'You can't feel what we feel': Multifaceted dyspnoea invisibility in advanced chronic obstructive pulmonary disease examined through interpretative phenomenological analysis

The invisibility of chronic breathlessness. Why don't we talk about the symptom?

PURPOSE OF REVIEW

Chronic breathlessness is distressing and debilitating, yet often under-recognised. This review summarises recent insights into the visibility of breathlessness and delineates potential contributing factors to its invisibility.

RECENT FINDINGS

Chronic breathlessness' invisibility is multi-faceted and often leads to avoidance behaviour by patients. The symptom's presence, severity and impacts can be hidden from patients, caregivers, clinicians and the public due to its insidiousness, supposed subjectivity, stigma and the ability to be modulated by reducing exertion. This leads to patients' under-reporting of their breathlessness in clinic and low levels of public unawareness. Other contributing factors can include clinicians' failure to initiate conversations about breathlessness at times because of lack of knowledge about assessment and treatment, or prioritising disease management over symptom management.

SUMMARY

There is robust evidence that chronic breathlessness is often missed, unacknowledged or misunderstood by patients, caregivers, clinicians and society. Optimised clinical recognition and response may help to reverse these trends. Longitudinal studies are needed to explore whether such perceptions can be changed. Intervention studies should address every aspect of invisibility - from clinical improvements to minimising stigma and validating the subjective experience of patients.

Empathetic solicitude attenuates the affective and sensory dimensions of CO2-induced dyspnea: A randomized parallel arm experimental trial in healthy humans

Dyspnea testifies to profound suffering in patients and its relief is a priority for caregivers. This can be achieved by correcting causative disorders ("etiopathogenic" approach) or targeting the dyspnea itself ("symptomatic" approach), as is done for pain. Empathetic solicitude from caregivers has an intrinsic analgesic effect, but its effects on dyspnea have not been formally documented. This study tests the hypothesis that the empathetic solicitude behavior of a caregiver during experimental induction of acute and intense dyspnea would have a mitigating effect. In a double-blind, randomized, controlled experimental trial, 80 healthy participants were assigned to a neutral behavior arm or a solicitude behavior arm. During two successive visits (V1 and V2), dyspnea was induced through CO2-rebreathing and (i) assessed in an immediate manner using 10 cm affective and sensory visual analog scales (A-VAS and S-VAS) and (ii) post hoc using the Multidimensional Dyspnea Profile (MDP). A-VAS ratings at the end of the dyspnea challenge were significantly lower at V2 in the "solicitude behavior" arm than in the "neutral behavior" arm (6.69 [3.825-9.67] vs. 8.05 [6.43-10], p = 0.039). There were no significant differences between arms regarding S-VAS. MDP analysis showed that CO2-rebreathing induced dyspnea of the air hunger type, with statistically significant reductions in its intensity and both the sensory and affective dimensions of dyspnea. This study shows that empathetic solicitude can reduce the affective and sensory dimensions of experimentally induced dyspnea in healthy volunteers. Future studies should evaluate the impact of empathetic solicitude on clinical dyspnea.

Existential aspects of breathlessness in serious disease

PURPOSE OF THE REVIEW

Breathlessness may evoke existential threat but may also affect the person with serious illness or their caregiver/s in other important ways which can be considered 'existential'. This review explores existential aspects of breathlessness in people with serious illness and presents recent studies of assessment and management of associated distress and suffering.

RECENT FINDINGS

Both existential distress and breathlessness are multidimensional and include a range of constructs, many of which have behavioural consequences. Existential distress tracks closely with distressing breathing potentially due to shared underlying neurobiological processing. Paradoxically 'contagious' and isolating effects of breathlessness and related distress have been recently highlighted. Approaches to screening and assessment vary. Preliminary studies have investigated novel approaches to breathing-related anxiety and existential distress.

SUMMARY

Studies with existential constructs as outcome measures in people with breathlessness are scarce. Interventions for existential distress developed for those with malignant disease may be beneficial for those with non-malignant conditions, but adaptations may be required. Recently proposed taxonomies of existential distress/concerns may guide assessment and direct novel therapeutic interventions in people living with serious illness and breathlessness-related distress. Neglecting existential aspects of breathlessness represents a missed opportunity to support holistic well-being in people with serious illness.

Explain Breathlessness: Could 'Usual' Explanations Contribute to Maladaptive Beliefs of People Living with Breathlessness?

BACKGROUND

Explanations provided by healthcare professionals contribute to patient beliefs. Little is known about how healthcare professionals explain chronic breathlessness to people living with this adverse sensation.

METHODS

A purpose-designed survey disseminated via newsletters of Australian professional associations (physiotherapy, respiratory medicine, palliative care). Respondents provided free-text responses for their usual explanation and concepts important to include, avoid, or perceived as difficult to understand by recipients. Content analysis coded free text into mutually exclusive categories with the proportion of respondents in each category reported.

RESULTS

Respondents (n = 61) were predominantly clinicians (93%) who frequently (80% daily/weekly) conversed with patients about breathlessness. Frequent phrases included within usual explanations reflected breathlessness resulting from medical conditions (70% of respondents) and physiological mechanisms (44%) with foci ranging from multifactorial to single-mechanism origins. Management principles were important to include and phrases encouraging maladaptive beliefs were important to avoid. The most frequent difficult concept identified concerned inconsistent relationships between oxygenation and breathlessness. Where explanations included the term 'oxygen', a form of cognitive shortcut (heuristic) may contribute to erroneous beliefs.

CONCLUSIONS

This study presents examples of health professional explanations for chronic breathlessness as a starting point for considering whether and how explanations could contribute to adaptive or maladaptive breathlessness beliefs of recipients.

Medical hypnosis mitigates laboratory dyspnoea in healthy humans: a randomised, controlled experimental trial

QUESTION

Dyspnoea persisting despite treatments of underlying causes requires symptomatic approaches. Medical hypnosis could provide relief without the untoward effects of pharmacological approaches. We addressed this question through experimentally induced dyspnoea in healthy humans (inspiratory threshold loading (excessive inspiratory effort) and carbon dioxide stimulation (air hunger)).

MATERIAL AND METHODS

20 volunteers (10 women, aged 21-40 years) were studied on four separate days. The order of the visits was randomised in two steps: firstly, the "inspiratory threshold loading first" versus "carbon dioxide first" group (n=10 in each group); secondly, the "medical hypnosis first" versus "visual distraction first" subgroup (n=5 in each subgroup). Each visit comprised three 5-min periods (reference, intervention, washout) during which participants used visual analogue scales (VAS) to rate the sensory and affective dimensions of dyspnoea, and after which they completed the Multidimensional Dyspnea Profile.

RESULTS

Medical hypnosis reduced both dimensions of dyspnoea significantly more than visual distraction (inspiratory threshold loading: sensory reduction after 5 min 34% of full VAS versus 8% (p=0.0042), affective reduction 17.6% versus 2.4% (p=0.044); carbon dioxide: sensory reduction after 5 min 36.9% versus 3% (p=0.0015), affective reduction 29.1% versus 8.7% (p=0.0023)). The Multidimensional Dyspnea Profile showed more marked sensory effects during inspiratory threshold loading and more marked affective effects during carbon dioxide stimulation.

ANSWER TO THE QUESTION

Medical hypnosis was more effective than visual distraction at attenuating the sensory and affective dimensions of experimentally induced dyspnoea. This provides a strong rationale for clinical studies of hypnosis in persistent dyspnoea patients.

Disability and long-term breathlessness: a cross-sectional, population study

INTRODUCTION

Disability, resulting from altered interactions between individuals and their environment, is a worldwide issue causing inequities and suffering. Many diseases associated with breathlessness cause disability but the relationship between disability and the severity of breathlessness itself is unknown.This study evaluated associations between disability using the WHO's Disability Assessment Schedule (WHODAS) 2.0 and levels of long-term breathlessness limiting exertion.

METHODS

This population-based, cross-sectional online survey (n=10 033) reflected the most recent national census (2016) by age, sex, state/territory of residence and rurality. Assessments included self-reported disability (WHODAS 2.0 12-item (range 12 (no disability) to 60 (most severe disability)) assessed in 6 domains) and long-term breathlessness limiting exertion (modified Medical Research Council (mMRC) breathlessness scale; 0-4 (4-most severe)). Days in the last month affected by breathlessness were reported.

RESULTS

Of respondents (52% women; mean age 45), mean total disability score was 20.9 (SD 9.5). 42% (n=4245) had mMRC >0 (mMRC1 31% (n=3139); mMRC2 8% (n=806); mMRC3,4 3% (n=300)). Every level of long-term breathlessness limiting exertion was associated with greater levels of disability (total p <0.001; each domain p <0.001). The most compromised domains were Mobility and Participation.In the last 30 days, people with severe breathlessness (mMRC 3-4): experienced disability (20 days); reduced activities/work (10 days); and completely forwent activities (another 5 days).

CONCLUSIONS

Disability should be in the definition of persistent breathlessness as it is systematically associated with long-term breathlessness limiting exertion in a grade-dependent, multidimensional manner. Disability should be assessed in people with long-term breathlessness to optimise their social well-being and health.

"In their own words": delineating the contours of dyspnea invisibility in patients with advanced chronic obstructive pulmonary disease from quantitative discourse analysis

BACKGROUND

Dyspnea conveys an upsetting or distressing experience of breathing awareness. It heavily weighs on chronic respiratory disease patients, particularly when it persists despite maximal treatment of causative abnormalities. The physical, psychological and social impacts of persistent dyspnea are ill-appreciated by others. This invisibility constitutes a social barrier and impedes access to care. This study aimed to better understand dyspnea invisibility in patients with chronic obstructive pulmonary disease (COPD) through quantitative discourse analysis.

METHODS

We conducted a lexicometric analysis (lemmatization, descending hierarchical classification, multicomponent analysis, similarity analysis) of 11 patients' discourses (6 men, severe COPD; immediate postexacerbation rehabilitation) to identify semantic classes and communities, which we then confronted with themes previously identified using interpretative phenomenological analysis (IPA).

RESULTS

Class#1 ("experience and need for better understanding"; 38.9% of semantic forms, 50% of patients) illustrates the gap that patients perceive between their experience and what others see, confirming the importance of dyspnea invisibility in patients' concerns. Class#2 ("limitations"; 28.7% of forms) and Class#3 (management"; 13.1% of forms) point to the weight of daily limitations in performing basic activities, of the need to accept or adapt to the constraints of the disease. These three classes matched previously identified IPA-derived themes. Class#4 ("hospitalization"; 18.2% of forms) points to the importance of interactions with the hospital, especially during exacerbations, which constitutes novel information.

CONCLUSIONS

Lexicometry confirms the importance of dyspnea invisibility as a burden to COPD patients.

Exploring the Experience of Breathlessness with the Common-Sense Model of Self-Regulation (CSM)

Chronic breathlessness is a multidimensional, unpleasant symptom common to many health conditions. The Common-Sense Model of Self-Regulation (CSM) was developed to help understand how individuals make sense of their illness. This model has been underused in the study of breathlessness, especially in considering how information sources are integrated within an individual's cognitive and emotional representations of breathlessness. This descriptive qualitative study explored breathlessness beliefs, expectations, and language preferences of people experiencing chronic breathlessness using the CSM. Twenty-one community-dwelling individuals living with varying levels of breathlessness-related impairment were purposively recruited. Semi-structured interviews were conducted with questions reflecting components of the CSM. Interview transcripts were synthesized using deductive and inductive content analysis. Nineteen analytical categories emerged describing a range of cognitive and emotional breathlessness representations. Representations were developed through participants' personal experience and information from external sources including health professionals and the internet. Specific words and phrases about breathlessness with helpful or nonhelpful connotations were identified as contributors to breathlessness representations. The CSM aligns with current multidimensional models of breathlessness and provides health professionals with a robust theoretical framework for exploring breathlessness beliefs and expectations.