What is the best approach to manage a 74-year-old female (F) with a history of schizophrenia, asthma, and previous negative cardiac workup (Holter (holter monitor), echo (echocardiogram), CXR (chest X-ray), and troponin (trop)) presenting with chronic shortness of breath (SOB) likely secondary to anxiety?

Management of Chronic Shortness of Breath in a 74-Year-Old Female with Schizophrenia and Asthma

For a 74-year-old female with schizophrenia, asthma, and chronic shortness of breath likely due to anxiety with previously negative cardiac workup, the most appropriate management approach is to first optimize asthma control with appropriate medications while simultaneously addressing the anxiety component with benzodiazepines for acute episodes and buspirone for long-term management.

Initial Assessment

• Confirm that previous cardiac workup (Holter, echocardiogram, chest X-ray, and troponin) remains relevant by checking for any new cardiac symptoms or changes in clinical presentation 1
• Evaluate asthma control status by assessing frequency of symptoms, medication compliance, and potential exacerbating factors 1
• Assess for possible dysfunctional breathing patterns which can mimic or exacerbate asthma symptoms, particularly in patients with anxiety 1
• Consider performing spirometry to objectively measure current lung function and response to bronchodilators 1

Asthma Management

• Optimize controller medications according to current guidelines, ensuring patient is on appropriate inhaled corticosteroids (ICS) with or without long-acting beta-agonists (LABAs) 1
• Provide short-acting beta-agonists (SABAs) for rescue therapy, but monitor for overuse which may indicate poor asthma control 1
• Consider adding leukotriene modifiers which can be used daily or intermittently to prevent exercise-induced bronchoconstriction without leading to tolerance 1
• Ensure proper inhaler technique, which may be particularly important in elderly patients with schizophrenia who might have cognitive or coordination challenges 1, 2

Anxiety Management

• For acute anxiety episodes with associated dyspnea, short-acting benzodiazepines such as alprazolam may be beneficial, particularly when panic symptoms are present 1, 3
• For long-term management, consider buspirone starting at 5 mg twice daily (maximum 20 mg three times daily), which is particularly effective for anxiety in patients with chronic respiratory conditions 1, 4
• Be aware that buspirone may take 2-4 weeks to become effective, so patient education about expectations is important 4
• Consider selective serotonin reuptake inhibitors (SSRIs) as an alternative for managing both anxiety and panic symptoms if buspirone is ineffective 1

Special Considerations for Schizophrenia

• Ensure coordination of care between psychiatric and medical providers to optimize medication management and avoid drug interactions 5, 2
• Be aware that patients with schizophrenia may have poorer asthma control and medication adherence compared to the general population 5, 2
• Consider more frequent follow-up visits to monitor both psychiatric and respiratory symptoms 2
• Evaluate for potential medication interactions between psychotropic medications and respiratory medications 6

Non-Pharmacological Interventions

• Implement pulmonary rehabilitation which combines cardiovascular fitness, self-confidence building, and stress control techniques 1
• Teach relaxation techniques such as yoga which may help manage both anxiety and dyspnea 1
• Consider oxygen therapy during exercise if desaturation is documented, as this can increase exercise capacity 1
• Provide education on dysfunctional breathing patterns and techniques to normalize breathing during anxiety episodes 1, 7

Follow-Up Plan

• Schedule regular follow-up visits to assess response to therapy and adjust treatment as needed 1
• Monitor for signs of worsening psychiatric symptoms that could impact respiratory status 7
• Reassess cardiac status if symptoms change or worsen despite optimal management of asthma and anxiety 1
• Consider home pulse oximetry monitoring to objectively assess oxygen saturation during symptomatic episodes 1

Pitfalls and Caveats

• Avoid attributing all symptoms to anxiety without thoroughly excluding organic causes, especially in elderly patients 1
• Be cautious with long-term use of benzodiazepines due to risk of dependence and potential respiratory depression in patients with underlying lung disease 1
• Remember that patients with schizophrenia may have altered perception and reporting of symptoms, making objective measurements particularly important 2, 7
• Consider that abnormal breathing patterns in schizophrenia may be directly related to the psychiatric condition and not just secondary to anxiety 7