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Filipe CB, Carreira NR, Reis-Pina P. Optimizing breathlessness management in amyotrophic lateral sclerosis: insights from a comprehensive systematic review. BMC Palliat Care 2024; 23:100. [PMID: 38622643 PMCID: PMC11020819 DOI: 10.1186/s12904-024-01429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Breathlessness is a prevalent symptom affecting the quality of life (QOL) of Amyotrophic Lateral Sclerosis (ALS) patients. This systematic review explored the interventions for controlling breathlessness in ALS patients, emphasizing palliative care (PALC), non-invasive ventilation (NIV), opioids, and non-pharmacological strategies. METHODS A comprehensive search of PubMed, Cochrane Library, and Web of Science databases was conducted. Eligibility criteria encompassed adults with ALS or motor neuron disease experiencing breathlessness. Outcomes included QOL and symptom control. Study designs comprised qualitative studies, cohort studies, and randomized controlled trials. RESULTS Eight studies were included, most exhibiting low bias risk, comprising one randomized controlled trial, three cohort studies, two comparative retrospective studies, and two qualitative studies (interviews). Most studies originated from Europe, with one from the United States of America. The participants totaled 3423, with ALS patients constituting 95.6%. PALC consultations significantly improved symptom assessment, advance care planning, and discussions about goals of care. NIV demonstrated efficacy in managing breathlessness, with considerations for device limitations. Opioids were effective, though predominantly studied in non-ALS patients. Non-pharmacological strategies varied in efficacy among patients. CONCLUSION The findings underscore the need for individualized approaches in managing breathlessness in ALS. PALC, NIV, opioids, and non-pharmacological strategies each play a role, with unique considerations. Further research, especially ALS-specific self-management studies, is warranted.
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Affiliation(s)
- Catarina Bico Filipe
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal
| | - Nuno Reis Carreira
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal
- North Lisboa Hospital Centre, Santa Maria Hospital, Lisboa, Portugal
| | - Paulo Reis-Pina
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal.
- Bento Menni Palliative Care Unit, Sintra, Portugal.
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2
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Tiller NB, Kinninger A, Abbasi A, Casaburi R, Rossiter HB, Budoff MJ, Adami A. Physical Activity, Muscle Oxidative Capacity, and Coronary Artery Calcium in Smokers with and without COPD. Int J Chron Obstruct Pulmon Dis 2022; 17:2811-2820. [PMID: 36353139 PMCID: PMC9639376 DOI: 10.2147/copd.s385000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Severe chronic obstructive pulmonary disease (COPD) is partly characterized by diminished skeletal muscle oxidative capacity and concurrent dyslipidemia. It is unknown whether such metabolic derangements increase the risk of cardiovascular disease. This study explored associations among physical activity (PA), muscle oxidative capacity, and coronary artery calcium (CAC) in COPDGene participants. Methods Data from current and former smokers with COPD (n = 75) and normal spirometry (n = 70) were retrospectively analyzed. Physical activity was measured for seven days using triaxial accelerometry (steps/day and vector magnitude units [VMU]) along with the aggregate of self-reported PA amount and PA difficulty using the PROactive D-PPAC instrument. Muscle oxidative capacity (k) was assessed via near-infrared spectroscopy, and CAC was assessed via chest computerized tomography. Results Relative to controls, COPD patients exhibited higher CAC (median [IQR], 31 [0–431] vs 264 [40–799] HU; p = 0.003), lower k (mean ± SD = 1.66 ± 0.48 vs 1.25 ± 0.37 min−1; p < 0.001), and lower D-PPAC total score (65.2 ± 9.9 vs 58.8 ± 13.2; p = 0.003). Multivariate analysis—adjusting for age, sex, race, diabetes, disease severity, hyperlipidemia, smoking status, and hypertension—revealed a significant negative association between CAC and D-PPAC total score (β, −0.05; p = 0.013), driven primarily by D-PPAC difficulty score (β, −0.03; p = 0.026). A 1 unit increase in D-PPAC total score was associated with a 5% lower CAC (p = 0.013). There was no association between CAC and either k, steps/day, VMU, or D-PPAC amount. Conclusion Patients with COPD and concomitantly elevated CAC exhibit greater perceptions of difficulty when performing daily activities. This may have implications for exercise adherence and risk of overall physical decline.
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Affiliation(s)
- Nicholas B Tiller
- Institute of Respiratory Medicine and Exercise Physiology, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - April Kinninger
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Asghar Abbasi
- Institute of Respiratory Medicine and Exercise Physiology, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Richard Casaburi
- Institute of Respiratory Medicine and Exercise Physiology, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Harry B Rossiter
- Institute of Respiratory Medicine and Exercise Physiology, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- Correspondence: Harry B Rossiter, Institute of Respiratory Medicine and Exercise Physiology, Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Carson Street, CDCRC Building, Torrance, CA, 90502, USA, Tel +1 310-222-8200, Email
| | - Matthew J Budoff
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Alessandra Adami
- Department of Kinesiology, University of Rhode Island, Kingston, RI, USA
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Abstract
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.
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Affiliation(s)
- Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States; Faculty of Health Sciences, Virginia Tech, Blacksburg, VA, United States.
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4
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Aronson KI, Suzuki A. Health Related Quality of Life in Interstitial Lung Disease: Can We Use the Same Concepts Around the World? Front Med (Lausanne) 2021; 8:745908. [PMID: 34692737 PMCID: PMC8526733 DOI: 10.3389/fmed.2021.745908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/31/2021] [Indexed: 01/17/2023] Open
Abstract
Health-Related Quality of Life (HRQOL) is increasingly viewed as an important patient-centered outcome by leading health organizations, clinicians, and patients alike. This is especially true in the interstitial lung disease community where patients often struggle with progressive and debilitating disease with few therapeutic options. In order to test the effectiveness of new pharmacologic therapies and non-pharmacologic interventions globally in ILD, this will require expansion of clinical research studies to a multinational level and HRQOL will be an important endpoint to many. In order to successfully expand trials across multiple nations and compare the results of studies between different communities we must recognize that there are differences in the concepts of HRQOL across the world and have strategies to address these differences. In this review, we will describe the different global influences on HRQOL both generally and in the context of ILD, discuss the processes of linguistic translation and cross-cultural adaptation of HRQOL Patient Reported Outcome Measures (PROMs), and highlight the gaps and opportunities for improving HRQOL measurement in ILD across the world.
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Affiliation(s)
- Kerri I. Aronson
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Atsushi Suzuki
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Banzett RBB, Sheridan AR, Baker KM, Lansing RW, Stevens JP. 'Scared to death' dyspnoea from the hospitalised patient's perspective. BMJ Open Respir Res 2021; 7:7/1/e000493. [PMID: 32169831 PMCID: PMC7069254 DOI: 10.1136/bmjresp-2019-000493] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/22/2019] [Accepted: 12/05/2019] [Indexed: 11/04/2022] Open
Abstract
Because dyspnoea is seldom experienced by healthy people, it can be hard for clinicians and researchers to comprehend the patient’s experience. We collected patients’ descriptions of dyspnoea in their own words during a parent study in which 156 hospitalised patients completed a quantitative multidimensional dyspnoea questionnaire. These volunteered comments describe the severity and wide range of experiences associated with dyspnoea and its impacts on a patients’ life. They provide insights not conveyed by structured rating scales. We organised these comments into the most prominent themes, which included sensory experiences, emotional responses, self-blame and precipitating events. Patients often mentioned air hunger (‘Not being able to get air is the worst thing that could ever happen to you.’), anxiety, and fear (‘Scared. I thought the world was going to end, like in a box.’). Their value in patient care is suggested by one subject’s comment: ‘They should have doctors experience these symptoms, especially dyspnoea, so they understand what patients are going through.’ Patients’ own words can help to bridge this gap of understanding.
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Affiliation(s)
- Robert B B Banzett
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA .,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew R Sheridan
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kathy M Baker
- Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert W Lansing
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jennifer P Stevens
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Pulmonary, Critical Care, and Sleep Medicine; Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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6
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Aronson KI, Danoff SK, Russell AM, Ryerson CJ, Suzuki A, Wijsenbeek MS, Bajwah S, Bianchi P, Corte TJ, Lee JS, Lindell KO, Maher TM, Martinez FJ, Meek PM, Raghu G, Rouland G, Rudell R, Safford MM, Sheth JS, Swigris JJ. Patient-centered Outcomes Research in Interstitial Lung Disease: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e3-e23. [PMID: 34283696 PMCID: PMC8650796 DOI: 10.1164/rccm.202105-1193st] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: In the past two decades, many advances have been made to our understanding of interstitial lung disease (ILD) and the way we approach its treatment. Despite this, many questions remain unanswered, particularly those related to how the disease and its therapies impact outcomes that are most important to patients. There is currently a lack of guidance on how to best define and incorporate these patient-centered outcomes in ILD research. Objectives: To summarize the current state of patient-centered outcomes research in ILD, identify gaps in knowledge and research, and highlight opportunities and methods for future patient-centered research agendas in ILD. Methods: An international interdisciplinary group of experts was assembled. The group identified top patient-centered outcomes in ILD, reviewed available literature for each outcome, highlighted important discoveries and knowledge gaps, and formulated research recommendations. Results: The committee identified seven themes around patient-centered outcomes as the focus of the statement. After a review of the literature and expert committee discussion, we developed 28 research recommendations. Conclusions: Patient-centered outcomes are key to ascertaining whether and how ILD and interventions used to treat it affect the way patients feel and function in their daily lives. Ample opportunities exist to conduct additional work dedicated to elevating and incorporating patient-centered outcomes in ILD research.
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7
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Abstract
The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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8
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Banerjee G, Rose A, Briggs M, Plant P, Johnson MI. Could kinesiology taping of the inspiratory muscles help manage chronic breathlessness? An opinion paper. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1872137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- G. Banerjee
- Centre for Pain Research, School of Clinical & Applied Sciences, Leeds Beckett University, Leeds, UK
| | - A. Rose
- Coach House Sports Physiotherapy Clinic, Leeds, UK
| | - M. Briggs
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - P. Plant
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - M. I. Johnson
- Centre for Pain Research, School of Clinical & Applied Sciences, Leeds Beckett University, Leeds, UK
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9
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Hallowell RW, Schwartzstein R, O'Donnell CR, Sheridan A, Banzett RB. Controlled Delivery of 80 mg Aerosol Furosemide Does Not Achieve Consistent Dyspnea Relief in Patients. Lung 2020; 198:113-120. [PMID: 31728632 PMCID: PMC11001166 DOI: 10.1007/s00408-019-00292-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Aerosol furosemide may be an option to treat refractory dyspnea, though doses, methods of delivery, and outcomes have been variable. We hypothesized that controlled delivery of high dose aerosol furosemide would reduce variability of dyspnea relief in patients with underlying pulmonary disease. METHODS Seventeen patients with chronic exertional dyspnea were recruited. Patients rated recently recalled breathing discomfort on a numerical rating scale (NRS) and the multidimensional dyspnea profile (MDP). They then performed graded exercise using an arm-ergometer. The NRS was completed following each exercise grade, and the MDP was repeated after a pre-defined dyspnea threshold was reached. During separate visits, patients received either aerosol saline or 80 mg of aerosol furosemide in a randomized, double-blind, crossover design. After treatment, graded exercise to the pre-treatment level was repeated, followed by completion of the NRS and MDP. Treatment effect was defined as the difference between pre- and post-treatment NRS at end exercise, expressed in absolute terms as % Full Scale. "Responders" were defined as those showing treatment effect ≥ 20% of full scale. RESULTS Final analysis included 15 patients. Neither treatment produced a statistically significant change in NRS and there was no significant difference between treatments (p = 0.45). There were four "responders" and one patient whose dyspnea worsened with furosemide; two patients were responders with saline, of whom one also responded to furosemide. No adverse events were reported. CONCLUSIONS High dose controlled delivery aerosol furosemide was not statistically different from saline placebo at reducing exercise-induced dyspnea. However, a clinically meaningful improvement was noted in some patients.
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Affiliation(s)
- Robert W Hallowell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Carl R O'Donnell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew Sheridan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA.
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10
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A Multidimensional Profile of Dyspnea in Hospitalized Patients. Chest 2019; 156:507-517. [PMID: 31128117 DOI: 10.1016/j.chest.2019.04.128] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 11/23/2022] Open
Abstract
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.
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11
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Adler D, Janssens JP. The Pathophysiology of Respiratory Failure: Control of Breathing, Respiratory Load, and Muscle Capacity. Respiration 2018; 97:93-104. [PMID: 30423557 DOI: 10.1159/000494063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022] Open
Abstract
The purpose of this review is to provide an overview on how interactions between control of breathing, respiratory load, and muscle function may lead to respiratory failure. The mechanisms involved vary according to the underlying pathology, but respiratory failure is most often the result of an imbalance between the muscular pump and the mechanical load placed upon it. Changes in respiratory drive and response to CO2 seem to be important contributors to the pathophysiology of respiratory failure. Inspiratory muscle dysfunction is also frequent but is not a mandatory prerequisite to respiratory failure since increased load may also be sufficient to precipitate it. It is crucial to recognize these interactions to be able to timeously establish patients on mechanical ventilation and adapt the ventilator settings to their respiratory system physiology.
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Affiliation(s)
- Dan Adler
- Division of Lung Diseases, University Hospitals of Geneva and Geneva Medical School, Geneva, Switzerland,
| | - Jean-Paul Janssens
- Division of Lung Diseases, University Hospitals of Geneva and Geneva Medical School, Geneva, Switzerland
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12
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Morélot-Panzini C, O'Donnell CR, Lansing RW, Schwartzstein RM, Banzett RB. Aerosol furosemide for dyspnea: Controlled delivery does not improve effectiveness. Respir Physiol Neurobiol 2017; 247:146-155. [PMID: 29031573 DOI: 10.1016/j.resp.2017.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 01/23/2023]
Abstract
Aerosolized furosemide has been shown to relieve dyspnea; nevertheless, all published studies have shown great variability in response. This dyspnea relief is thought to result from the stimulation of slowly adapting pulmonary stretch receptors simulating larger tidal volume. We hypothesized that better control over aerosol administration would produce more consistent dyspnea relief; we used a clinical ventilator to control inspiratory flow and tidal volume. Twelve healthy volunteers inhaled furosemide (40mg) or placebo in a double blind, randomized, crossover study. Breathing Discomfort was induced by hypercapnia during constrained ventilation before and after treatment. Both treatments reduced breathing discomfort by 20% full scale. Effectiveness of aerosol furosemide treatment was weakly correlated with larger tidal volume. Response to inhaled furosemide was inversely correlated to furosemide blood level, suggesting that variation among subjects in the fate of deposited drug may determine effectiveness. We conclude that control of aerosol delivery conditions does not improve consistency of treatment effect; we cannot, however, rule out placebo effect.
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Affiliation(s)
- Capucine Morélot-Panzini
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale, F-75013, Paris, France.
| | - Carl R O'Donnell
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
| | - Robert W Lansing
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA
| | - Richard M Schwartzstein
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
| | - Robert B Banzett
- Pulmonary Division, Beth Israel Deaconess MC, Boston, MA, 02215, USA; Harvard Med School, Boston, MA, 02115, USA
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13
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Calverley PM. Chronic breathlessness: symptom or syndrome? Eur Respir J 2017; 49:49/5/1700366. [DOI: 10.1183/13993003.00366-2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/28/2017] [Indexed: 11/05/2022]
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14
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Neder JA, Hirai DM, Jones JH, Zelt JT, Berton DC, O'Donnell DE. A 56-Year-Old, Otherwise Healthy Woman Presenting With Light-headedness and Progressive Shortness of Breath. Chest 2017; 150:e23-7. [PMID: 27396797 DOI: 10.1016/j.chest.2016.02.672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 01/19/2016] [Accepted: 02/01/2016] [Indexed: 11/16/2022] Open
Abstract
A 56-year-old white woman was referred to the pulmonary clinic for evaluation of unexplained shortness of breath. She enjoyed good health until 3 months prior to this visit when she reported experiencing recurrent episodes of shortness of breath and oppressive retrosternal chest discomfort with radiation to the neck. Episodes lasting 5 to 10 min often occurred at rest and were inconsistently related to physical activity. These symptoms became progressively worse and were often associated with light-headedness and presyncope. Her past medical history was uneventful apart from a prior diagnosis of breast cysts and suspected prolactinoma. Her symptoms escalated to such a level that she was forced to seek urgent medical attention at our institutional ED on two separate occasions in the preceding weeks. These visits precipitated a number of investigations and, eventually, a referral to the pulmonary clinic.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Daniel M Hirai
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Joshua H Jones
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Joel T Zelt
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Danilo C Berton
- Respiratory Division, Department of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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15
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Tsukada S, Masaoka Y, Yoshikawa A, Okamoto K, Homma I, Izumizaki M. Coupling of dyspnea perception and occurrence of tachypnea during exercise. J Physiol Sci 2017; 67:173-180. [PMID: 27117877 PMCID: PMC10717682 DOI: 10.1007/s12576-016-0452-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 04/12/2016] [Indexed: 11/26/2022]
Abstract
During exercise, tidal volume initially contributes to ventilatory responses more than respiratory frequency, and respiratory frequency then increases rapidly while tidal volume stabilizes. Dyspnea intensity is also known to increase in a threshold-like manner. We tested the possibility that the threshold of tachypneic breathing is equal to that of dyspnea perception during cycle ergometer exercise (n = 27). Dyspnea intensity was scored by a visual analog scale. Thresholds were expressed as values of pulmonary O2 uptake at each breakpoint. Dyspnea intensity and respiratory frequency started increasing rapidly once the intensity of stimuli exceeded a threshold level. The thresholds for dyspnea intensity and for occurrence of tachypnea were significantly correlated. An intraclass correlation coefficient of 0.71 and narrow limits of agreement on the Bland-Altman plot indicated a good agreement between these thresholds. These results suggest that the start of tachypneic breathing coincides with the threshold for dyspnea intensity during cycle ergometer exercise.
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Affiliation(s)
- Setsuro Tsukada
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
- Department of Neurology, Showa University School of Medicine, Tokyo, Japan
| | - Yuri Masaoka
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Akira Yoshikawa
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Keiji Okamoto
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Ikuo Homma
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Masahiko Izumizaki
- Department of Physiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
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Chowienczyk S, Javadzadeh S, Booth S, Farquhar M. Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer. J Pain Symptom Manage 2016; 52:259-64. [PMID: 27233139 DOI: 10.1016/j.jpainsymman.2016.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 01/15/2016] [Accepted: 02/13/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Verbal descriptors are important in understanding patients' experience of breathlessness. OBJECTIVES The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness. METHODS We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis. RESULTS Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness. CONCLUSION The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.
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Affiliation(s)
- Sarah Chowienczyk
- Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Shagayegh Javadzadeh
- Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Sara Booth
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Morag Farquhar
- Department of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge, United Kingdom.
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17
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Faisal A, Alghamdi BJ, Ciavaglia CE, Elbehairy AF, Webb KA, Ora J, Neder JA, O'Donnell DE. Common Mechanisms of Dyspnea in Chronic Interstitial and Obstructive Lung Disorders. Am J Respir Crit Care Med 2016; 193:299-309. [PMID: 26407036 DOI: 10.1164/rccm.201504-0841oc] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The mechanisms underlying dyspnea in interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) are unknown. OBJECTIVES To examine whether the relationship between inspiratory neural drive to the diaphragm and exertional dyspnea intensity is different in ILD and COPD, given the marked differences in static respiratory mechanics between these conditions. METHODS We compared sensory-mechanical relationships in patients with ILD, patients with COPD, and healthy control subjects (n = 16 each) during incremental cycle exercise with diaphragmatic electromyography (EMGdi) and respiratory pressure measurements. MEASUREMENTS AND MAIN RESULTS In patients with mild to moderate ILD or COPD with similarly reduced inspiratory capacity, the peak oxygen uptake, work rate, and ventilation were lower (P < 0.05) than in healthy control subjects. EMGdi expressed as a percentage of the maximum (EMGdi/EMGdi,max), respiratory effort (esophageal pressure expressed as percentage of the maximum), and ventilation were higher (P < 0.05) at rest and during exercise in both patients with ILD and patients with COPD than in control subjects. Each of these measurements was similar in the ILD and COPD groups. A Vt inflection and critically reduced inspiratory reserve volume occurred at a lower (P < 0.05) ventilation in the ILD and COPD groups than in control subjects. Patients with ILD had greater diaphragmatic activity, whereas patients with COPD had greater expiratory muscle activity. The relationship between dyspnea intensity and EMGdi/EMGdi,max during exercise was similar in all three groups. In ILD and COPD, descriptors alluding to inspiratory difficulty were selected more frequently, with a greater disparity between EMGdi/EMGdi,max and Vt. CONCLUSIONS Disease-specific differences in mechanics and respiratory muscle activity did not influence the key association between dyspnea intensity and inspiratory neural drive to the diaphragm.
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Affiliation(s)
- Azmy Faisal
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,2 Faculty of Physical Education for Men and
| | - Bader J Alghamdi
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,3 King Saud Bin Abdulaziz University for Health Science, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Casey E Ciavaglia
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Amany F Elbehairy
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada.,4 Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt; and
| | - Katherine A Webb
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Josuel Ora
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - J Alberto Neder
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- 1 Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada
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18
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Vermeulen F, Garcia G, Ninane V, Laveneziana P. Activity limitation and exertional dyspnea in adult asthmatic patients: What do we know? Respir Med 2016; 117:122-30. [PMID: 27492522 DOI: 10.1016/j.rmed.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/11/2016] [Accepted: 06/06/2016] [Indexed: 12/21/2022]
Abstract
Limitation of activity is the most cited symptom described by uncontrolled asthma patients. Assessment of activity limitation can be undertaken through several ways, more or less complex, subjective or objective. Yet little is known about the link between patients sensations and objective measurements. The present review reports the current knowledge regarding activity limitation and symptom perception (i.e., exertional dyspnea) in adult patients with asthma. This work is based on references indexed by PubMed, irrespective of the year of publication. Overall, patients with stable asthma do not have a more sedentary lifestyle than healthy subjects. However, during a cycle ergometric test, the maximal load is reduced when FEV1, FVC and muscle strengths are decreased. Additionally, during the six-minute walking test, mild asthma patients walk less than healthy subjects even if the minimal clinically important difference is not reached. The major complaint of asthma patients when exercising is dyspnea that is mainly related to the inspiratory effort and also to dynamic hyperinflation in some circumstances. Finally, the administration of bronchodilator does not improve the ventilatory pattern and the exercise capacity of asthma patients and little is known on its effect on exertional dyspnea. The present review allows to conclude that until now there is no gold standard test allowing the objective assessment of "activity limitation and exertional dyspnea" in asthma patients.
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Affiliation(s)
| | - Gilles Garcia
- AP-HP, University Hospital Bicêtre, Pulmonary Function Laboratory, Reference Centre for Severe Pulmonary Hypertension, DHU TORINO "Thorax Innovation", Le Kremlin-Bicêtre, France; University Paris-South 11, Faculty of Medicine, Le Kremlin-Bicêtre, France; INSERM U999, LabEx LERMIT, Surgical Centre Marie Lannelongue, Le Plessis-Robinson, France
| | - Vincent Ninane
- Chest Service, St Pierre University Hospital, Brussels, Belgium; Université Libre de Bruxelles, Faculty of Medicine, Bruxelles, Belgium
| | - Pierantonio Laveneziana
- University Sorbonne, UPMC University Paris 06, INSERM, UMRS1158 Clinical and Experimental Respiratory Neurophysiology, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Unit of Respiration, Exercise and Dyspnea Assessment (Unit EFRED, Department "R3S", Pôle PRAGUES), Paris, France
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19
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Morélot-Panzini C, Gilet H, Aguilaniu B, Devillier P, Didier A, Perez T, Pignier C, Arnould B, Similowski T. Real-life assessment of the multidimensional nature of dyspnoea in COPD outpatients. Eur Respir J 2016; 47:1668-79. [PMID: 27076585 DOI: 10.1183/13993003.01998-2015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/20/2016] [Indexed: 11/05/2022]
Abstract
Dyspnoea is a prominent symptom of chronic obstructive pulmonary disease (COPD). Recent multidimensional dyspnoea questionnaires like the Multidimensional Dyspnea Profile (MDP) individualise the sensory and affective dimensions of dyspnoea. We tested the MDP in COPD outpatients based on the hypothesis that the importance of the affective dimension of dyspnoea would vary according to clinical characteristics.A multicentre, prospective, observational, real-life study was conducted in 276 patients. MDP data were compared across various categories of patients (modified Medical Research Council (mMRC) dyspnoea score, COPD Assessment Test (CAT) score, Global Initiative for Chronic Obstructive Lung Disease (GOLD) airflow obstruction categories, GOLD "ABCD" categories, and Hospital Anxiety and Depression Scale (HADS)). Univariate and multivariate regressions were conducted to explore factors influencing the affective dimension of dyspnoea. Cluster analysis was conducted to create homogeneous patient profiles.The MDP identified a more marked affective dimension of dyspnoea with more severe mMRC, CAT, 12-item Short-Form Health Survey mental component, airflow obstruction and HADS. Multivariate analysis identified airflow obstruction, depressive symptoms and physical activity as determinants of the affective dimension of dyspnoea. Patients clustered into an "elderly, ex-smoker, severe disease, no rehabilitation" group exhibited the most marked affective dimension of dyspnoea.An affective/emotional dimension of dyspnoea can be identified in routine clinical practice. It can contribute to the phenotypic description of patients. Studies are needed to determine whether targeted therapeutic interventions can be designed and whether they are useful.
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Affiliation(s)
- Capucine Morélot-Panzini
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS1158 "Neurophysiologie respiratoire expérimentale et clinique", Paris, France AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | | | | | | | - Alain Didier
- Service de Pneumologie, Hôpital Larrey, Centre Hospitalier Régional et Universitaire de Toulouse, Toulouse, France
| | - Thierry Perez
- Clinique des Maladies Respiratoires, Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | | | | | - Thomas Similowski
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS1158 "Neurophysiologie respiratoire expérimentale et clinique", Paris, France AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
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20
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Bonde E, Andersson E, Brisman J, Eklöf M, Ringsberg KC, Torén K. Dissociation of dysfunctional breathing and odour intolerance among adults in a general-population study. CLINICAL RESPIRATORY JOURNAL 2016; 7:176-82. [PMID: 22621613 DOI: 10.1111/j.1752-699x.2012.00299.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many patients present with a mixture of respiratory problems such as shortness of breath, heavy breathing, coughing and odour intolerance. If these patients are diagnosed as asthma, it might sometimes be a false diagnosis. Concepts such as sensory hyperreactivity, hyperventilation, asthma-like symptoms, odour intolerance and dysfunctional breathing are used to refer to these patients. Non-respiratory symptoms such as headache, fatigue and bloating are sometimes also part of the clinical picture. Our aim was to use factor analysis to increase our understanding of breathing-related symptoms in a general-population frame. METHODS A respiratory questionnaire was answered by 10 108 subjects in a general-population sample. Items aiming to identify individuals with breathing-related symptoms and asthma were included. We used factor analysis with Varimax rotation to extract discriminatory components (i.e. groups of symptoms), based on the questionnaire items. The aim was to find groups of items (factors) as distinct as possible, still allowing overlap and showing the importance of each item in the separated factor. RESULTS Five distinct factors were identified in the factor analysis, representing dysfunctional breathing, odour intolerance, asthma, bronchitis and a group with mixed symptoms, respectively. These five factors explained 55% of the variance. CONCLUSIONS Based on our findings, we conclude that non-asthmatic breathing-related symptoms may be separated into at least two categories in a general population, odour intolerance and dysfunctional breathing. These two categories seem to be two distinct groups of subjects with breathing-related symptoms and may represent different clinical entities separated from asthma and bronchitis.
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Affiliation(s)
- Ellen Bonde
- Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
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21
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Banzett RB, O'Donnell CR, Guilfoyle TE, Parshall MB, Schwartzstein RM, Meek PM, Gracely RH, Lansing RW. Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research. Eur Respir J 2015; 45:1681-91. [PMID: 25792641 PMCID: PMC4450151 DOI: 10.1183/09031936.00038914] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/19/2014] [Indexed: 12/02/2022]
Abstract
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
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Carl R O'Donnell
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Tegan E Guilfoyle
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark B Parshall
- College of Nursing, University of New Mexico, Albuquerque, NM, USA
| | - Richard M Schwartzstein
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Paula M Meek
- College of Nursing, University of Colorado, Denver, Aurora, CO, USA
| | - Richard H Gracely
- Department of Endodontics, UNC School of Dentistry, Center for Neurosensory Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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22
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Walters GI, Soundy A, Robertson AS, Burge PS, Ayres JG. Understanding health beliefs and behaviour in workers with suspected occupational asthma. Respir Med 2015; 109:379-88. [PMID: 25657173 DOI: 10.1016/j.rmed.2015.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/28/2014] [Accepted: 01/18/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Long delays from symptom onset to the diagnosis of occupational asthma have been reported in the UK, Europe and Canada and workers are often reluctant to seek medical help or workplace solutions for their symptoms. Reducing this delay could improve workers' quality of life, and reduce the societal cost of occupational asthma. This study aimed to explore reasons behind such delays. METHODS A purposive sample of 20 individuals diagnosed with, or under investigation for, occupational asthma (median age = 52; 70% male; 80% white British) undertook a single semi-structured interview. Interviews were transcribed verbatim and thematic analysis was undertaken in order to explore health beliefs and identify barriers to diagnosis. RESULTS Four themes were identified: (1) workers' understanding of symptoms, (2) working relationships, (3) workers' course of action and (4) workers' negotiation with healthcare professionals. Understanding of symptoms varied between individuals, from a lack of insight into the onset, pattern and nature of symptoms, through to misunderstanding of what they represented, or ignorance of the existence of asthma as a disease entity. Workers described reluctance to discuss health issues with managers and peers, through fear of job loss and a perceived lack of ability to find a solution. The evolution of workers' understanding depended upon how actively they looked to define symptoms or seek a solution. Proactive workers were motivated to seek authoritative help and negotiate inadequate healthcare encounters with GPs. CONCLUSION Understanding workers' health beliefs will enable policy makers and clinicians to develop better workplace interventions that may aid diagnosis and reduce delay in identifying occupational asthma.
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Affiliation(s)
- Gareth I Walters
- Institute of Occupational and Environmental Medicine, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Andy Soundy
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Alastair S Robertson
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - P Sherwood Burge
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Jon G Ayres
- Institute of Occupational and Environmental Medicine, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Fernandes AK, Ziegler B, Konzen GL, Sanches PRS, Müller AF, Pereira RP, Dalcin PDTR. Repeatability of the evaluation of perception of dyspnea in normal subjects assessed through inspiratory resistive loads. Open Respir Med J 2015; 8:41-7. [PMID: 25614771 PMCID: PMC4296474 DOI: 10.2174/1874306401408010041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose: Study the repeatability of the evaluation of the perception of dyspnea using an inspiratory resistive loading system in healthy subjects.
Methods: We designed a cross sectional study conducted in individuals aged 18 years and older. Perception of dyspnea was assessed using an inspiratory resistive load system. Dyspnea was assessed during ventilation at rest and at increasing resistive loads (0.6, 6.7, 15, 25, 46.7, 67, 78 and returning to 0.6 cm H2O/L/s). After breathing in at each level of resistive load for two minutes, the subject rated the dyspnea using the Borg scale. Subjects were tested twice (intervals from 2 to 7 days).
Results: Testing included 16 Caucasian individuals (8 male and 8 female, mean age: 36 years). The median scores for dyspnea rating in the first test were 0 at resting ventilation and 0, 2, 3, 4, 5, 7, 7 and 1 point, respectively, with increasing loads. The median scores in the second test were 0 at resting and 0, 0, 2, 2, 3, 4, 4 and 0.5 points, respectively. The intra-class correlation coefficient was 0.57, 0.80, 0.74, 0.80, 0.83, 0.86, 0.91, and 0.92 for each resistive load, respectively. In a generalized linear model analysis, there was a statistically significant difference between the levels of resistive loads (p<0.001) and between tests (p=0.003). Dyspnea scores were significantly lower in the second test.
Conclusion: The agreement between the two tests of the perception of dyspnea was only moderate and dyspnea scores were lower in the second test. These findings suggest a learning effect or an effect that could be at least partly attributed to desensitization of dyspnea sensation in the brain.
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Affiliation(s)
- Andréia K Fernandes
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil
| | - Bruna Ziegler
- Programa de Pós-Graduação em Ciências Pneumológicas, UFRGS, Brazil
| | - Glauco L Konzen
- Programa de Pós-Graduação em Ciências Pneumológicas, UFRGS, Brazil
| | - Paulo R S Sanches
- Serviço de Engenharia Biomédica do Hospital de Clínicas de Porto Alegre (HCPA), Brazil
| | - André F Müller
- Serviço de Engenharia Biomédica do Hospital de Clínicas de Porto Alegre (HCPA), Brazil
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Binks AP, Evans KC, Reed JD, Moosavi SH, Banzett RB. The time-course of cortico-limbic neural responses to air hunger. Respir Physiol Neurobiol 2014; 204:78-85. [PMID: 25263029 DOI: 10.1016/j.resp.2014.09.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/09/2014] [Accepted: 09/11/2014] [Indexed: 01/30/2023]
Abstract
Several studies have mapped brain regions associated with acute dyspnea perception. However, the time-course of brain activity during sustained dyspnea is unknown. Our objective was to determine the time-course of neural activity when dyspnea is sustained. Eight healthy subjects underwent brain blood oxygen level dependent functional magnetic imaging (BOLD-fMRI) during mechanical ventilation with constant mild hypercapnia (∼ 45 mm Hg). Subjects rated dyspnea (air hunger) via visual analog scale (VAS). Tidal volume (V(T)) was alternated every 90 s between high VT (0.96 ± 0.23 L) that provided respiratory comfort (12 ± 6% full scale) and low V(T) (0.48 ± 0.08 L) which evoked air hunger (56 ± 11% full scale). BOLD signal was extracted from a priori brain regions and combined with VAS data to determine air hunger related neural time-course. Air hunger onset was associated with BOLD signal increases that followed two distinct temporal profiles within sub-regions of the anterior insula, anterior cingulate and prefrontal cortices (cortico-limbic circuitry): (1) fast, BOLD signal peak <30s and (2) slow, BOLD signal peak >40s. BOLD signal during air hunger offset followed fast and slow temporal profiles symmetrical, but inverse (signal decreases) to the time-courses of air hunger onset. We conclude that differential cortico-limbic circuit elements have unique contributions to dyspnea sensation over time. We suggest that previously unidentified sub-regions are responsible for either the acute awareness or maintenance of dyspnea. These data enhance interpretation of previous studies and inform hypotheses for future dyspnea research.
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Affiliation(s)
- Andrew P Binks
- Department of Biomedical Sciences, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Karleyton C Evans
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Jeffrey D Reed
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Shakeeb H Moosavi
- Department of Biological and Medical Sciences, Oxford Brookes University, Oxford, UK
| | - Robert B Banzett
- Harvard Medical School, Boston, MA, USA; Division Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Wheelock ÅM, Wheelock CE. Trials and tribulations of 'omics data analysis: assessing quality of SIMCA-based multivariate models using examples from pulmonary medicine. MOLECULAR BIOSYSTEMS 2014; 9:2589-96. [PMID: 23999822 DOI: 10.1039/c3mb70194h] [Citation(s) in RCA: 221] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Respiratory diseases are multifactorial heterogeneous diseases that have proved recalcitrant to understanding using focused molecular techniques. This trend has led to the rise of 'omics approaches (e.g., transcriptomics, proteomics) and subsequent acquisition of large-scale datasets consisting of multiple variables. In 'omics technology-based investigations, discrepancies between the number of variables analyzed (e.g., mRNA, proteins, metabolites) and the number of study subjects constitutes a major statistical challenge. The application of traditional univariate statistical methods (e.g., t-test) to these "short-and-wide" datasets may result in high numbers of false positives, while the predominant approach of p-value correction to account for these high false positive rates (e.g., FDR, Bonferroni) are associated with significant losses in statistical power. In other words, the benefit in decreased false positives must be counterbalanced with a concomitant loss in true positives. As an alternative, multivariate statistical analysis (MVA) is increasingly being employed to cope with 'omics-based data structures. When properly applied, MVA approaches can be powerful tools for integration and interpretation of complex 'omics-based datasets towards the goal of identifying biomarkers and/or subphenotypes. However, MVA methods are also prone to over-interpretation and misuse. A common software used in biomedical research to perform MVA-based analyses is the SIMCA package, which includes multiple MVA methods. In this opinion piece, we propose guidelines for minimum reporting standards for a SIMCA-based workflow, in terms of data preprocessing (e.g., normalization, scaling) and model statistics (number of components, R2, Q2, and CV-ANOVA p-value). Examples of these applications in recent COPD and asthma studies are provided. It is expected that readers will gain an increased understanding of the power and utility of MVA methods for applications in biomedical research.
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Affiliation(s)
- Åsa M Wheelock
- Respiratory Medicine Unit, Department of Medicine, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.
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Valiengo LCL, Benseñor IM, Lotufo PA, Fraguas R, Brunoni AR. Transcranial direct current stimulation and repetitive transcranial magnetic stimulation in consultation-liaison psychiatry. Braz J Med Biol Res 2013; 46:815-23. [PMID: 24141608 PMCID: PMC3854309 DOI: 10.1590/1414-431x20133115] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 07/15/2013] [Indexed: 11/22/2022] Open
Abstract
Patients with clinical diseases often present psychiatric conditions whose
pharmacological treatment is hampered due to hazardous interactions with the
clinical treatment and/or disease. This is particularly relevant for major
depressive disorder, the most common psychiatric disorder in the general
hospital. In this context, nonpharmacological interventions could be useful
therapies; and, among those, noninvasive brain stimulation (NIBS) might be an
interesting option. The main methods of NIBS are repetitive transcranial
magnetic stimulation (rTMS), which was recently approved as a nonresearch
treatment for some psychiatric conditions, and transcranial direct current
stimulation (tDCS), a technique that is currently limited to research scenarios
but has shown promising results. Therefore, our aim was to review the main
medical conditions associated with high depression rates, the main obstacles for
depression treatment, and whether these therapies could be a useful intervention
for such conditions. We found that depression is an important and prevalent
comorbidity in a variety of diseases such as epilepsy, stroke, Parkinson's
disease, myocardial infarction, cancer, and in other conditions such as
pregnancy and in patients without enteral access. We found that treatment of
depression is often suboptimal within the above contexts and that rTMS and tDCS
therapies have been insufficiently appraised. We discuss whether rTMS and tDCS
could have a significant impact in treating depression that develops within a
clinical context, considering its unique characteristics such as the absence of
pharmacological interactions, the use of a nonenteral route, and as an
augmentation therapy for antidepressants.
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Affiliation(s)
- L C L Valiengo
- Centro de Pesquisas Clínicas, Hospital Universitário, Universidade de São Paulo, São PauloSP, Brasil
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Johnson MJ, Abernethy AP, Currow DC. The evidence base for oxygen for chronic refractory breathlessness: issues, gaps, and a future work plan. J Pain Symptom Manage 2013; 45:763-75. [PMID: 23017616 DOI: 10.1016/j.jpainsymman.2012.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/03/2012] [Accepted: 03/09/2012] [Indexed: 10/27/2022]
Abstract
Breathlessness or "shortness of breath," medically termed dyspnea, is a common and distressing symptom featuring strongly in advanced lung, cardiac, and neuromuscular diseases; its prevalence and intensity increase as death approaches. However, despite the increasing understanding in the genesis of breathlessness, as well as an increasing portfolio of treatment options, breathlessness is still difficult to manage and engenders helplessness in caregivers and health care professionals and fear for patients. Although hypoxemia does not appear to be the dominant driver for breathlessness in advanced disease, the belief that oxygen is important for the relief of acute, chronic, and acute-on-chronic shortness of breath is firmly embedded in the minds of patients, caregivers, and health care professionals. This article presents current understanding of the use of oxygen for treating refractory breathlessness in advanced disease. The objective is to highlight what is still unknown, set a research agenda to resolve these questions, and highlight methodological issues for consideration in planned studies.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom.
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Herer B. [Outcomes of a pulmonary rehabilitation program including singing training]. Rev Mal Respir 2012; 30:194-202. [PMID: 23497929 DOI: 10.1016/j.rmr.2012.10.602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/08/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Respiratory education by singing may be considered in the course of pulmonary rehabilitation to help control breathing and reduce dyspnoea. METHODS We have undertaken singing training during pulmonary rehabilitation in 45 patients, mean age 60.1 ± 10.0 years, suffering from COPD (n=37) or other chronic respiratory disorders (n=8). The parameters measured at the beginning and end of course of rehabilitation were: forced vital capacity, FEV1, total lung capacity, residual volume, 6 min walking distance, VO2max, maximum pressure, MRC dyspnoea score, Cincinnati questionnaires and VSRQ (simplified visual respiratory questionnaire). RESULTS The following were the principal significant variations observed (initial value, % variation, significance): 6 minutes walk (326 ± 114 m, +13.8%, P=0.006); VO2max (18,1 ± 6.1 ml/kg/min, +8.3%, P=0.01); P max (75 ± 31 W, +14.7%, P=0.001); MRC score (2.3 ± 0.6, -21.7%, P<10(-4)); VSRQ score (34 ± 13, +50.0%, P<10(-6)). There was no significant change in the level of dyspnoea evaluated by the Cincinnati score. CONCLUSION These results are in favor of a beneficial effect of singing during pulmonary rehabilitation.
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Affiliation(s)
- B Herer
- Service de pneumologie, centre médical de Forcilles, 77170 Férolles-Attilly, France.
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Cafarella PA, Effing TW, Usmani ZA, Frith PA. Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: a literature review. Respirology 2012; 17:627-38. [PMID: 22309179 DOI: 10.1111/j.1440-1843.2012.02148.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a serious contemporary health issue. Psychological co-morbidities such as anxiety and depression are common in COPD. Current evidence for treatment options to reduce anxiety and depression in patients with COPD was examined. There is evidence available for the efficacy of pharmacological treatments, cognitive behavioural therapy, pulmonary rehabilitation, relaxation therapy and palliative care in COPD. Therapeutic modalities that have not been proven effective in decreasing anxiety and depression in COPD, but which have theoretical potential among patients, include interpersonal psychotherapy, self-management programmes, more extensive disease management programmes, supportive therapy and self-help groups. Besides pulmonary rehabilitation that is only available for a small percentage of patients, management guidelines make scant reference to other options for the treatment of mental health problems. The quantity and quality of research on mental health treatments in COPD have historically been insufficient to support their inclusion in COPD treatment guidelines. In this review, recommendations regarding assessment, treatment and future research in this important field were made.
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Affiliation(s)
- Paul A Cafarella
- Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, South Australia, Australia
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Teixeira CA, Rodrigues Júnior AL, Straccia LC, Vianna EDSO, Silva GAD, Martinez JAB. Dyspnea descriptors developed in Brazil: application in obese patients and in patients with cardiorespiratory diseases. J Bras Pneumol 2012; 37:446-54. [PMID: 21881734 DOI: 10.1590/s1806-37132011000400006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/09/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To develop a set of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) for use in Brazil and to investigate the usefulness of these descriptors in four distinct clinical conditions that can be accompanied by dyspnea. METHODS We collected 111 dyspnea descriptors from 67 patients and 10 health professionals. These descriptors were analyzed and reduced to 15 based on their frequency of use, similarity of meaning, and potential pathophysiological value. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. RESULTS The use of this set of descriptors led to a solution with seven clusters, designated sufoco (suffocating), aperto (tight), rápido (rapid), fadiga (fatigue), abafado (stuffy), trabalho/inspiração (work/inhalation), and falta de ar (shortness of breath). Overlapping of descriptors was quite common among the patients, regardless of their clinical condition. Asthma was significantly associated with the sufoco and trabalho/inspiração clusters, whereas COPD and heart failure were associated with the sufoco, trabalho/inspiração, and falta de ar clusters. Obesity was associated only with the falta de ar cluster. CONCLUSIONS In Brazil, patients who are accustomed to perceiving dyspnea employ various descriptors in order to describe the symptom, and these descriptors can be grouped into similar clusters. In our study sample, such clusters showed no usefulness in differentiating among the four clinical conditions evaluated.
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Affiliation(s)
- Christiane Aires Teixeira
- Department of Clinical Medicine, University of São Paulo at Ribeirão Preto School of Medicine – Ribeirão Preto, Brazil
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435-52. [PMID: 22336677 PMCID: PMC5448624 DOI: 10.1164/rccm.201111-2042st] [Citation(s) in RCA: 1064] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012. [PMID: 22336677 DOI: 10.1164/rccm.201111–2042st] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Meek PM, Banzett R, Parsall MB, Gracely RH, Schwartzstein RM, Lansing R. Reliability and validity of the multidimensional dyspnea profile. Chest 2012; 141:1546-1553. [PMID: 22267681 DOI: 10.1378/chest.11-1087] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Most measures of dyspnea assess a single aspect (intensity or distress) of the symptom. We developed the Multidimensional Dyspnea Profile (MDP) to measure qualities and intensities of the sensory dimension and components of the affective dimension. The MDP is not indexed to a particular activity and can be applied at rest, during exertion, or during clinical care. We report on the development and testing of the MDP in patients with a variety of acute and chronic cardiopulmonary conditions. METHODS One hundred fifty-one adults admitted to the ED with breathing symptoms completed the MDP three times in the ED, twice at least 1 h apart (T1, T2), and near discharge from the ED (T3). Measures were repeated in 68 patients twice in a follow-up session 4 to 6 weeks later (T4-T5). The ED sample was 56% men with a mean age of 53 ± 15 years; the follow-up sample was similar. RESULTS Factor analysis resulted in a two-factor solution with a total explained variance of 63%, 74%, and 72% at T1, T2, and T3, respectively. One domain related to primary sensory qualities and immediate unpleasantness, and the second encompassed emotional response. For the two domains, Cronbach α ranged from 0.82 to 0.95, and the intraclass correlation coefficient ranged from 0.91 to 0.98. Repeated-measures analysis was significant for change (T1, T3, T4), showing responsiveness to change in MDP domains with treatment (F([2,66]) = 19.67, P > .001). CONCLUSIONS These analyses support the reliability, validity, and responsiveness to clinical change of the MDP with two domains in an acute care and follow-up setting.
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Affiliation(s)
- Paula M Meek
- College of Nursing, University of Colorado - Denver, Aurora, CO.
| | - Robert Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA; Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Mark B Parsall
- College of Nursing, University of New Mexico, Albuquerque, NM
| | - Richard H Gracely
- Center for Neurosensory Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Richard M Schwartzstein
- Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA; Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Robert Lansing
- Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA
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Banzett RB, Adams L, O'Donnell CR, Gilman SA, Lansing RW, Schwartzstein RM. Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response. Am J Respir Crit Care Med 2011; 184:920-7. [PMID: 21778294 PMCID: PMC3208656 DOI: 10.1164/rccm.201101-0005oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 07/06/2011] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Opioids are commonly used to relieve dyspnea, but clinical data are mixed and practice varies widely. OBJECTIVES Evaluate the effect of morphine on dyspnea and ventilatory drive under well-controlled laboratory conditions. METHODS Six healthy volunteers received morphine (0.07 mg/kg) and placebo intravenously on separate days (randomized, blinded). We measured two responses to a CO(2) stimulus: (1) perceptual response (breathing discomfort; described by subjects as "air hunger") induced by increasing partial pressure of end-tidal carbon dioxide (Pet(CO2)) during restricted ventilation, measured with a visual analog scale (range, "neutral" to "intolerable"); and (2) ventilatory response, measured in separate trials during unrestricted breathing. MEASUREMENTS AND MAIN RESULTS We determined the Pet(CO2) that produced a 60% breathing discomfort rating in each subject before morphine (median, 8.5 mm Hg above resting Pet(CO2)). At the same Pet(CO2) after morphine administration, median breathing discomfort was reduced by 65% of its pretreatment value; P < 0.001. Ventilation fell 28% at the same Pet(CO2); P < 0.01. The effect of morphine on breathing discomfort was not significantly correlated with the effect on ventilatory response. Placebo had no effect. CONCLUSIONS (1) A moderate morphine dose produced substantial relief of laboratory dyspnea, with a smaller reduction of ventilation. (2) In contrast to an earlier laboratory model of breathing effort, this laboratory model of air hunger established a highly significant treatment effect consistent in magnitude with clinical studies of opioids. Laboratory studies require fewer subjects and enable physiological measurements that are difficult to make in a clinical setting. Within-subject comparison of the response to carefully controlled laboratory stimuli can be an efficient means to optimize treatments before clinical trials.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
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Izumizaki M, Masaoka Y, Homma I. Coupling of dyspnea perception and tachypneic breathing during hypercapnia. Respir Physiol Neurobiol 2011; 179:276-86. [PMID: 21939787 DOI: 10.1016/j.resp.2011.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 08/19/2011] [Accepted: 09/08/2011] [Indexed: 10/17/2022]
Abstract
Respiratory rhythm is susceptible to behavioral influences including emotions. Since laboratory dyspnea induces negative emotions, we examined whether tachypneic breathing occurs in relation to perception of dyspnea during CO(2) rebreathing (n=21). Dyspnea intensity scored by a visual analog scale and respiratory frequency started to increase rapidly once the intensity of the stimuli exceeded a threshold for the end-tidal CO(2) fraction. The thresholds for dyspnea and respiratory frequency were similar (7.5±0.1% and 7.6±0.2% of the end-tidal CO(2) fraction, respectively), while the threshold for tidal volume (8.0±0.2%), when the tidal volume had stabilized, was significantly higher than the thresholds for dyspnea (p<0.01) and respiratory frequency (p<0.05). A positive correlation was found between the thresholds for dyspnea and respiratory frequency (r=0.81, p<0.001), and these thresholds showed good agreement on a Bland-Altman plot. These findings suggest that the start of tachypneic breathing is coupled with the threshold for dyspnea.
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Affiliation(s)
- Masahiko Izumizaki
- Department of Physiology, Showa University School of Medicine, Tokyo, Japan.
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Yorke J, Russell AM, Swigris J, Shuldham C, Haigh C, Rochnia N, Hoyle J, Jones PW. Assessment of dyspnea in asthma: validation of The Dyspnea-12. J Asthma 2011; 48:602-8. [PMID: 21635136 DOI: 10.3109/02770903.2011.585412] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dyspnea is a prominent symptom in asthma. The Dyspnea-12 (D-12), an instrument that quantifies breathlessness using 12 descriptors that tap the physical and affective aspects, has shown promise for the measurement of dyspnea in cardiorespiratory disease. OBJECTIVE We report the results of a study designed to test the validity and reliability of the D-12 in a population of patients with asthma. METHODS This cross-sectional study included 102 patients with asthma. Subjects completed the D-12, Hospital Anxiety and Depression scale, St. George's Respiratory Questionnaire (SGRQ), and Medical Research Council scale. Confirmatory factor analysis confirmed the two-component structure of the D-12 (i.e., seven items that tap the physical aspects of breathlessness and five items that tap the affective aspects). RESULTS The D-12 subscales had excellent internal reliability (Cronbach's alpha for the "physical" score was 0.94 and the affective score was 0.95). The D-12 physical component was more strongly correlated with SGRQ Symptoms (r = 0.648), SGRQ Activities (r = 0.635) and Medical Research Council grade (r = 0.636), while the affective component was more strongly correlated with SGRQ Impacts (r = 0.765) and Hospital Anxiety and Depression scale scores (anxiety r = 0.641 and depression r = 0.602). CONCLUSION This study supports validity of the D-12 for use in the assessment of dyspnea of patients with asthma. It assesses one of the most pertinent symptoms of asthma from two viewpoints-physical and affective.
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Affiliation(s)
- Janelle Yorke
- School of Nursing and Midwifery, College of Health & Social Care, University of Salford, Greater Manchester, UK.
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Pickering EE, Semple SJ, Nazir MS, Murphy K, Snow TM, Cummin AR, Moosavi SH, Guz A, Holdcroft A. Cannabinoid effects on ventilation and breathlessness: A pilot study of efficacy and safety. Chron Respir Dis 2011; 8:109-18. [PMID: 21436223 DOI: 10.1177/1479972310391283] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Based on the neurophysiology of dyspnoea and the distribution of cannabinoid receptors within the central nervous system, we hypothesize that the unpleasantness of breathlessness will be ameliorated in humans by cannabinoids, without respiratory depression. Five normal and four chronic obstructive pulmonary disease (COPD) subjects entered a double blind, randomized, placebo-controlled crossover study with two test days. Subjects received sublingual cannabis extract or placebo. A maximum of 10.8 mg tetrahydrocannabinol and 10 mg cannabidiol were given. Breathlessness was simulated using fixed carbon dioxide loads. Measurements taken were of breathlessness (visual analogue scale [VAS] and breathlessness descriptors), mood and activation, end-tidal carbon dioxide tension and ventilatory parameters. These were measured at baseline and 2 hours post placebo and drug administration. Normal and COPD subjects showed no differences in breathlessness VAS scores and respiratory measurements before and after placebo or drug. After drug administration, COPD subjects picked ‘air hunger’ breathlessness descriptors less frequently compared to placebo. We have shown that breathlessness descriptors may detect an amelioration of the unpleasantness of breathlessness by cannabinoids without a change in conventional breathlessness ratings (VAS). A stimulus more specific for air hunger may be needed to demonstrate directly a drug effect on breathlessness. However, this study shows that the inclusion of respiratory descriptors may contribute to the assessment of drug effects on breathlessness.
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Affiliation(s)
- Elspeth E Pickering
- North Thames West Region, London, UK, Imperial College Healthcare, NHS Trust, London, UK
| | - Stephen J Semple
- National Heart and Lung Institute (NHLI), Imperial College London, Charing Cross Hospital Campus, London, UK
| | | | - Kevin Murphy
- Imperial College Healthcare, NHS Trust, London, UK
| | | | | | - Shakeeb H Moosavi
- National Heart and Lung Institute (NHLI), Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Abraham Guz
- National Heart and Lung Institute (NHLI), Imperial College London, Charing Cross Hospital Campus, London, UK
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Williams M, Cafarella P, Olds T, Petkov J, Frith P. Affective Descriptors of the Sensation of Breathlessness Are More Highly Associated With Severity of Impairment Than Physical Descriptors in People With COPD. Chest 2010; 138:315-22. [DOI: 10.1378/chest.09-2498] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:111-20. [DOI: 10.1097/spc.0b013e32833a1dfc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The dyspnea target: can we zero in on opioid responsiveness in advanced chronic obstructive pulmonary disease? Curr Opin Support Palliat Care 2010; 4:92-6. [DOI: 10.1097/spc.0b013e3283392788] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Contemporary issues in refractory dyspnoea in advanced chronic obstructive pulmonary disease. Curr Opin Support Palliat Care 2010; 4:56-62. [DOI: 10.1097/spc.0b013e328338c1c6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Evans KC. Cortico-limbic circuitry and the airways: insights from functional neuroimaging of respiratory afferents and efferents. Biol Psychol 2010; 84:13-25. [PMID: 20211221 PMCID: PMC2908728 DOI: 10.1016/j.biopsycho.2010.02.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 02/01/2010] [Accepted: 02/11/2010] [Indexed: 01/25/2023]
Abstract
After nearly two decades of active research, functional neuroimaging has demonstrated utility in the identification of cortical, limbic, and paralimbic (cortico-limbic) brain regions involved in respiratory control and respiratory perception. Before the recent boon of human neuroimaging studies, the location of the principal components of respiratory-related cortico-limbic circuitry had been unknown and their function had been poorly understood. Emerging neuroimaging evidence in both healthy and patient populations suggests that cognitive and emotional/affective processing within cortico-limbic circuitry modulates respiratory control and respiratory perception. This paper will review functional neuroimaging studies of respiration with a focus on whole brain investigations of sensorimotor pathways that have identified respiratory-related neural circuitry known to overlap emotional/affective cortico-limbic circuitry. To aid the interpretation of present and future findings, the complexities and challenges underlying neuroimaging methodologies will also be reviewed as applied to the study of respiration physiology.
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Affiliation(s)
- Karleyton C Evans
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 13th Street, Charlestown, MA 02129, USA.
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Patterns of Brain Activity in Response to Respiratory Stimulation in Patients with Idiopathic Hyperventilation (IHV). ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 669:341-5. [DOI: 10.1007/978-1-4419-5692-7_70] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax 2009; 65:21-6. [PMID: 19996336 PMCID: PMC2795166 DOI: 10.1136/thx.2009.118521] [Citation(s) in RCA: 217] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- J Yorke
- School of Nursing, Faculty of Health and Social Care, University of Salford, Greater Manchester, UK.
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