Reliability and validity of dyspnea sensory quality descriptors in heart failure patients treated in an emergency department

Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission

CONTEXT

Dyspnea is an uncomfortable and distressing sensation experienced by hospitalized patients.

OBJECTIVES

There is no large-scale study of the prevalence and intensity of patient-reported dyspnea at the time of admission to the hospital.

METHODS

Between March 2014 and September 2016, we conducted a prospective cohort study among all consecutive hospitalized patients at a single tertiary care center in Boston, MA. During the first 12 hours of admission to medical-surgical and obstetric units, nurses at our institution routinely collect a patient's 1) current level of dyspnea on a 0-10 scale with 10 anchored at "unbearable," 2) worst dyspnea in the past 24 hours before arrival at the hospital on the same 0-10 scale, and 3) activities that were associated with dyspnea before admission. The prevalence of dyspnea was identified, and tests of difference were performed across patient characteristics.

RESULTS

We analyzed 67,362 patients, 12% of whom were obstetric patients. Fifty percent of patients were admitted to a medical-surgical unit after treatment in the emergency department. Among all noncritically ill inpatients, 16% of patients experienced dyspnea in the 24 hours before the admission. Twenty-three percent of patients admitted through the emergency department reported any dyspnea in the past 24 hours. Eleven percent experienced some current dyspnea when interviewed within 12 hours of admission with 4% of patients experiencing dyspnea that was rated 4 or greater. Dyspnea of 4 or more was present in 43% of patients admitted with respiratory diagnoses and 25% of patients with cardiovascular diagnoses. After multivariable adjustment for severity of illness and patient comorbidities, patients admitted on the weekend or during the overnight nursing shift were more likely to report dyspnea on admission.

CONCLUSION

Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

The breath of life. Patients' experiences of breathing during and after mechanical ventilation

INTRODUCTION

Breathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients' self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV.

METHOD

A qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews.

FINDINGS

Four out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through.

CONCLUSION

Breathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients' and clinicians assessments of breathlessness. The results suggest patients' own reports of breathing should form part of nursing interventions and follow-up to support patients' quest for meaning.

Selecting symptom instruments for cardiovascular populations

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments.

Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research

There is growing awareness that dyspnoea, like pain, is a multidimensional experience, but measurement instruments have not kept pace. The Multidimensional Dyspnea Profile (MDP) assesses overall breathing discomfort, sensory qualities, and emotional responses in laboratory and clinical settings. Here we provide the MDP, review published evidence regarding its measurement properties and discuss its use and interpretation. The MDP assesses dyspnoea during a specific time or a particular activity (focus period) and is designed to examine individual items that are theoretically aligned with separate mechanisms. In contrast, other multidimensional dyspnoea scales assess recalled recent dyspnoea over a period of days using aggregate scores.

Previous psychophysical and psychometric studies using the MDP show that: 1) subjects exposed to different laboratory stimuli could discriminate between air hunger and work/effort sensation, and found air hunger more unpleasant; 2) the MDP immediate unpleasantness scale (A₁) was convergent with common dyspnoea scales; 3) in emergency department patients, two domains were distinguished (immediate perception, emotional response); 4) test–retest reliability over hours was high; 5) the instrument responded to opioid treatment of experimental dyspnoea and to clinical improvement; 6) convergent validity with common instruments was good; and 7) items responded differently from one another as predicted for multiple dimensions.

The Multidimensional Dyspnea Profile provides a unified, reliable instrument for both clinical and laboratory researchhttp://ow.ly/Ix8ic

Old and new tools to assess dyspnea in the hospitalized patient

In the assessment of dyspnea one has to take into account both the patient's own experience of the symptom and the clinicians observations of breathing rates, sounds and effort to get a complete picture. In addition, to choose appropriate treatment, the underlying cause of dyspnea needs to be assessed. While tools for clinical evaluation of heart failure have gained great interest in research and found a place in guidelines and clinical practice, the same cannot be said for instruments to assess patient self-reported dyspnea. To date, no specific dyspnea rating tool has been recommend over another. Reports from clinical practice are lacking and large; international studies in this field are warranted.

Test-retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study

BACKGROUND

Dyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients.

METHODS

Patients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration ("now" MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach's alpha. Test-retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains.

RESULTS

PCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach's alpha = .89 to .94; Emotional Response, 5 items; Cronbach's alpha = .81 to .85). Test-retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively).

CONCLUSIONS

During an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test-retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea

BACKGROUND

Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.

PURPOSE

The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.

METHODS

An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.

RESULTS

Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains.

CONCLUSIONS

Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea

BACKGROUND

Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.

PURPOSE

The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.

METHODS

An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.

RESULTS

Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains.

CONCLUSIONS

Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

Factors associated with delayed care-seeking in hospitalized patients with heart failure

OBJECTIVE

This study sought to evaluate the contributions of symptom recognition and clinical factors to delays in care-seeking.

METHODS

A descriptive correlational study design was used to study 75 patients (mean age, 74.7 years; SD, 10.86 years; range, 40 to 96 years) admitted to a tertiary-care medical center with recurrent symptoms (New York Heart Association classes 2 to 4). The sample was 52% male and 85.3% white. The Heart Failure Somatic Perception Scale (HFSPS) was used to examine symptoms, and additional data were collected on physiologic, social, and demographic factors.

RESULTS

The mean HFSPS score was 37.52 (range, 2 to 74; possible range, 0 to 90). Subjects reported 2 to 16 out of 18 possible symptoms. Durations of individual symptoms ranged from 5 minutes to 8 years, with individual patients describing a variety of symptom combinations and multiple time frames, depending on the specific symptom. Most subjects (80%) reported a mixture of acute and chronic symptoms. A pattern of chronic vs. acute symptoms was associated with proactive vs. emergent care-seeking, respectively. The HFSPS scores did not correlate with care-seeking behavior.

CONCLUSION

Symptom recognition is a complex phenomenon, and few factors differentiate emergent from proactive care-seeking.

Validation of a three-factor measurement model of dyspnea in hospitalized adults with heart failure

OBJECTIVE

The purpose of this study was to validate a 3-factor measurement model of dyspnea sensory quality (WORK-EFFORT, TIGHTNESS, SMOTHERING-AIR HUNGER) originally derived in patients with exacerbated chronic obstructive pulmonary disease.

METHODS

In this validation study, adult patients with heart failure were enrolled after hospital admission (median hospital day 1) and asked to rate the intensity of dyspnea sensory quality descriptors on the day of enrollment (study day 1; N = 119) and in a recall version for the day of admission (study day 0; n = 97).

RESULTS

Confirmatory factor analysis demonstrated good model fit for both days. Cronbach's α for each factor was greater than .87 for both study days.

CONCLUSION

This is the first study to validate a previously specified measurement model of dyspnea sensory quality in an independent sample. Results indicate that measurement of dyspnea sensory quality in exacerbated cardiopulmonary disease does not necessarily require disease-specific questionnaires.

A review of dyspnea in acute heart failure syndromes

In acute heart failure syndrome (AHFS), dyspnea is one of the most common but least understood presenting symptoms for hospitalization. For this reason, dyspnea relief is increasingly becoming a focus in the development of therapies for the treatment of AHFS, and currently stands as an acceptable primary end point for regulatory approval by governmental agencies. This raises the question of how best to measure such a subjective symptom. In this review, we will describe the basis for dyspnea, provide a detailed description of the strengths and weaknesses of the current best tools used to measure it, and describe future directions for future development of dyspnea measurement in AHFS.

Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12

RATIONALE

Dyspnoea is a debilitating and distressing symptom that is reflected in different verbal descriptors. Evidence suggests that dyspnoea, like pain perception, consists of sensory quality and affective components. The objective of this study was to develop an instrument that measures overall dyspnoea severity using descriptors that reflect its different aspects.

METHODS

81 dyspnoea descriptors were administered to 123 patients with chronic obstructive pulmonary disease (COPD), 129 with interstitial lung disease and 106 with chronic heart failure. These were reduced to 34 items using hierarchical methods. Rasch analysis informed decisions regarding further item removal and fit to the unidimensional model. Principal component analysis (PCA) explored the underlying structure of the final item set. Validity and reliability of the new instrument were further assessed in a separate group of 53 patients with COPD.

RESULTS

After removal of items with hierarchical methods (n = 47) and items that failed to fit the Rasch model (n = 22), 12 were retained. The "Dyspnoea-12" had good internal reliability (Cronbach's alpha = 0.9) and fit to the Rasch model (chi(2) p = 0.08). Items patterned into two groups called "physical"(n = 7) and "affective"(n = 5). In the separate validation study, Dyspnoea-12 correlated with the Hospital Anxiety and Depression Scale (anxiety r = 0.51; depression r = 0.44, p<0.001, respectively), 6-minute walk distance (r = -0.38, p<0.01) and MRC (Medical Research Council) grade (r = 0.48, p<0.01), and had good stability over time (intraclass correlation coefficient = 0.9, p<0.001).

CONCLUSION

Dyspnoea-12 fulfills modern psychometric requirements for measurement. It provides a global score of breathlessness severity that incorporates both "physical" and "affective" aspects, and can measure dyspnoea in a variety of diseases.

Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup

Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future 'between study' comparisons. Discussion of the physiology of breathlessness is included.

The multiple dimensions of dyspnea: review and hypotheses

Although dyspnea is a common and troubling symptom, our understanding of the neurophysiology of dyspnea is woefully incomplete. Most measurements of dyspnea treat it as a single entity. Although the multidimensional dyspnea concept has been mentioned for many decades, only recently has the concept been the subject of experimental tests. Emerging evidence has begun to favor the hypothesis that dyspnea comprises multiple dimensions or components that can be measured as different entities. Most recently, studies have begun to show that there is a separable 'affective dimension' (i.e. unpleasantness and emotional impact). Understanding of the multidimensional measurement of pain is far in advance of dyspnea, and has enabled progress in the neurophysiology of pain, including identification of separate neural structures subserving various elements of pain perception. We propose here a multidimensional model of dyspnea based on a state-of-the-art pain model, and review existing evidence in the light of this model.

The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort

RATIONALE

It is hypothesized that the affective dimension of dyspnea (unpleasantness, emotional response) is not strictly dependent on the intensity of dyspnea.

OBJECTIVES

We tested the hypothesis that the ratio of immediate unpleasantness (A(1)) to sensory intensity (SI) varies depending on the type of dyspnea.

METHODS

Twelve healthy subjects experienced three stimuli: stimulus 1: maximal eucapnic voluntary hyperpnea against inspiratory resistance, requiring 15 times the work of resting breathing; stimulus 2: Pet(CO(2)) 6.1 mm Hg above resting with ventilation restricted to less than spontaneous breathing; stimulus 3: Pet(CO(2)) 7.7 mm Hg above resting with ventilation further restricted. After each trial, subjects rated SI, A(1), and qualities of dyspnea on the Multidimensional Dyspnea Profile (MDP), a comprehensive instrument tested here for the first time.

MEASUREMENTS AND MAIN RESULTS

Stimulus 1 was always limited by subjects failing to meet a higher ventilation target; none signaled severe discomfort. This evoked work and effort sensations, with relatively low unpleasantness (mean A(1)/SI = 0.64). Stimulus 2, titrated to produce dyspnea ratings similar to those subjects gave during stimulus 1, evoked air hunger and produced significantly greater unpleasantness (mean A(1)/SI = 0.95). Stimulus 3, increased until air hunger was intolerable, evoked the highest intensity and unpleasantness ratings and high unpleasantness ratio (mean A(1)/SI = 1.09). When asked which they would prefer to repeat, all subjects chose stimulus 1.

CONCLUSIONS

(1) Maximal respiratory work is less unpleasant than moderately intense air hunger in this brief test; (2) unpleasantness of dyspnea can vary independently from perceived intensity, consistent with the prevailing model of pain; (3) separate dimensions of dyspnea can be measured with the MDP.

A systematic review of measures of end-of-life care and its outcomes

OBJECTIVE

To identify psychometrically sound measures of outcomes in end-of-life care and to characterize their use in intervention studies.

DATA SOURCES

English language articles from 1990 to November 2005 describing measures with published psychometric data and intervention studies of end-of-life care.

STUDY DESIGN

Systematic review of end-of-life care literature.

EXTRACTION METHODS

Two reviewers organized identified measures into 10 major domains. Eight reviewers extracted and characterized measures from intervention studies.

PRINCIPAL FINDINGS

Of 24,423 citations, we extracted 200 articles that described 261 measures, accepting 99 measures. In addition to 35 measures recommended in a prior systematic review, we identified an additional 64 measures of the end-of-life experience. The most robust measures were in the areas of symptoms, quality of life, and satisfaction; significant gaps existed in continuity of care, advance care planning, spirituality, and caregiver well-being. We also reviewed 84 intervention studies in which 135 patient-centered outcomes were assessed by 97 separate measures. Of these, 80 were used only once and only eight measures were used in more than two studies.

CONCLUSIONS

In general, most measures have not undergone rigorous development and testing. Measure development in end-of-life care should focus on areas with identified gaps, and testing should be done to facilitate comparability across the care settings, populations, and clinical conditions. Intervention research should use robust measures that adhere to these standards.

Which measurement scales should we use to measure breathlessness in palliative care? A systematic review

INTRODUCTION

There is no universally accepted measurement scale to assess breathlessness in adult palliative care patients. This significantly hampers clinical practice and research into effective interventions. The aim is to systematically identify and appraise breathlessness measurement scales, which are validated for use in palliative care or which show potential for use.

METHODS

We undertook systematic searches of electronic databases (Cochrane databases 2005, MEDLINE 1966-2005, OLDMEDLINE 1950-1965, EMBASE 1980-2005, PsycINFO 1872-2005, AMED 1985-2005, CINAHL 1982-2005, SIGLE 1980-2005) with follow-up searches (reference lists of included papers, hand-searches of relevant journals). The basic search strategy was 'breathlessness (etc.) AND measurement (scales, validation etc.) AND palliative care/cardiac failure/respiratory disease/ neoplasm etc.', modified for each database, without language restriction. Patient-based scales with evaluations of at least two psychometric characteristics were included. Exercise-based tests were excluded. Scales were appraised with particular emphasis on construct validity and responsiveness.

RESULTS

We identified 29 scales: six to measure breathlessness severity, four to assess breathlessness descriptions, and 19 to measure functional impact of breathlessness.

SEVERITY

The Numeric Rating Scale (NRS) and modified Borg Scale have been evaluated in COPD (the NRS has also been evaluated in cancer). Both require further assessment of responsiveness and test-retest reliability over time intervals relevant to palliative care. Visual Analogue Scales have also been evaluated, but require larger sample sizes than NRS for evidence of intervention effectiveness.

DESCRIPTIONS

The Japanese Cancer Dyspnoea Scale (CDS) has been evaluated in patients with cancer, but requires further assessment of construct validity and responsiveness. FUNCTIONAL IMPACT: The Chronic Respiratory Questionnaire dyspnoea subscale (CRQ-D) has been evaluated in chronic lung diseases and heart failure; the MND Respiratory Scale is similar. CRQ-D has face and construct validity, test-retest reliability and responsiveness, and shows promise for palliative care.

CONCLUSION

The NRS, modified Borg, CRQ-D and CDS appear most suitable for use in palliative care, but further evaluation is required before adopting any scale as standard. This review has been registered with the Cochrane collaboration and will be published and updated as a Cochrane review.

Descriptors of dyspnea by patients with chronic obstructive pulmonary disease versus congestive heart failure

OBJECTIVES

The purpose of this study was to determine whether differences existed between reports of dyspnea in stable chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) subjects.

METHODS

Sixty stable COPD (n=30) and CHF (n=30) male, outpatient subjects were studied. Subjects were asked to both endorse (from a pre-designed list of descriptors) and volunteer terms that best described their breathing discomfort. Subjects also reported the frequency and the intensity of breathlessness (0-10 scale) using the Pulmonary Functional Status and Dyspnea Questionnaire.

RESULTS

From the endorsed list of descriptors, my breath does not go out all the way, was significantly different (COPD=11, CHF=4, P<.05) between groups. The most common terms volunteered by COPD subjects were scary (n=5, P<.02), hard to breathe (n=5), shortness of breath (n=4), and cannot get enough air (n=4), whereas CHF subjects volunteered the terms, shortness of breath (n=9), gasping (n=6), and cannot get enough air (n=4). There was no difference in the frequency with which both groups experienced dyspnea or times per month they reported severe to very severe dyspnea. Subjects with COPD experienced a higher intensity of breathlessness on different occasions P<.05.

CONCLUSIONS

Stable COPD and CHF patients use and recognize a variety of terms that describe their breathing distress. There was, however, only 1 unique term among the endorsed and volunteered terms, and that was among the COPD subjects. COPD and CHF subjects shared many common terms and also experienced dyspnea with similar frequency. The uniqueness of terms among the COPD group was less clear. The study highlights the variability of the dyspnea experience among COPD and CHF patients and the potential difficulty identifying unique dyspnea terms in these subjects.

Psychometric characteristics of dyspnea descriptor ratings in emergency department patients with exacerbated chronic obstructive pulmonary disease

The purpose of this study was to evaluate the reliability, content validity, and factor structure of dyspnea sensory quality descriptor ratings in emergency department (ED) patients with exacerbated chronic obstructive pulmonary disease (COPD). During an ED visit 104 patients with COPD rated the intensity of 16 dyspnea sensory quality descriptors (numerical ratings of 0-10) in relation to how they felt when they decided to come to the ED (Decision) and 1 week before the visit. Content validity of 15 descriptors was supported. Factor analysis of Decision ratings resulted in seven descriptors and three factors (alpha=.88; 74% common variance): Smothering/Suffocating/Hunger for air (alpha=.87); Effort/Work (alpha=.87); and Tight/Constricted (alpha=.74). Results indicate that the intensity of sensory quality descriptors can be measured reliably in COPD patients during an exacerbation of COPD. The initial descriptor list of descriptors could be cut by more than half while retaining satisfactory psychometric properties.

Dyspnea: the continuing challenge of palliative management

The management of dyspnea is a challenge even for the most experienced palliative medicine teams. In the absence of effective treatment for the underlying disease, therapeutic options are limited to the supplementation of oxygen, the use of opioids, and multidisciplinary nonpharmacologic interventions. There is increased research into both the physiology of dyspnea and the correlates of the symptom in advanced disease. Hopefully, this research will lead to improved therapy in the future. This article reviews current literature on dyspnea with a focus on publications in 2001.

Characteristics and treatment of patients with heart failure in the emergency department

INTRODUCTION

This study was conducted to develop a detailed profile of patients who come to the emergency department for heart failure treatment.

METHODS

Patient interviews were supplemented by medical record reviews in a convenience sample of 57 participants. A structured interview guide included data concerning patient characteristics and ED treatment.

RESULTS

Participants used a variety of self-care strategies before coming to the emergency department. Many of the patients studied (25%) reported barriers to medication adherence, such as memory problems and lack of knowledge regarding self-administration. The most frequently reported symptoms were breathing difficulties (88%), chest discomfort (35%), and fatigue (16%). Seventy-four percent of the participants were classified as specific activity scale class III or IV, indicating moderate to severe functional limitation. Mean quality of life at the time of interview was 5.1 (on a 1 to 10 scale). Length of stay was < or = 2 days for 33%.

DISCUSSION

A number of the findings of this study have implications for ED nurses. For example, almost one third of the patients studied had not received directions for a low-sodium diet during hospitalization, when fluid volume overload with sodium retention was the most common cause of hospitalization in a study of patients with decompensated heart failure. Hospital lengths of stay of no more than 2 days suggest that early detection and treatment of acute heart failure may reduce the need for ED visits for some patients. Patients need education and support with self-help strategies and need to better understand the administration of their medication.

Dyspnea duration, distress, and intensity in emergency department visits for heart failure

BACKGROUND

Dyspnea is the most common symptom among patients with heart failure (HF) who present to the emergency department (ED), but it is not clear which dimensions of the symptom prompt ED visits, or whether dyspnea characteristics are related to visit disposition.

PURPOSE

The goal of this study was to explore the influence of dyspnea duration, distress, and intensity on decisions of patients with HF to come to an ED and the disposition of visits.

METHODS

The study population consisted of patients treated for HF in an urban university hospital ED (N = 57) who were interviewed retrospectively. Open-ended questions pertained to symptoms in general and dyspnea at the time of the visit. Subjects rated recalled dyspnea distress (0 = not at all bothered by breathing; 4 = bothered very much by breathing) for when they decided to come to the ED (Decision) and a week before the visit (Week Before), as well as duration--the number of days before the visit that dyspnea was recalled as having been as severe as at Decision. After the interviews, a subsample (n = 34) rated the intensity of a set of dyspnea sensory quality descriptors for Decision and Week Before (0 = not endorsed; 1 = very mild; 10 = very severe). Charts were also reviewed.

RESULTS

Seventy percent recalled dyspnea as the most distressing symptom at Decision, or the primary reason for the visit; 88% were admitted. Dyspnea duration was unrelated to admission. Duration was 3 days or less for 65% of the sample, but 6 days or more for 35%. There was no duration-related difference in dyspnea distress or intensity at Decision, but subjects with a duration < or =3 days reported lower levels of both dimensions for Week Before with significant increases from Week Before to Decision. Those with longer episodes reported high levels of distress and intensity in both time frames with no significant change in either dimension.

CONCLUSION

Subjects reported high levels of distress and intensity at Decision, regardless of dyspnea duration. Differences in recalled duration were associated with 2 distinct patterns in distress and intensity ratings but were not associated with admission. Dyspnea duration does not appear to be a valid criterion for judging condition severity in HF-related visits to the ED.