, 18 micrograms inhaled once daily to reduce dynamic hyperinflation
- Indacaterol — long-acting beta-2 agonist, 150 micrograms inhaled once daily
- Salbutamol (100 micrograms inhaled, 2 rescue puffs in case of exacerbation of dyspnea).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 4
- Treatment options
- 3