Dalhousie dyspnea scales: Pictorial scales to measure dyspnea during induced bronchoconstriction

Inborn errors of metabolism in palliative care

BACKGROUND

In parallel with the increase in the number of children with life-limiting or life-threatening diseases, the need for and right to pediatric palliative care is also increasing. This study aimed to examine the metabolic diseases, evaluate the symptoms, and review the needs of children who were admitted to the pediatric palliative care service.

METHODS

Following the approval of the local ethics committee (18/7/2019-107), the computer records of patients hospitalized in the pediatric palliative care service between December 1, 2018 and January 6, 2019 were reviewed retrospectively. Dr Behçet Uz Children's Hospital, Pediatric Palliative Care Center is third center in Turkey. Our pediatric palliative care center has one year of experience.

RESULTS

In the study period, there were 101 patients who were hospitalized in the pediatric palliative care service. Eighteen patients (19.7%) diagnosed with inborn errors of metabolism were included in the study. The mean age was 3.2 ± 2.1 (0-8) years. Although it could not be shown statistically, the duration of hospitalization of patients with congenital malformation was long.

CONCLUSION

Pediatric palliative care provides the best care with the control of various symptoms in neurodegenerative congenital metabolic diseases that do not have treatment or treatment, but progressive symptoms cannot be prevented.

Design and Comprehension Testing of Tailored Asthma Control Infographics for Adults with Persistent Asthma

BACKGROUND

Adherence to daily inhaled corticosteroid medication is important for asthma control but low health literacy is a barrier to comprehension of control status and may contribute to medication nonadherence. Infographics tailored with patients' own data can support comprehension of health status, but these have not been applied to asthma successfully.

OBJECTIVES

This two-phased study developed and tested tailored infographics of (1) scores on the Asthma Control Questionnaire (ACQ), a self-report measure of symptom burden, and (2) pulmonary function test (PFT) results. The infographics are intended for use as communication and adherence-promotion tools in clinical interactions.

METHODS

For both phases, participants (18+ years, English- or Spanish-speaking, persistent asthma) were recruited through two primary care clinics. In Phase I, we used a hybrid iterative participatory design process to refine prototype designs. In Phase II, we conducted individual comprehension assessment interviews with the finalized designs. Infographics were hand-tailored for each participant using their ACQ score and PFT results collected at the start of the interview. Two independent raters scored interview transcripts for gist and verbatim comprehension based on a predetermined rubric.

RESULTS

The five Phase I design sessions led to final prototypes that participants (n = 21) considered appealing and easy to comprehend. All Phase II participants (n = 10) demonstrated complete gist and verbatim comprehension. Participants reacted favorably to receiving their information via infographics and expressed intentions to engage in self-management behaviors (e.g., medication adherence, smoking cessation, weight loss, and review of their care plan) in response to the information.

CONCLUSION

This study provides preliminary evidence that infographics can support comprehension of asthma control status and promote self-management intentions among adults with persistent asthma. Infographics can be programmed into electronic health records and/or standalone applications to allow for instant tailoring at the point of care.

Exertional Dyspnea in Childhood: Is There an Iceberg Beneath the Apex?

This essay expounds on fundamental, quantitative elements of the exercise ventilation in children, which was the subject of the Tom Rowland Lecture given at the NASPEM 2018 Conference. Our knowledge about how much ventilation rises during aerobic exercise is reasonably solid; our understanding of its governance is a work in progress, but our grasp of dyspnea and ventilatory limitation in children (if it occurs) remains embryonic. This manuscript summarizes ventilatory mechanics during dynamic exercise, then proceeds to outline our current understanding of mechanisms of dyspnea, particularly during exercise (exertional dyspnea). Most research in this field has been done in adults, and the vast majority of these studies in patients with chronic obstructive pulmonary disease. To what extent conclusions drawn from this literature apply to children and adolescents-both healthy and those with cardiopulmonary disease-will be discussed. The few, recent, pertinent, pediatric studies will be reviewed in an attempt to provide an empirical basis for proposing a hypothetical model to study exertional dyspnea in youth. Just as somatic growth will have consequences for ventilatory and exercise capacity, so too will neural developmental plasticity and experience affect perception of dyspnea. Our path to understand how these evolving inputs and influences summate during a child's life will be Columbus' India.

Pediatric Palliative Care for Children with Progressive Non-Malignant Diseases

A substantial number of children cared for by pediatric palliative care physicians have progressive non-malignant conditions. Some elements of their care overlap with care for children with cancer while other elements, especially prognosis and trajectory, have nuanced differences. This article reviews the population, physical-emotional and social concerns, and trajectory.

Dalhousie Pictorial Scales Measuring Dyspnea and Perceived Exertion during Exercise for Children and Adolescents

RATIONALE

Alternative scales to measure dyspnea and perceived exertion have been sought due to concerns regarding understanding and validity of any Borg scale in pediatric populations.

OBJECTIVES

To demonstrate content validity of Dalhousie Dyspnea and Perceived Exertion Scales developed for children and adolescents.

METHODS

We obtained ratings for dyspnea and perceived exertion using both Borg CR-10 and Dalhousie Scales during incremental cycle exercise in 100 children and adolescents, healthy or with respiratory disease. Content validity was determined by correlating perceived leg exertion rating versus heart rate or %peak work capacity and dyspnea rating versus ventilation expressed as %peak ventilation. The stimulus-perceptual response was modeled as a quadratic function with a delay term. Reproducibility, cross-modality usage, and language effects were assessed in a small group of Italian children during treadmill exercise.

MEASUREMENTS AND MAIN RESULTS

Pictorial ratings of dyspnea and perceived exertion measured by both scale ratings rose as expected with increasing exercise intensity in children and adolescents, demonstrating excellent correlation between perceived leg exertion versus exercise intensity and dyspnea rating versus ventilation (median Spearman ρ ≥ 0.9) with either scale. There were no systematic differences in dyspnea or perceived exertion ratings between children with or without respiratory disease. Understandability and reproducibility of the Dalhousie scales was affirmed in Italian-speaking subjects performing treadmill exercise.

CONCLUSIONS

Dalhousie Dyspnea and Perceived Exertion Scales offer an alternative to the Borg scale for use during exercise in pediatric subjects. Children and adolescents exhibit large variation in patterns of ratings of dyspnea and perceived exertion in incremental exercise.

Management of respiratory symptoms in paediatric palliative care

PURPOSE OF REVIEW

Respiratory symptoms in children with life-limiting and life-threatening conditions are common, distressing and have a lasting impact, yet there is a paucity of evidence to guide clinicians in their management. This article makes a series of recommendations for the management of the most frequent and distressing respiratory symptoms encountered in paediatrics (dyspnoea, cough, haemoptysis and retained secretions) with attention to the evidence from research.

RECENT FINDINGS

There are very few paediatric studies exploring any aspect of respiratory symptoms in paediatric palliative care, so much of the evidence base has been drawn from adult studies, few of which have been published in the past 12-18 months.

SUMMARY

In the absence of well designed paediatric studies we need to judiciously apply what we can extrapolate from adult studies to each child we are treating; selecting interventions and approaches carefully, adjusting them when there is no evidence of individual benefit.

Dalhousie Dyspnea and perceived exertion scales: psychophysical properties in children and adolescents

Children and adolescents vary widely in their perception of, or capacity to rate, sensations during exercise using the Borg scale. We sought to measure sensory-perceptual responses obtained using Dalhousie Dyspnea and Perceived Exertion Scales in 79 pediatric subjects during maximal exercise challenge and to determine the psychophysical function relationship(s). Concurrent validity was assessed by canonical plots of mean ratings on either scale, which showed showing very good correlations for perceived leg exertion vs work, and dyspnea vs ventilation. Both scales yielded similar results with respect to goodness of fit regardless of whether data was fitted to a power or quadratic function provided a delay term was included. The quadratic model fixed the exponent of the power law at 2 but, unlike a power model, allowed characterization of individual responses that increased and then plateaued. Dalhousie Dyspnea and Perceived Exertion Scales offer an alternative to Borg scale during exercise in pediatric populations.

Palliation of Dyspnea in pediatrics

Dyspnea is a complex physiologic and psychosocial symptom that is difficult to characterize and measure, but essential to treat, as it has a significant effect on quality of life. Although palliation of dyspnea in the child with chronic illness is an under-researched area, children and their families cannot wait for the research to catch up with their current needs. This article addresses several aspects of dyspnea in pediatrics palliative care, with an eye toward practical suggestions for evaluation and management.

Development and validation of a pictorial nausea rating scale for children

OBJECTIVE

The lack of a widely used, validated measure limits pediatric nausea management. The goal of this study was to create and validate a pictorial scale with regular incremental levels between scores depicting increasing nausea intensity.

METHODS

A pictorial nausea scale of 0 to 10 with 6 faces (the Baxter Retching Faces [BARF] scale) was developed in 3 stages. The BARF scale was validated in emergency department patients with vomiting and in healthy patients undergoing day surgery procedures. Patients were presented with visual analog scales for nausea and pain, the pictorial Faces Pain Scale-Revised, and the BARF scale. Patients receiving opioid analgesics or antiemetic agents had their pain and nausea assessed before and 30 minutes after therapy. Spearman's ρ correlation coefficients were calculated. A Wilcoxon matched-pair rank test compared pain and nausea scores before and after antiemetic therapy.

RESULTS

Thirty oncology patients and 15 nurses participated in the development of the scale, and 127 patients (52, emergency department; 75, day surgery) ages 7 to 18 years participated in the validation. The Spearman ρ correlation coefficient of the first paired BARF and visual analog scale for nausea scores was 0.93. Visual analog scales for nausea and BARF scores were significantly higher in patients requiring antiemetic agents (P = .0001) and decreased significantly after treatment (P = .0002), while posttreatment VAS (P = .20) and FPSR scores (P =.47) for patients receiving only antiemetic agents did not [corrected].

CONCLUSIONS

We describe the development of a pictorial scale with beginning evidence of construct validity for a self-report assessment of the severity of pediatric nausea. The scale had convergent and discriminant validity, along with an ability to detect change after treatment.

Desempenho de uma escala analógica visual legendada na determinação do grau de dispneia durante teste de broncoespasmo induzido por exercício em crianças e adolescentes asmáticos

OBJETIVO: Existe uma relação indireta entre a obstrução das vias aéreas em asma e a intensidade de falta de ar (dispneia). Uma escala visual analógica legendada de dispneia com escore de 0-3 pontos tem sido amplamente utilizada na avaliação da broncoconstrição, embora a percepção de tal obstrução seja muito variável. O objetivo deste estudo foi determinar se crianças e adolescentes são capazes de perceber a broncoconstrição aguda induzida por exercício (BAIE), bem como medir o poder discriminatório de uma escala visual analógica legendada de dispneia em relação à intensidade de BAIE. MÉTODOS: Estudo transversal com 134 crianças e adolescentes asmáticos que foram submetidos a um teste de broncoespasmo induzido por seis minutos de exercício em um cicloergômetro. A intensidade da dispneia foi determinada utilizando-se uma escala visual analógica legendada de dispneia antes de cada determinação de VEF1. A escala tem um escore de 0-3 pontos, com desenhos em uma sequência lógica variando entre "sem sintomas" e "dispneia grave". As variáveis foram determinadas no momento basal, assim como em 5, 10 e 20 minutos após o término do teste de exercício. A acurácia da escala de dispneia em detectar o grau de BAIE foi determinada através de curvas ROC para a queda de VEF1 após o exercício, usando pontos de corte de 10%, 20%, 30% e 40%. RESULTADOS: Dos pacientes selecionados, 111 completaram o estudo, e 52 (46,8%) apresentaram BAIE. A área sob a curva ROC progressivamente aumentou com o aumento do grau de broncoconstrição. CONCLUSÕES: Em crianças e adolescentes asmáticos, a acurácia desta escala de dispneia melhora com o aumento do percentual de queda em VEF1 após o exercício. Entretanto, o valor preditivo da escala é subótimo quando a porcentagem de queda em VEF1é menor.

Frequency and self-management of pain, dyspnea, and cough in cystic fibrosis

Cystic fibrosis (CF) has been transformed from a fatal diagnosis in infancy to a chronic disease of children and young adults. Symptom patterns and disease burden in CF may be shifting to reflect the relatively healthier, older population with the disease. Self-management of symptoms is a hallmark of chronic illness, and yet we do not have a good understanding of how CF patients monitor or manage their symptoms. Children and adults were recruited through clinics in three Canadian provinces. Questionnaires with open-ended and close-ended questions in English and French, designed to assess the frequency, severity, and self-management of pain, breathlessness, and cough, were mailed to all the eligible participants. One hundred twenty-three respondents completed the survey, for a response rate of 64%. Eighty-four percent (103 of 123) of participants reported having pain. They reported an average of 2.1 locations of pain, with headache and abdominal pain most frequently described. Sixty-four percent (76 of 123) of participants reported having breathlessness, and 83% (99 of 123) of participants reported experiencing cough. Sixty-three percent (62 of 99) of participants with cough reported that cough always or sometimes interfered with their sleep. A variety of pharmacological and nonpharmacological treatments were used to manage symptoms. Pain and dyspnea are more common than suspected and a wide variety of pharmacological and nonpharmacological measures are used to treat symptoms. Cough is difficult to assess, but disturbed sleep may be an indicator of cough severity and an important symptom to consider when evaluating the overall burden of illness in those with CF.

Plethysmographic lung volumes in children with sighing dyspnea

BACKGROUND

This study compared the plethysmographic lung volumes of children with sighing dyspnea with healthy children and tested the hypothesis that sighing children suffer from hyperinflation or gas trapping as a cause of dyspnea.

METHODS

From January 2006 to December 2006, pediatric patients with sighing dyspnea presenting to the pulmonary clinic of a tertiary children's hospital who had no apparent cardiopulmonary diseases were prospectively enrolled; normal healthy children were invited to participate for comparison. Baseline pre-bronchodilator spirometry and post-inhaled bronchodilator spirometry were measured for the determination of bronchodilator response. Plethysmographic lung volumes were determined solely for total lung capacity, residual volume (RV) and functional residual capacity (FRC) without the use of inhaled bronchodilator according to standard procedure.

RESULTS

Eighteen sighing children (10 boys) and 10 healthy subjects (six boys) were included in the present study. They had a median age of 13 years (range, 8-15 years) and 13 years (range, 8-17 years), respectively. The mean baseline forced vital capacity (FVC) of subjects with dyspnea was 79.4 +/- 16.7% of predicted, while that of the normal control children was 88.4 +/- 6.7%, which was not statistically significantly different. Forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC % of predicted were within normal limits and indicated no bronchodilator response. RV and RV/total lung capacity (TLC) were elevated in children with sighing dyspnea that were not measured by spirometry, but TLC and FRC measured on plethysmography (FRC(pleth)) were not increased.

CONCLUSIONS

RV and RV/TLC were higher in children with sighing dyspnea that were not measured by spirometry, but TLC and FRC(pleth) were not increased. The causal link between dysfunctional breathing patterns and changes in static lung volumes was not able to be determined in the present study. The possibility of heterogeneity of patients with sighing dyspnea obscures the significance of lung volume discrepancy in this population; further subdivision of children with sighing dyspnea in a larger cohort of patients is required.

Pediatric Dyspnea Scale for use in hospitalized patients with asthma

BACKGROUND

Asthma is a leading cause of pediatric hospitalizations across the country, yet no clinical instrument exists that incorporates the child's perception of dyspnea in determining discharge readiness.

OBJECTIVE

We sought to develop the Pediatric Dyspnea Scale (PDS) to support discharge decision making in hospitalized asthmatic patients and to compare the performance of the PDS with traditional markers of asthma control in predicting outcomes after discharge.

METHODS

Asthmatic children aged 6 to 18 years hospitalized for an exacerbation were included in the study. The PDS score, demographics, asthma severity, spirometric results, peak expiratory flow rate, and fraction of exhaled nitric oxide were assessed at the time of discharge. A telephone call 14 days after discharge determined relapse, activity limitation, asthma control, and asthma-related quality-of-life outcomes.

RESULTS

Eighty-nine patients were enrolled, of whom 70 completed the telephone follow-up. Eight patients had a relapse, and 29 complained of limited activity. A PDS score of greater than 2 on the 7-point scale was a significant predictor of these poor outcomes, with each additional point of the PDS doubling the risk. A higher score on the PDS also correlated with worse asthma control and poor asthma-specific quality of life. The PDS performed better than FEV(1), peak expiratory flow rate, or fraction of exhaled nitric oxide in predicting the outcomes of interest.

CONCLUSION

The PDS, which is easy to use in children as young as 6 years of age, might be able to predict adverse outcomes after hospitalization for an asthma exacerbation and should be used as a tool to help guide inpatient discharge decisions.

Dyspnoea in children. Does development alter the perception of breathlessness?

Dyspnoea, the perception of an unpleasant and/or uncomfortable sensation of breathlessness, offers several physiological, anatomical and teleological analogies with pain. Pain perception has been shown to exist in the newborn, suggesting that dyspnoea may also occur from birth onwards. The perception of breathlessness will be subservient to developmental changes in the behaviour of sensors and lung and muscular receptors implicated in dyspnoea, some of which are known to be active at time of birth. For example, perinatal resetting of the arterial chemoreceptor could lead to transient depression of the dyspnoeic response to hypoxia. However, though early evoked ventilatory responses and peripheral receptor maturation do exist, dyspnoea will only occur if the corresponding central neural circuitry undergoes parallel maturation. Our knowledge of dyspnoea in later childhood is based on a small number of clinical or psychophysical studies, predominantly dealing with asthma and exercise. There is a thus a clear need for systematic assessment of the existence and severity of dyspnoea sensing in younger children that takes into account its role as an alarm mechanism for triggering adaptive and/or protective responses.

Exhaled nitric oxide measurements in hospitalized children with asthma

BACKGROUND

The reproducibility of exhaled nitric oxide (FE(NO)) measurements performed in pediatric hospitalized asthmatics has not been previously evaluated.

OBJECTIVE

To evaluate the reproducibility of FE(NO) measurements in the hospital; to look for differences between those who were and were not able to perform FE(NO) measurements; and to assess any factors correlated with FE(NO) measurements.

METHODS

89 hospitalized pediatric asthmatics performed FE(NO), FEV1, and peak expiratory flow rate (PEFR) maneuvers in triplicate at the time of discharge. Reproducibility was assessed using the intraclass correlation coefficient (ICC) and coefficient of variation (CV). Demographic and measured variables were compared between those who were and were not able to perform FE(NO) measurements. Correlation of FE(NO) with other variables was investigated.

RESULTS

FE(NO) measurements showed clinically acceptable ICC and CV values (0.973 and 5.59%, respectively). These values were superior to the values obtained for FEV1 and PEFR. Subjects who successfully performed the FE(NO) measurements were older, had higher PEFR readings, and had a lower asthma dyspnea score. No correlation was found between FE(NO) and traditional asthma factors, though multiple factors did trend towards significance.

CONCLUSION

FE(NO) measurements can be obtained in hospitalized pediatric patients with good reproducibility. While the majority of children will be able to provide such readings, those who are younger and with a more severe exacerbation may be unsuccessful in doing so. Further research is needed to determine how best to incorporate FE(NO) values into the hospital setting.