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I'm A Doctor and This COVID Symptom Scares Me The Most

What it means, and how to treat it.

Of all the unpleasant symptoms I have witnessed as a doctor, the one I fear the most is breathlessness, sometimes called shortness of breath. It's a common symptom of COVID-19 and in this article, I'll tell you how to recognize it and what to do if you do. Read on, and to ensure your health and the health of others, don't miss these Sure Signs You've Already Had Coronavirus.

What must it be like to experience acute, severe breathlessness? When I try to imagine this, I think about how it feels when you dive into a swimming pool and swim towards the surface, desperate to take a breath. There's an excruciating feeling of frantic anticipation about the need to take a breath—a sort of bursting feeling inside your chest. This usually only lasts seconds, because as you break through the surface of the water, you take a huge gasp of air, and instantaneously that frantic need-to-breathe feeling disappears. 

But imagine if you felt like that for most of the time—for example, if you had severe COVID pneumonia? Each gasp you manage to take fails to end that desperate feeling away. It's absolutely, unimaginably distressing.

If you ask people who have had an acute, severe asthma attack, they'll tell you that being unable to breathe is the most frightening thing they've ever experienced. People often describe the fear and anxiety which comes with a sense of impending doom, that something terrible is about to happen.

These are the most important things to know about COVID-related shortness of breath, how to cope with it, and when it's a medical emergency. 


The Normal Respiratory Rate

woman in sportswear with eyes closed training in fitness studio, calm fit millennial female practice yoga

We all breathe regularly, in and out, without thinking about it. We vary our breathing unconsciously all day long, when we speak, eat, and drink, or perhaps to stop ourselves from breathing in a large cloud of exhaust fumes. 

We usually only become aware of our breathing if something is wrong, and we start to feel breathless. The medical term for breathlessness is dyspnea.

  • The respiratory rate is one of our four vital signs (pulse rate, blood pressure, respiratory rate, and body temperature).
  • The respiratory rate is the number of times we breathe in and out every minute, at rest.
  • For an adult, a normal respiratory rate is 12 to 16 breaths per minute.


The Importance Of Our Vital Signs

The heart rate monitor

Our bodies are like any well-oiled machine. As long as all the body parts and organs are in good working order, all is well. But if something stresses the mechanics, or a body part (or organ) fails, the machine falters, and these vital signs become deranged. If you go to the doctor feeling unwell, this is why they first check these four vital signs—looking for engine failure.


We Must Breathe To Stay Alive

man relaxing after work breathing fresh air sitting at home office desk with laptop

Breathing is essential for human beings to stay alive. When we breathe in, oxygen passes into our lungs and diffuses through tiny capillaries into the bloodstream. At the same time, carbon dioxide passes out of these capillaries and into the lungs, and we breathe this out. This transfer of gases takes place continuously in tiny, air sacs within the lungs, called alveoli. 


What Causes Breathlessness?

Doctor nurse in protective face mask listening to breath with a stethoscope suspecting Coronavirus (COVID-19).

If anything disturbs this transfer of gases, your brain notices there is less oxygen on board and instructs your body to breathe faster and more deeply to raise those oxygen levels ASAP. Your brain continues to tell your body to do this until whatever has caused the reduced oxygen supply has been rectified. 

If you're breathless because you ran for a bus, the breathless sensation will disappear soon after you get on the bus and sit down. But if you feel breathless because of COVID-19 pneumonia, the feeling lasts much longer, sometimes for several weeks.

Many things disturb gas transfer in the lungs. Here are some common examples:

  • Infection. For example, COVID-19 causes pneumonia, which results in a build-up of fluid within the alveoli. The presence of this fluid reduces the efficiency of oxygen and carbon dioxide transfer. 
  • Respiratory conditions, such as asthma, cause the bronchioles (lung tubes) to contract and narrow, meaning not enough air can physically get into the lungs.
  • In COPD, the lungs are damaged by smoking, and the alveoli fill with tar and mucus.
  • Other medical conditions can cause fibrosis in lung tissue, meaning the lungs are stiff, and cannot expand and contract appropriately.  
  • If your blood circulation is compromised—for example, low blood volumes, dehydration, or shock—this can also cause breathlessness. 


What Happens When You Get Infected With COVID-19?

Imagine today was the day you became infected with COVID-19. Perhaps you unknowingly  shared a subway car with an infected person, who was also unknowingly shedding virus. Somehow as you jostled for a seat and sat down for around 15 minutes, you managed to breathe in enough viral particles to become infected. 

These tiny virus particles enter the cells lining your airways: Your mouth, nasal passageways, and respiratory tract. Once they enter your cells, they reproduce, creating many more viral particles which spread throughout your body. You are now excreting the virus when you breathe out, cough or sneeze, and can infect anyone else nearby. 

It seems incredible that despite all this going on, a huge 80% of people with COVID have no symptoms and are unaware they have it. But this seems to be the case. This is a trick of a clever virus— if a virus wants to succeed, it must operate by stealth and not get caught!

So all these fresh new viruses can now be transmitted in respiratory droplets when you exhale air, or when you cough or sneeze. They can also survive on infected surfaces, including your hands, and inanimate objects such as worktops, kitchen equipment, and toilet seats. This is why covering your nose and mouth with a face mask, washing your hands frequently, and keeping your home and bathrooms clean, are vital to prevent you from inadvertently infecting someone else. 

One COVID-positive person can infect up to 403 others over a 30-day period. However, if social distancing and infection control measures are followed as above, this reduces the risk of transmission by more than 95%—to only 2.5 people becoming newly infected.

It's not as simple as just having a COVID test. Strange as it may seem, in an early infection a COVID antigen test may be negative.


COVID-19 Symptoms–All About Breathlessness

Asian woman having difficulty breathing in bedroom at night

The most symptoms of COVID-19 infection are fever and a dry cough. However, 5% to 60% of COVID patients complain of breathlessness. This tends to set in between day four and day 10. Not everyone with COVID becomes breathless, but for those who do, it's a poor prognostic sign. 

Why does COVID-19 make you breathless? The virus causes pneumonia. As the virus spreads down inside your lower respiratory tract, your lung tissues become inflamed. There is a build-up of inflammatory fluid in tiny air sacs called the alveoli. The presence of this fluid impedes the diffusion of oxygen from the lungs and into the bloodstream, meaning your oxygen saturation starts to fall.

As soon as the brain recognizes these falling oxygen levels, you breathe faster and more deeply, to draw more air into your lungs. It now seems hard work to breathe. As time passes, if you still haven't developed sufficient antibodies to clear the virus, your respiratory rate can continue to increase. You may notice you feel breathless at rest just sitting in a chair, and any of your usual activities are difficult or impossible. You can't walk far, and you probably can't manage the stairs. If your symptoms are as bad as this, it's an emergency.

In severe acute COVID, admission to intensive care is generally advised if oxygen saturation falls below 93%, and/or your respiratory rate is greater than 30 breaths per minute.


Who Might Be At Risk Of Dyspnea With COVID?

Many individual risk factors put you at a higher risk of severe COVID-19 infection. Many of these are either medical conditions or lifestyle factors which put your respiratory function under additional stress. For example:

  • Older age. Your immune system is less efficient as you age.
  • Chronic lung conditions—e.g. asthma, chronic obstructive airways disease (COPD), emphysema, chronic bronchitis—impair lung function.
  • Heart disease. Any heart condition, such as angina, a heart attack, or heart failure, means you are more at risk of severe COVID -19 infection.
  • Diabetes. High blood sugars increase the risk of COVID-19. Uncontrolled diabetes doubles your risk of death.
  • High blood pressure. More deaths from COVID-19 seem to occur in patients with high blood pressure, but whether this is directly due to high blood pressure itself, or whether it is due to other medical conditions often associated with high blood pressure is still unknown.
  • Smoking. Smokers are at greater risk of severe COVID-19 infection than non-smokers. 
  • Kidney disease. A recent US 2020 meta-analysis concluded that the risk of severe COVID-19 infection in people with chronic kidney disease is three times higher. 
  • Liver disease. People with liver disease such as cirrhosis, fatty liver, hepatocellular carcinoma and liver transplants are also at increased risk of severe COVID-19 infection. 
  • Neurological disease. There seems to be a link between increased risk of death from severe COVID infection and dementia, as well as to other neurological conditions such as stroke.
  • A  weakened immune system. There have been several case reports of severe COVID-19 infections in patients with organ transplantation and with various types of autoimmune disease. The exact risk posed by an underactive immune system is not well understood, but anyone with a compromised immune system is currently believed to be at higher risk from COVID-19 infection.
  • Obesity. UK data analysis shows that two-thirds of patients admitted to ICU with severe COVID-19 were overweight or obese.
  • BAME (Black and minority ethnics) groups.  It's not clear why people from BAME groups are more at risk from COVID-19, but it may be due to a combination of factors including factors such as deprivation, crowded housing, and/or type of employment. Studies are underway to find out more.
  • Your job. The risk of COVID infection is three times higher in frontline medical care staff, despite the use of PPE. A July 2020 study in The Lancet, reported 2,747 COVID cases per 100,000 in healthcare staff, compared to 242 per 100,000 for the general population. The calculation was adjusted because health care staff are more likely than the general public to be tested. However, even after adjusting for this, they were still three times more likely to become infected. 


Living With a COVID-19 Infection

Sick woman with fever checking her temperature with a thermometer at home

It can be hard to know when to call for help with COVID infection. After all, when you test positive, you're first told firmly to stay at home. However, remember:

  • 4 out of 5 patients have only a mild infection. 
  • 80% of people with COVID have no symptoms, or only very mild symptoms.
  • COVID-19 is a virus, so antibiotics will not work.
  • It's a question of rest, fluids, and letting time pass so your body can develop antibodies and get rid of the virus.

You need to stay home and self-isolate for at least 10 days after your symptoms first appeared. After this, if you just have a cough and loss of sense of taste or smell, you can stop self-isolating, but if you have any other symptoms you should continue self-isolating until these have gone. Here's how to self isolate.

Everyone in your household should also self-isolate for 14 days from the day you first had symptoms. 

However, for some patients, symptoms can be unpleasant and severe. One of these miserable symptoms is feeling breathless.


What Do We Know About COVID-19 And Feeling Breathless?


If COVID symptoms develop, it's usually around five days after becoming infected. The majority of people with symptoms complain of a fever and a cough. Breathlessness is only present in 31% to 40% of sufferers.

The degree of breathlessness can be mild, moderate or severe. Your condition may worsen rapidly, sometimes within hours or even minutes.

In the majority of people, the feeling of breathlessness will improve as your body develops antibodies and fights off the infection. However, in small numbers of people, this can get worse, necessitating admission to the hospital and/or intensive care treatment. In the most serious cases, a mechanical ventilator is needed to take over breathing.

The overall risk of death from COVID infection is about 1.4%. The risk increases with increasing age: 1 in 300 under age 60, 1 in 16  aged over 60, and 1 in 7 aged over 80.


When Is Breathlessness An Emergency?

Infected patient woman with face mask lying in bed at disease treatment room, doctor wearing protective clothing take care of the sick in quarantine at hospital

If you're severely breathless, this is a medical emergency. If you have any of the following signs, you or a caretaker should call 911 without delay.

  • Being unable to finish a sentence without taking a breath
  • Being unable to speak
  • Being unable to do normal things like walk to the bathroom or manage the stairs
  • Feeling confused, or disorientated
  • Feeling scared about your breathing/inability to breathe
  • Developing new symptoms such as chest pain, or coughing up blood/blood-stained sputum


How Can You Assess Your Own Breathing?

woman with headache in front of a bathroom mirror

It's virtually impossible to properly assess your own breathing, especially if your symptoms are severe. If you are concerned at all, it's best to get an urgent medical assessment and not to wait.   


"Happy Hypoxemia"

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One of the strange things about COVID infection is that infected patients may not fully realize just how breathless they really are. 

To feel breathless, your brain has to recognize the situation and send out an alert. But in COVID infection, for unclear reasons this mechanism is blunted. This has led to a term—"happy hypoxemia"—meaning quite often, COVID patients are very breathless but comparatively unaware of the seriousness of their condition.

As a result, it takes longer for them or their caretakers to appreciate how seriously ill they are and leads to a delay in getting to the hospital.

Don't take any risks. If you're concerned about your breathing, get a proper medical assessment without delay.


How Can Doctors Assess Your Breathing?

woman video chat doctor

Doctors are often now faced with having to assess your condition on a video link. They need to have some simple ways of judging how your breathing is affected. Sometimes, they use an algorithm called the Roth score. This is how it works.

You are asked to take a breath and count to 30 slowly out loud. The doctor will time how long it takes before you take a breath while reciting the numbers. If it's under 8 seconds, your oxygen saturation is likely to be less than 95%. If it's within 5 seconds, your oxygen saturation is likely to be less than 91%.

In fact, the Roth Score is not that accurate. The main problem is that it can lead to you being advised to go to the hospital too often. However, it is a practical and simple way for you to get some idea of how bad your breathing is.


Other 'Red Flag' Questions

Teenage boy sick in bed with Covid-19 symptoms

It's also important to keep tabs on how things are changing. What can't you do today that you could do yesterday? 

How would you answer the following questions? 

  • Are you so breathless that you are unable to speak more than a few words?
  • Are you breathing harder or faster than usual when doing nothing at all?
  • Are you so ill that you've stopped doing all of your usual daily activities?

If the answer to one or more of these questions is "yes," you need urgent medical help.


Other Signs Of Difficulty Breathing

Elderly woman feeling unwell,she's headache and painful around chest area.

You can tell people are having difficulty breathing by observing the following clinical signs and  features. People who can't breathe well, have to work hard at their breathing. 

They often 

  • Sit up straight and can't lie back on their pillows or lie flat in bed
  • Hold onto the table in front of them, or for example a  pile of pillows, as they struggle to breathe
  • Use additional muscles to breathe such as their neck muscles
  • Use their diaphragms to breathe, so you can see the abdomen moving in and out with each breath
  • Have flared nostrils as they try to suck more air in through their nasal passages
  • Have difficulty eating and drinking, as they can't risk interrupting their breathing
  • Can't communicate, as they can't listen well or speak, and may get agitated and irritable as their breathing takes over everything
  • May be disoriented, and not know the day, or time, or be confused
  • May not be able to take their usual medications
  • Their lips may look thin and blue, and their fingertips and nail beds may look blue – this is cyanosis which occurs when oxygen saturation levels are low.
  • Have a tremor. If they hold out their hands straight in front of them with the wrists extended, a flapping tremor may be seen, which is a sign of metabolic disturbance due to retaining carbon dioxide.
  • May have sporadic muscle jerks or twitches.
  • Can have cold hands and feet.


What Can You Do To Help Relieve Symptoms Of Breathlessness?

deep breath

The best way to improve breathlessness is to treat the underlying cause. But for COVID-19, which is a virus, there is still no effective treatment. You just have to wait for your body to produce antibodies to kill the virus.

However, there are some things which can be done to help support breathing and help relieve the sensation of breathlessness.

  • Sit upright. A chair may be better than a bed. Sit forward and have something in front of you to rest your hands on.
  • Try to stay calm. This is easier said than done, but anxiety makes breathlessness worse. Try to breathe deeply and slowly. Get into a rhythm: Breathe in on the count of one, and out as you count 2 and 3. It's always important to breathe out for longer than you breathe in. Remember you need to expel air from your lungs to have room to get more air in, so the breathing out is an important part of the process.  If you don't breathe out fully, you will retain more carbon dioxide. Make sure you are not just panting, with short quick breaths, as this is counterproductive. 
  • Actively use your diaphragm to breathe. Think about raising your rib cage when you breathe in, by lifting from the midriff upwards. You can see and feel your tummy moving in and out when you do this properly.
  • Some people find pursing their lips when they exhale helps. This is because you empty your lungs better when you breathe out against a forced resistance.
  • Keep the window open or sit by a door. Fresh air helps, however with COVID the use of fans is not permitted because of the increased risk of spreading infection.
  • Keep hydrated. You need a good blood volume to maintain good blood circulation. Have sips, little and often. 
  • Take your regular medication. This includes any inhalers or nebulizers you usually use.
  • Steam inhalations can help loosen mucus and soothe inflamed airways. Vicks or other vapor rubs can be helpful. Try a hot shower. 
  • Use a home humidifier. Research has shown the virus spreads more rapidly in dry environmental conditions. When the air is dry, mucus is thicker and the small ciliated cells lining the airways are less good at moving mucus up and away from the lungs. The CDC recommends the use of a humidifier to treat COVID. Aim for around 50% air humidity. You can achieve this just by having a pan of gently boiling water in the room. Or by purchasing a humidifier.


Chest Exercises

Curly woman feeling bad and suffering from strong cough while having flu

Have you heard of the Huff technique?

When you huff, think of what you do when you polish a mirror. Breath out forcefully and rapidly, once or twice. To do this you will contract your chest and stomach muscles suddenly. It may bring on a coughing bout as you will have loosened some chest secretions – which is good.

Do this for about 10 minutes, two to three times a day. Stop doing it when you have done the huff cycle twice but not coughed up any mucus.


Sleeping Positions

woman sleeping on sofa

Sleep can be difficult if lying down brings on your cough and makes the breathlessness worse. Only do what feels possible. In principle, you need to move around and alter the position of your chest to drain all the different lobes of the lungs. So when you sleep, try using pillows to prop yourself up on one side, then the other side, even head-down a little, even for short periods to encourage the fluid and mucus in your lungs to shift.


Oxygen Therapy

woman makes inhalation nebulizer at home

Your oxygen saturation level will determine whether you need additional oxygen. In general, you need oxygen if your oxygen saturation is less than 92%, but this threshold is sometimes lowered if you have other chronic diseases.  This is simply measured using a device called a pulse oximeter.

  • Oxygen gas is supplied via a face mask for you to breathe in, in hospital. However, if simply breathing in more oxygen does not improve your oxygen levels, CPAP may be tried.
  • Continuous Positive Airways Pressure (CPAP) – This means oxygen is piped into your lungs under pressure. Although this is often effective, there is an increased risk of transmitting the virus to other healthcare workers, and staff need highly effective PPE.
  • Mechanical ventilation – This means you are sedated, and the machine takes over breathing for you. This is a high-risk situation. Only around 33% of those ventilated for COVID infection will recover.


Practical Support

One way to feel less breathless is to reduce the demands upon your body. The less active you can be with your domestic duties, the more energy is left over for you to concentrate on breathing and give your body time to recover. This means thinking about personal organization. You may need someone to help you.

  • Shop once a week, online if possible, and get home delivery, rather than running out of things every day.
  • Buy simple prepared foods that don't need much effort to cook.
  • Keep everything within reach, so you don't continually need to reach to high shelves or rummage in cupboards.
  • Accept help from friends, families, and neighbors. They can walk the dog and water your garden. Conserve your energy for getting well.
  • Keep a list of important numbers next to your phone. Have these also programmed into your phone, so it's easy to call for help.
  • Pace yourself during the day. Accept that things will take longer – don't rush. You have time to breathe calmly and get through each day the best you can. 
  • It's OK to feel tired. Illness is exhausting. Rest is important for healing. Don't feel bad about not being able to do anything. Sit quietly, breathe, and distract yourself with TV or music.
  • Eat for health. Eat small nourishing portions of foods to support your immune system and give you energy. 


Staying Positive

Sick young woman eating broth to cure cold in bed at home

Many people living through the pandemic are finding their mental health is not good right now.  If you become infected with COVID, this brings a range of pressures, anxiety, and restrictions, and it's likely to stress your mental health even more.

Try to stay calm and positive. Anxiety and stress harm the immune response. Tell yourself firmly that you will beat this infection and follow all advice carefully. 

Think of the good points:

  • Although COVID is a serious infection, around 99% of people survive.
  • Those with the most severe infections seem to have the best antibody response.
  • Only visit trusted resources such as government or charity websites for reliable information. Don't allow yourself to get hoodwinked or made anxious by fake news.
  • Don't listen to the news too often. A constant deluge of sensationalist stories doesn't help. Listen to music or read a book instead.
  • Keep in contact with friends and family. Although you will no doubt be self-isolating, you can have phone and video calls with friends and family. This is very important.
  • The CDC has published a list of resources and telephone hotlines.

As for yourself: To get through this pandemic at your healthiest, don't miss these 35 Places You're Most Likely to Catch COVID.

Deborah Lee, MD
Dr. Deborah Lee is a health and medical writer with an emphasis on women's health. Read more about Deborah