Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission

Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay

BACKGROUND

Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied.

OBJECTIVES

The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay.

METHODS

In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives.

RESULTS

Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis.

CONCLUSIONS

A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Impact of serial cardiopulmonary point-of-care ultrasound exams in patients with acute dyspnoea: a randomised, controlled trial

BACKGROUND

Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnoea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnoea compared with usual care alone.

METHODS

This was a randomised, controlled, blinded-outcome trial conducted in three EDs in Denmark between 9 October 2019 and 26 May 2021. Patients aged ≥18 years admitted with a primary complaint of dyspnoea were allocated 1:1 with block randomisation to usual care, which included a single cardiopulmonary PoCUS within 1 hour of arrival (control group) or usual care (including a PoCUS within 1 hour of arrival) plus two additional PoCUS performed at 2 hours interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnoea measured on a verbal dyspnoea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4 and 5 hours.

RESULTS

There were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was -1.09 (95% CI -1.51 to -0.66) and -1.66 (95% CI -2.09 to -1.23) after 4 and 5 hours, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group.

CONCLUSION

Therapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnoea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilising the patient faster.

TRIAL REGISTRATION NUMBER

NCT04091334.

Rating Dyspnea and Pain: "No" is Not Always "Zero"

Nurses routinely assess pain in hospitalized patients; similar assessment of dyspnea is increasing. Most nurses start with a yes-no question when assessing pain or dyspnea; many record "no" as a zero rating, skipping the rating scale. We tested the hypothesis that recording "no" answers as "zero" fails to detect the symptoms that would have been detected with a rating scale. Nurses asked 60 patients yes-no questions about the presence of dyspnea and pain, then asked patients to rate the symptoms using a 0-10 scale. All "yes" answers were followed by a concordant rating (i.e., greater than zero). More than 25% of "no" answers were followed by a discordant rating (> zero). Documenting "no" as "zero" missed information potentially useful in care planning; patients who rate dyspnea above zero are at greater risk of adverse outcomes. This information can also provide opportunity to start a discussion with patients who may benefit from symptom management.

'Involve me and I learn': an experiential teaching approach to improve dyspnea awareness in medical residents

BACKGROUND

Dyspnea is a frightening and debilitating experience. It attracts less attention than pain ('dyspnea invisibility'), possibly because of its non-universal nature. We tested the impact of self-induced experimental dyspnea on medical residents.

MATERIALS AND METHODS

During a teaching session following the principles of experiential learning, emergency medicine residents were taught about dyspnea theoretically, observed experimental dyspnea in their teacher, and personally experienced self-induced dyspnea. The corresponding psychophysiological reactions were described. Immediate and 1-year evaluations were conducted to assess course satisfaction (overall 0-20 grade) and the effect on the understanding of what dyspnea represents for patients.

RESULTS

Overall, 55 emergency medicine residents participated in the study (26 men, median age 26 years). They were moderately satisfied with previous dyspnea teaching (6 [5-7] on a 0-10 numerical rating scale [NRS]) and expressed a desire for an improvement in the teaching (8 [7-9]). Immediately after the course they reported improved understanding of patients' experience (7 [6-8]), which persisted at 1 year (8 [7-9], 28 respondents). Overall course grade was 17/20 [15-18], and there were significant correlations with experimental dyspnea ratings (intensity: r = 0.318 [0.001-0.576], p = 0.043; unpleasantness: r = 0.492 [0.208-0.699], p = 0.001). In multivariate analysis, the only factor independently associated with the overall course grade was 'experiential understanding' (the experimental dyspnea-related improvement in the understanding of dyspneic patients' experience). A separate similar experiment conducted in 50 respiratory medicine residents yielded identical results.

CONCLUSIONS

This study suggests that, in advanced medical residents, the personal discovery of dyspnea can have a positive impact on the understanding of what dyspnea represents for patients. This could help fight dyspnea invisibility.

Tests to uncover and assess breathlessness: a proposed framework

PURPOSE OF REVIEW

Breathlessness is a common, distressing, and limiting symptom that many people avoid by reducing their activity. This review discusses exertional tests that can be used for uncovering and assessing breathlessness depending on the person's severity of illness, function, the setting, and aim of the assessment.

RECENT FINDINGS

Standardized exertional tests are useful to uncover 'hidden' breathlessness earlier in people who may have adapted their physical activity to limit their breathing discomfort. In 'more fit' ambulatory people and outpatients, cardiopulmonary exercise testing is the gold standard for assessing symptom severity, underlying conditions, and mechanisms and treatment effects. Among field tests, the 6-min walk test is not useful for assessing breathlessness. Instead, the 3-min step test and walk test are validated for measuring breathlessness change in chronic obstructive pulmonary disease. In people with more severe illness (who are most often not breathless at rest), reported tests include upper limb exercise or counting numbers aloud, but a valid and useful test for this population is lacking.

SUMMARY

A framework for selecting the most appropriate test to assess breathlessness validly is proposed, and research needs are identified.

BEE FIRST: A standardized point-of-care ultrasound approach to a patient with dyspnea

Dyspnea is a common complaint in patients who present to the emergency department and can be due to numerous etiologies. This case report details a 90-year-old female with a history significant for hypertension, hyperlipidemia, and new diagnosis of ovarian malignancy whose symptoms increased over the past three days. Point-of-care Ultrasonography showed multiple B-lines, a plethoric IVC without respiratory variation, a markedly low EF and a lack of RV dilation. There was also no evidence of effusion which led the emergency medicine team to the diagnosis of acute decompensated heart failure. This quick diagnosis was possible due to using the standardized POCUS approach guided by the BEE FIRST algorithm. BEE FIRST can help physicians remember: B-lines are indicative of interstitial thickening, Effusion such as pericardial or pleural should be checked for, Ejection Fraction is useful in assessing for heart failure, IVC/Infection/Infarct correlates with central venous pressure, and can be used to assess volume status, check for enlargement, evidence of pneumonia, subpleural consolidation “shred sign”, hepatization of lung, and/or pulmonary infarction related to pulmonary embolism, Right Heart Strain can indicate pulmonary embolism or pulmonary hypertension, Sliding Lung can assess for pneumothorax and pleural characteristics, and lastly, Thrombosis/Tumor can assess for myxoma and interrogation of lower extremities for deep vein thrombosis can aid in dyspnea differentiation. In this report, we demonstrate how the framework BEE FIRST offers a standardized stepwise approach to the utilization of POCUS in a patient with acute dyspnea in the ED setting.

Dyspnea

The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.

Dyspnea: Common Side Effect

For dyspnea, standards of care are based on emerging evidence-based practice.&nbsp;Dyspnea, or shortness of breath, is a subjective experience of breathing discomfort marked by distinct sensations of varying intensity. Resulting from interactions among physiologic, psychological, social, and environmental factors, dyspnea may lead to secondary physiologic and behavioral responses. Dyspnea can be caused by cardiac and pulmonary disease (e.g., congestive heart failure, acute coronary syndrome, pneumonia, chronic obstructive pulmonary disease, pulmonary embolism), as well as other conditions (e.g., anemia, mental disorders, lung cancer).

Feasibility study of a multicentre cluster randomised control trial to investigate the clinical and cost-effectiveness of a structured diagnostic pathway in primary care for chronic breathlessness: protocol paper

INTRODUCTION

Chronic breathlessness is a common and debilitating symptom, associated with high healthcare use and reduced quality of life. Challenges and delays in diagnosis for people with chronic breathlessness frequently occur, leading to delayed access to therapies. The overarching hypothesis is a symptom-based approach to diagnosis in primary care would lead to earlier diagnosis, and therefore earlier treatment and improved longer-term outcomes including health-related quality of life. This study aims to establish the feasibility of a multicentre cluster randomised controlled trial to assess the clinical and cost-effectiveness of a structured diagnostic pathway for breathlessness in primary care.

METHODS AND ANALYSIS

Ten general practitioner (GP) practices across Leicester and Leicestershire will be cluster randomised to either a structured diagnostic pathway (intervention) or usual care. The structured diagnostic pathway includes a panel of investigations within 1 month. Usual care will proceed with patient care as per normal practice. Eligibility criteria include patients presenting with chronic breathlessness for the first time, who are over 40 years old and without a pre-existing diagnosis for their symptoms. An electronic template triggered at the point of consultation with the GP will aid opportunistic recruitment in primary care. The primary outcome for this feasibility study is recruitment rate. Secondary outcome measures, including time to diagnosis, will be collected to help inform outcomes for the future trial and to assess the impact of an earlier diagnosis. These will include symptoms, health-related quality of life, exercise capacity, measures of frailty, physical activity and healthcare utilisation. The study will include nested qualitative interviews with patients and healthcare staff to understand the feasibility outcomes, explore what is 'usual care' and the study experience.

ETHICS AND DISSEMINATION

The Research Ethics Committee Nottingham 1 has provided ethical approval for this research study (REC Reference: 19/EM/0201). Results from the study will be disseminated by presentations at relevant meetings and conferences including British Thoracic Society and Primary Care Respiratory Society, as well as by peer-reviewed publications and through patient presentations and newsletters to patients, where available.

TRIAL REGISTRATION NUMBER

ISRCTN14483247.

Dyspnea could be accurately assessed by a caregiver in hospitalized patients with respiratory diseases: Interrater reliability and agreement study

BACKGROUND

The perception of dyspnea is a subjective feeling typically self-assessed by the patient. However, the assessment by a caregiver is sometimes required.

OBJECTIVES

The primary aim was to compare patient self-assessment and caregiver assessment of dyspnea (interrater reliability) using the modified Borg and visual analog scale (VAS) in hospitalized patients. The secondary aim was to compare dyspnea assessment between the two scales for patients and caregiver (inter-instrument reliability).

METHODS

Self-assessment of dyspnea intensity of hospitalized patients with respiratory diseases was compared with caregiver's assessment. Dyspnea intensity was measured using two scales, the modified Borg scale (0-10 scale) and the 10 cm VAS. Mean difference and 95% confidence interval (CI) between assessors (i.e. patient versus caregiver) were calculated for each scale. Inter- and intra-rater reliability was calculated using intraclass correlation coefficients (ICCs).

RESULTS

A total of 254 patients were recruited. The mean differences between patient and caregiver ratings were 0.31 (95% CI: 0.09, 0.53) for the modified Borg scale and 0.36 (95% CI: 0.06, 0.65) for the VAS scale. Interrater reliability was good for both scales with ICC of 0.79 (95% CI: 0.73, 0.84) for VAS and 0.82 (95% CI: 0.77, 0.86) for the modified Borg scale. The mean differences in scores between scales were 0.93 (95% CI 0.69, 1.17) for patients' ratings and 0.88 (95% CI 0.72, 1.04) for caregiver's rating. The inter-instrument reliability was moderate to good and similar for both assessors.

CONCLUSION

Dyspnea can be accurately estimated by caregivers when patients with lung diseases cannot self-report. Scores on the VAS to rate dyspnea were higher than the scores on the Borg scale.

Association of dyspnoea, mortality and resource use in hospitalised patients

As many as one in 10 patients experience dyspnoea at hospital admission but the relationship between dyspnoea and patient outcomes is unknown. We sought to determine whether dyspnoea on admission predicts outcomes.We conducted a retrospective cohort study in a single, academic medical centre. We analysed 67 362 consecutive hospital admissions with available data on dyspnoea, pain and outcomes. As part of the Initial Patient Assessment by nurses, patients rated "breathing discomfort" using a 0 to 10 scale (10="unbearable"). Patients reported dyspnoea at the time of admission and recalled dyspnoea experienced in the 24 h prior to admission. Outcomes included in-hospital mortality, 2-year mortality, length of stay, need for rapid response system activation, transfer to the intensive care unit, discharge to extended care, and 7- and 30-day all-cause readmission to the same institution.Patients who reported any dyspnoea were at an increased risk of death during that hospital stay; the greater the dyspnoea, the greater the risk of death (dyspnoea 0: 0.8% in-hospital mortality; dyspnoea 1-3: 2.5% in-hospital mortality; dyspnoea ≥4: 3.7% in-hospital mortality; p<0.001). After adjustment for patient comorbidities, demographics and severity of illness, increasing dyspnoea remained associated with inpatient mortality (dyspnoea 1-3: adjusted OR 2.1, 95% CI 1.7-2.6; dyspnoea ≥4: adjusted OR 3.1, 95% CI 2.4-3.9). Pain did not predict increased mortality. Patients reporting dyspnoea also used more hospital resources, were more likely to be readmitted and were at increased risk of death within 2 years (dyspnoea 1-3: adjusted hazard ratio 1.5, 95% CI 1.3-1.6; dyspnoea ≥4: adjusted hazard ratio 1.7, 95% CI 1.5-1.8).We found that dyspnoea of any rating was associated with an increased risk of death. Dyspnoea ratings can be rapidly collected by nursing staff, which may allow for better monitoring or interventions that could reduce mortality and morbidity.

Underlying contributing conditions to breathlessness among middle-aged individuals in the general population: a cross-sectional study

Introduction

Breathlessness is common in the general population and associated with poorer health. Prevalence, frequencies and overlap of underlying contributing conditions among individuals reporting breathlessness in the general population is unclear. The aim was to evaluate which conditions that were prevalent, overlapping and associated with breathlessness in a middle-aged general population.

Method

Cross-sectional analysis of individuals aged 50–65 years in the Swedish CArdioPulmonary bioImage Study pilot. Data from questionnaire, spirometry testing and fitness testing were used to identify underlying contributing conditions among participants reporting breathlessness (a modified Medical Research Scale (mMRC) score ≥1). Multivariate logistic regression was used to identify independent associations with breathlessness.

Results

1097 participants were included; mean age 57.5 years, 50% women and 9.8% (n=108) reported breathlessness (mMRC ≥1). Main underlying contributing conditions were respiratory disease (57%), anxiety or depression (52%), obesity (43%) and heart disease or chest pain (35%). At least one contributing condition was found in 99.6% of all participants reporting breathlessness, while two or more conditions were present in 66%.

Conclusion

In a middle-aged general population, the main underlying contributing conditions to breathlessness were respiratory disease, anxiety or depression, obesity and heart disease or chest pain with a high level of overlap.

Why treatment efficacy on breathlessness in laboratory but not daily life trials? The importance of standardized exertion

PURPOSE OF REVIEW

Treatments for chronic breathlessness, including opioids and oxygen, have shown efficacy in the controlled laboratory setting, whereas effects have been inconsistent or absent in trials in daily life. This review discusses the lack of standardized exertion as a potential cause of false negative findings for breathlessness in daily life.

RECENT FINDINGS

The level of breathlessness can be modified by patients by changing their level of physical activity. Effects of opioids and oxygen have been shown at standardized level of exertion (iso-time) but not at the end of symptom-limited (peak) exertion. Trials in daily life reporting no effects on breathlessness did not standardize the exertion or employed insensitive methods, such as the 6-min walk test that should not be used for measuring breathlessness. Novel tests - the 3-min walk and stepping tests have been validated in chronic obstructive pulmonary disease and are responsive for measuring change in breathlessness.

SUMMARY

Breathlessness should be measured at standardized exertion, otherwise treatment effects may be biased or overlooked. Tests for valid measurement of breathlessness in clinical practice and daily life are available and emerging.

Opioids for breathlessness: a narrative review

Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10–30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world’s therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data.

Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis

CONTEXT

Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment.

OBJECTIVE

The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings.

METHODS

This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma.

RESULTS

Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care.

CONCLUSION

Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.

Detection and management of dyspnea in mechanically ventilated patients

PURPOSE OF REVIEW

In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management.

RECENT FINDINGS

As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report.

SUMMARY

Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.

A Multidimensional Profile of Dyspnea in Hospitalized Patients

BACKGROUND

Dyspnea is prevalent among hospitalized patients but little is known about the experience of dyspnea among inpatients. We sought to characterize the multiple sensations and associated emotions of dyspnea in patients admitted with dyspnea to a tertiary care hospital.

METHODS

We selected patients who reported breathing discomfort of at least 4/10 on admission (10 = unbearable). Research staff recruited 156 patients within 24 hours of admission and evaluated daily patients' current and worst dyspnea with the Multidimensional Dyspnea Profile; patients participated in the study 2.6 days on average. The Multidimensional Dyspnea Profile assesses overall breathing discomfort (A₁), intensity of five sensory qualities of dyspnea, and 5 negative emotional responses to dyspnea. Patients were also asked to rate whether current levels of dyspnea were "acceptable."

RESULTS

At the time of the first research interview, patients reported slight to moderate dyspnea (A₁ median 4); however, most patients reported experiencing severe dyspnea in the 24 hours before the interview (A₁ mean 7.8). A total of 54% of patients with dyspnea ≥4 on day 1 found the symptom unacceptable. The worst dyspnea each day in the prior 24 hours usually occurred at rest. Dyspnea declined but persisted through hospitalization for most patients. "Air hunger" was the dominant sensation, especially when dyspnea was strong (>4). Anxiety and frustration were the dominant emotions associated with dyspnea.

CONCLUSIONS

This first multidimensional portrait of dyspnea in a general inpatient population characterizes the sensations and emotions dyspneic patients endure. The finding that air hunger is the dominant sensation of severe dyspnea has implications for design of laboratory models of these sensations and may have implications for targets of palliation of symptoms.

Agreement Between Breathlessness Severity and Unpleasantness in People With Chronic Breathlessness: A Longitudinal Clinical Study

CONTEXT

Chronic breathlessness is a cardinal symptom in cardiopulmonary disease where both overall intensity or severity (S) and unpleasantness (U) are commonly quantified.

OBJECTIVE

We aimed to evaluate agreement between breathlessness severity and unpleasantness over eight days in patients with chronic breathlessness.

METHODS

Longitudinal analysis of 265 patients with chronic breathlessness who rated current overall breathlessness severity and unpleasantness on a 0-100 mm visual analogue scale (VAS) in the morning and evening over eight days. A total of 3630 paired overall severity-unpleasantness (S-U) differences were analyzed; median 15 (IQR 13-16) per patient. Agreement was evaluated using Bland-Altman plots. Associations of the difference between severity and unpleasantness (S-U difference) with clinical factors and perceived quality of life were analyzed using multilevel linear regression adjusted for confounders.

RESULTS

Over eight days, severity and unpleasantness scores were highly correlated, had similar variability, and varied more between patients than within patients. The mean S-U difference was small at 2.1 mm. Agreement between overall severity and unpleasantness was similar or higher than expected from the variability in individual scores. The S-U difference was similar across evaluated factors including age, sex, diagnosis, morning/evening assessment, modified Medical Research Council breathlessness score, morphine treatment, and presence of different sensory qualities of breathlessness. Higher overall severity and unpleasantness associated with worse perceived quality of life in a similar way.

CONCLUSION

In patients with chronic breathlessness over eight days, overall severity and unpleasantness of breathlessness were comparable and associated to other clinical factors in a similar manner.

Relating Experienced To Recalled breathlessness Observational (RETRO) study: a prospective study using a mobile phone application

Background

Breathlessness, the subjective sensation of breathing discomfort, is common and appears in the daily life of people with cardiorespiratory diseases. Physicians often rely on patient's history based on symptom recall. The relation between recalled and experienced breathlessness is still poorly understood. This paper presents the protocol for a study primarily aimed at evaluating the relationship between experienced breathlessness and (1) recalled breathlessness and (2) predicted future breathlessness.

Methods

A mobile phone application will be used to collect data during daily life. Medically stable participants, ≥18 years of age with mean daily breathlessness of Numerical Rating Scale (NRS) 3/10 and able to use a mobile phone with internet will rate their breathlessness intensity on a 0-10 NRS prompted the user several times daily for 1 week. Participants will recall their breathlessness each day and week. Multivariable random effects regression models will be used for statistical analyses.

Results

Results of the study will be submitted for publication in peer-reviewed journals and presented at relevant conferences.

Discussion

This protocol describes a study aimed at investigating previously unknown areas of the experience and recall of breathlessness using a new method of data collection.

Registration details

Prospectively registered with ClinicalTrials.gov (Nr: NCT03468205).

Ethics and dissemination

The study has received ethical approval from the Regional Ethical Review Board Lund (DNr 2017/149). After a general study information including that participation is entirely voluntary, participants will answer the eligibility criteria and be asked to consent to participate before entering the study questions. Written informed consent to participate will be obtained for participants in the clinical sub-cohort. Participation can be discontinued at the discretion of the participant in which case no further data will be collected.