Comparison of the Dyspnoea-12 and Multidimensional Dyspnoea Profile in people with COPD

An Update on Outcomes for COPD Pharmacological Trials: A COPD Investigators Report - Reassessment of the 2008 American Thoracic Society/European Respiratory Society Statement on Outcomes for COPD Pharmacological Trials

Background: In 2008, a dedicated American Thoracic Society/European Respiratory Society task force published a paper on the possible use and limitations of clinical outcomes and biomarkers to evaluate the impact of pharmacological therapy in patients with chronic obstructive pulmonary disease. Since then, our scientific understanding of chronic obstructive pulmonary disease has increased considerably; there has been a progressive shift from a one-size-fits-all diagnostic and therapeutic approach to a personalized approach; and many new treatments currently in development will require new endpoints to evaluate their efficacy adequately. Objectives: The emergence of several new relevant outcome measures motivated the authors to review advances in the field and highlight the need to update the content of the original report. Methods: The authors separately created search strategies for the literature, primarily based on their opinions and assessments supported by carefully chosen references. No centralized examination of the literature or uniform criteria for including or excluding evidence were used. Measurements and Main Results: Endpoints, outcomes, and biomarkers have been revisited. The limitations of some of those reported in the American Thoracic Society/European Respiratory Society task force document have been highlighted. In addition, new tools that may be useful, especially in evaluating personalized therapy, have been described. Conclusions: Because the "label-free" treatable traits approach is becoming an important step toward precision medicine, future clinical trials should focus on highly prevalent treatable traits, and this will influence the choice of outcomes and markers to be considered. The use of the new tools, particularly combination endpoints, could help better identify the right patients to be treated with the new drugs.

Validity and Reliability of the Japanese Version of the Dyspnea-12 Questionnaire in Patients With Lung Cancer

CONTEXT

The Dyspnea-12 questionnaire is a simple tool to assess dyspnea using qualitative descriptors that include both physical and emotional domains. However, the reliability and validity of the Japanese version in patients with lung cancer have not been assessed.

OBJECTIVE

To determine the reliability and validity of the Japanese version of the Dyspnea-12 questionnaire in patients with lung cancer.

METHODS

The assessment was based on the numerical rating scale (NRS), cancer dyspnea scale (CDS), and hospital anxiety and depression scale (HADS). Spearman's correlation assessed the convergent validity of Dyspnea-12 using these three scales. Exploratory factor analysis examined the construct validity. The reliability was verified using Cronbach's alpha. Anxiety, depression, clinical dyspnea, presence of chronic obstructive pulmonary disease (COPD), and patient status were identified by discriminating performance.

RESULTS

The analysis included 113 patients with lung cancer. A significant positive correlation was found between Dyspnea-12 and NRS, CDS, and HADS scores. Similar to the original version, factor analysis clearly classified Dyspnea-12 into two components (physical and emotional), thereby confirming its construct validity. Cronbach's alpha values for the total Dyspnea-12 and its physical and emotional components were 0.97, 0.95, and 0.96, respectively. Patients with anxiety, depression, and clinical dyspnea and those in the palliative phase had significantly higher Dyspnea-12 scores than their respective counterparts. The Dyspnea-12 scores of patients with and without COPD were similar.

CONCLUSION

The Japanese version of the Dyspnea-12 questionnaire is a useful and reliable tool to assess the multi-dimensional aspects of dyspnea in patients with lung cancer.

Optimising the Dyspnoea Challenge: exertional dyspnoea responses to changing treadmill gradients

BACKGROUND

The Dyspnoea Challenge is a two-minute treadmill walk designed to measure exertional dyspnoea(ED). To efficiently individualise workload, we aimed to assess; 1) whether the Dyspnoea Challenge is responsive to 1% changes in treadmill gradient and 2) the minimum gradient variation necessary to generate a clinically meaningful change in ED (≥1 modified Borg scale).

METHODS

Thirty individuals with COPD(GOLD II-IV) (age: 69.2 ± 9.2 years; FEV₁: 49.3 ± 19.1%) completed six Dyspnoea Challenges at a fixed treadmill speed of 3 km·h^-1 and at a gradient of between 3% and 8%, performed in random order. ED intensity and leg fatigue were measured using the 0-10 modified Borg scale. Heart rate(HR) and oxygen saturation(S_pO₂) were monitored continuously. A multidimensional dyspnoea profile(MDP) was used to quantify the discomfort, physical, e.g., work/effort and breathing frequency, and emotional components of ED.

RESULTS

Higher treadmill gradients generated stronger intensities of ED (3%:2.6 ± 1.8; 4%:2.8 ± 2.2; 5%:3.2 ± 2.2; 6%:3.4 ± 2.2; 7%:3.7 ± 1.8; 8%:4.0 ± 2.1units). Statistical changes were observed in ED(e.g.,3 vs. 5%: P = .03) and the MDP discomfort data(e.g.,4 vs. 6%: P = .04) at ≥ a 2% variation in treadmill gradient. Linear regression found a 4% variation in treadmill gradient corresponded to a rise in ED ≥ 1unit. Increases in ED intensity corresponded to heightened sensations of work/effort(P < .01) and breathing frequency(P < .01). There were no changes in emotional constructs(P = .27). While there was an increase in HR with increasing gradient(P < .01), no differences were observed in end-exercise S_pO₂(P = .79) or leg fatigue(P = .06).

CONCLUSION

To significantly change ED, the treadmill gradient must be manipulated by ≥ 2%, with a ≥ 4% change in gradient required to induce a clinically meaningful change in ED.

Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure

BACKGROUND

Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains.

OBJECTIVE

To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure.

DESIGN

We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G).

PARTICIPANTS

We used data from a multi-site randomized clinical trial among outpatients with heart failure.

MAIN MEASURES

We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods.

KEY RESULTS

Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change.

CONCLUSIONS

The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.

Validation of the Dyspnoea-12 and Multidimensional Dyspnea profile among older Swedish men in the population

Background

The Dyspnoea-12 (D12) and Multidimensional dyspnea profile (MDP) are commonly used instruments for assessing multiple dimensions of breathlessness but have not been validated in older people in the population. The aim of this study was to validate the D12 and MDP in 73-years old men in terms of the instruments’ underlying factor structures, internal consistency, and validity.

Methods

A postal survey was sent out to a population sample of 73-years old men (n = 1,193) in southern Sweden. The two-factor structures were evaluated with confirmatory factor analysis, internal consistency with Cronbach's alpha, and validity using Pearson´s correlations with validated scales of breathlessness, anxiety, depression, fatigue, physical/mental quality of life, body mass index (BMI), and cardiorespiratory disease.

Results

A total 684 men were included. Respiratory and cardiovascular disease were reported by 17% and 38%, respectively. For D12 and MDP, the proposed two-factor structure was not fully confirmed in this population. Internal consistency was excellent for all D12 and MDP domain scores (Cronbach's alpha scores > 0.92), and the instruments’ domains showed concurrent validity with other breathlessness scales, and discriminant validity with anxiety, depression, physical/mental quality of life, BMI, and cardiorespiratory disease.

Conclusions

In a population sample of 73-years old men, the D12 and MDP had good psychometrical properties in terms of reliability and validity, which supports that the instruments are valid for use in population studies of older men.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03166-5.

'The body says it': the difficulty of measuring and communicating sensations of breathlessness

Breathlessness is a sensation affecting those living with chronic respiratory disease, obesity, heart disease and anxiety disorders. The Multidimensional Dyspnoea Profile is a respiratory questionnaire which attempts to measure the incommunicable different sensory qualities (and emotional responses) of breathlessness. Drawing on sensorial anthropology we take as our object of study the process of turning sensations into symptoms. We consider how shared cultural templates of 'what counts as a symptom' evolve, mediate and feed into the process of bodily sensations becoming a symptom. Our contribution to the field of sensorial anthropology, as an interdisciplinary collaboration between history, anthropology and the medical humanities, is to provide a critique of how biomedicine and cultures of clinical research have measured the multidimensional sensorial aspects of breathlessness. Using cognitive interviews of respiratory questionnaires with participants from the Breathe Easy groups in the UK, we give examples of how the wording used to describe sensations is often at odds with the language those living with breathlessness understand or use. They struggle to comprehend and map their bodily experience of sensations associated with breathlessness to the words on the respiratory questionnaire. We reflect on the alignment between cognitive interviewing as a method and anthropology as a disciplinary approach. We argue biomedicine brings with it a set of cultural assumptions about what it means to measure (and know) the sensorial breathless body in the context of the respiratory clinic (clinical research). We suggest the mismatch between the descriptions (and confusion) of those responding to the respiratory questionnaire items and those selecting the vocabularies in designing it may be symptomatic of a type of historical testimonial epistemic injustice, founded on the prioritisation of clinical expertise over expertise by experience.

Dyspnoea-12 and Multidimensional Dyspnea Profile: Systematic Review of Use and Properties

CONTEXT

The Dyspnoea-12 (D-12) and Multidimensional Dyspnea Profile (MDP) were specifically developed for assessment of multiple sensations of breathlessness.

OBJECTIVES

This systematic review aimed to identify the use and measurement properties of the D-12 and MDP across populations, settings and languages.

METHODS

Electronic databases were searched for primary studies (2008-2020) reporting use of the D-12 or MDP in adults. Two independent reviewers completed screening and data extraction. Study and participant characteristics, instrument use, reported scores and minimal clinical important differences (MCID) were evaluated. Data on internal consistency (Cronbach's α) and test-retest reliability (intraclass correlation coefficient, ICC) were pooled using random effects models between settings and languages.

RESULTS

A total 75 publications reported use of D-12 (n = 35), MDP (n = 37) or both (n = 3), reflecting 16 chronic conditions. Synthesis confirmed two factor structure, internal consistency (Cronbach's α mean, 95% CI: D-12 Total = 0.93, 0.91-0.94; MDP Immediate Perception [IP] = 0.88, 0.85-0.90; MDP Emotional Response [ER] = 0.86, 0.82-0.89) and 14 day test-rest reliability (ICC: D-12 Total = 0.91, 0.88-0.94; MDP IP = 0.85, 0.70-0.93; MDP ER = 0.84, 0.73-0.90) across settings and languages. MCID estimates for clinical interventions ranged between -3 and -6 points (D-12 Total) with small variability in scores over 2 weeks (D-12 Total 2.8 (95% CI: 2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1) and six months (D-12 Total 2.9 (2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1)).

CONCLUSION

D-12 and MDP are widely used, reliable, valid and responsive across various chronic conditions, settings and languages, and could be considered standard instruments for measuring dimensions of breathlessness in international trials.

Multi-Dimensional Dyspnea-Related Scales Validated in Individuals With Cardio-Respiratory and Cancer Diseases. A Systematic Review of Psychometric Properties

CONTEXT

In order to examine the multi-dimensional nature of dyspnea and its impact on the activities of daily living (ADLs) in patients with cardio-respiratory and cancer diseases, validated measures are needed.

OBJECTIVES

Our aim was to identify all the multi-dimensional clinical scales assessing dyspnea and its impact on ADLs in patients with cardio-respiratory and cancer diseases, and to critically appraise their psychometric properties.

METHODS

Five databases were systematically searched up to July 2020. Eligible criteria were: the examination of at least one psychometric property, and the recruitment of adults with a cardio-respiratory or cancer disease in non-emergency settings. The characteristics and psychometric properties of the studies included were presented through a narrative synthesis. The methodological quality of the studies and evidence synthesis were rated using the "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" criteria.

RESULTS

Forty-three studies, for which eight assessment scales had been identified, were included in the review. At the time of the review, three multi-dimensional assessment scales were available for assessing dyspnea symptoms, and five multi-dimensional scales were available to examine the impact of dyspnea on ADLs. Although the use of these scales has rapidly grown, evidence of psychometric properties has been reported as limited in most of the scales.

CONCLUSION

Despite the potential of the identified scales, further studies are needed to strength evidence on the validity and reliability of the multi-dimensional dyspnea scales. Furthermore, more studies appraising the content validity and responsiveness of the scales are specifically recommended.

Examining the repeatability of a novel test to measure exertional dyspnoea in chronic obstructive pulmonary disease

BACKGROUND

Exertional dyspnoea(ED) is a hallmark of chronic obstructive pulmonary disease(COPD). We examined the repeatability and face validity of the end-exercise ED(ED_end) response during the Dyspnoea Challenge and compared those to the six-minute walk test (6MWT) in COPD.

METHODS

Twenty-six individuals with COPD(13 Females, age:69 ± 5.5yrs, FEV₁:63.4 ± 11.9 %) completed 2 × 6MWTs and 4 x Dyspnoea Challenges on three occasions. The challenge consisted of a two-minute treadmill walk at 80 % of 6MWT speed(3.9 ± 0.5 km·hr^-1) at either a low(LI_DC:5.3 ± 2%) or high angle of incline(HI_DC:9.5 ± 3%). Dyspnoea(0-10 scale), heart rate(HR) and oxygen saturation(S_pO₂) were monitored continuously.

RESULTS

Mean 6MWT distance was 488 ± 58 m. End-exercise ED and HR were higher in the HI_DC(ED_end 6.2 ± 2.0; HR: 123 ± 17beats·min^-1) compared to the LI_DC(ED_end 4.2 ± 2.0; HR: 119 ± 15beats·min^-1) and the 6MWT(ED_end 4.3 ± 2.0; HR: 115 ± 16beats·min^-1)(P < 0.01). SpO₂ was not different between 6MWT, LI_DC or HI_DC(P = 0.34). The intraclass correlation coefficient(ICC) for each intensity was excellent (HI_DC, ICC = 0.88, LI_DC, ICC = 0.93, P < 0.001) with neither reporting bias(HI_DC, P = 0.63; LI_DC, P = 0.94).

CONCLUSIONS

The Dyspnoea Challenge is a simple measure of ED that appears to have both repeatability and face validity. With further optimisation, this test may enhance the field-based clinical assessment of ED.

Breathlessness dimensions association with physical and mental quality of life: the population based VASCOL study of elderly men

Background

Breathlessness is a multidimensional symptom prevalent in elderly affecting many aspects of life. We aimed to determine how different dimensions of breathlessness are associated with physical and mental quality of life (QoL) in elderly men.

Methods

This was a cross-sectional, population-based analysis of 672 men aged 73 years in a Swedish county. Breathlessness was assessed using Dyspnoea-12 (D-12) and Multidimensional Dyspnoea Profile (MDP), and QoL using the Short Form 12 physical and mental scores. Scores were compared as z-scores across scales and analysed using multivariable linear regression, adjusted for smoking, body mass index and the presence of respiratory and cardiovascular disease.

Results

Worse breathlessness was related to worse physical and mental QoL across all the D-12 and MDP dimension scores. Physical QoL was most strongly associated with perceptional breathlessness scores, D-12 total and physical scores (95% CI −0.45 to −0.30). Mental QoL was more strongly influenced by affective responses, MDP emotional response score (95% CI −0.61 to −0.48). Head-to-head comparison of the instruments confirmed that D-12 total and physical scores most influenced physical QoL, while mental QoL was mostly influenced by the emotional responses captured by the MDP.

Conclusion

Breathlessness dimensions and QoL measures are associated differently. Physical QoL was most closely associated with sensory and perceptual breathlessness dimensions, while emotional responses were most strongly associated with mental QoL in elderly men. D-12 and MDP contribute complimentary information, where affective and emotional responses may be related to function, deconditioning and QoL.

Reliability and validity of the multidimensional dyspnea profile in hospitalized Chinese patients with respiratory diseases

Background:

Dyspnea is a multidimensional experience similar to pain and is one of the most common clinical presentations in patients with respiratory diseases. Accurately evaluating the experience of dyspnea allows nurses and physicians to deliver better medical services to patients. The multidimensional dyspnea profile emphasizes the psychosocial factors of dyspnea and assesses immediate discomfort, sensory qualities, and the emotional responses of patients with dyspnea. At present, the validity, reliability, and test–retest reliability of the multidimensional dyspnea profile in patients with respiratory diseases in China are unclear.

Objectives:

The aim of this study was to investigate the validity, reliability, and test–retest reliability of the Chinese version of the multidimensional dyspnea profile and to assess the convergent validity between the Chinese version of the multidimensional dyspnea profile and the modified Medical Research Council Dyspnea Scale.

Methods:

The factorial construct, intraclass correlations, internal consistency, and convergent validity of the Chinese version of the multidimensional dyspnea profile was evaluated using data from 231 inpatients with dyspnea from the respiratory department of a hospital. In the principal component analysis stage, 131 inpatients were evaluated. In the test–retest reliability analysis stage, 50 out of the 131 patients responded to the questionnaire again. In the confirmatory factor analysis, 100 inpatients from an independent sample were assessed.

Results:

The principal component analysis showed that the Chinese version of the multidimensional dyspnea profile had a two-factor structure: the immediate perceptual-related problem factor (6 items) and the emotional response-related problem factor (5 items). The convergent validity between the Chinese version of the multidimensional dyspnea profile and the modified Medical Research Council Dyspnea Scale was significant and acceptable based on the average variance extracted (r = .56, p < .001). The confirmatory factor analysis revealed a good model fit and provided support for the construct validity of the Chinese version of the multidimensional dyspnea profile. Overall, the internal consistency and intraclass correlation coefficient of the Chinese version of the multidimensional dyspnea profile were good.

Conclusion:

The 11-item Chinese version of the multidimensional dyspnea profile has acceptable validity and reliability in patients with respiratory diseases in China. In the future, more studies should be performed to further explore its clinical application.

How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease

Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg's 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.

Validity and reliability of the Multidimensional Dyspnoea Profile in older adults

Breathlessness is a common and distressing symptom in older adults and an independent predictor of adverse outcomes and yet its multidimensional assessment has not been validated in older adults. We apply and validate the Multidimensional Dyspnoea Profile (MDP) in a sample of adults 75 years and older in Belgium.

Breathlessness was rated with the MDP, the modified Borg Dyspnoea Scale (mBDS), the Short Physical Performance Battery (SPPB, a numerical rating scale for intensity and unpleasantness both before and after exertion), as well as with the Medical Research Council (MRC) Dyspnoea Scale. The Hospital Anxiety and Depression Scale (HADS) assessed the affective status. Factor structure was analysed with exploratory principal components analysis, internal consistency with Cronbach's alpha and concurrent validity with Spearman's correlation coefficients with other breathlessness scales, HADS and SPPB scores.

In 96 participants (mean age 85 years; 34% men) who rated breathlessness at both assessment points, exploratory principal components analysis identified two components: Immediate Perception (IP) and Emotional Reaction (ER), explaining most of the MDP item variance (65.37% before and 71.32% after exertion). Internal consistency was moderate to high for MDP-IP (Cronbach's alpha = 0.86 before and 0.89 after exertion) and MDP-ER (Cronbach's alpha = 0.89 before and 0.91 after exertion). The correlation patterns of MDP-IP and MDP-ER with other tests confirmed concurrent validity.

The domain structure, reliability and concurrent validity of MDP for breathlessness before and after exertion were confirmed in a sample of adults 75 years and older, supporting its use and further research for the multidimensional profiling of breathlessness in older adults.

Domain structure, reliability and concurrent validity of the MDP were confirmed in a sample of adults aged ≥75 years before and after exertion, supporting its use for the multidimensional assessment of breathlessness in this age grouphttps://bit.ly/3emiNRW

Determination of the minimal important difference for Dyspnoea-12 questionnaire in patients with COPD, after pulmonary rehabilitation

INTRODUCTION

The authors of the international task force about the management of Dyspnoea recommend assessing sensory and affective components of dyspnoea. The Dyspnoea-12 questionnaire (D-12) allows to assess both components of dyspnoea. D-12 is valid and reliable but its sensitivity to pulmonary rehabilitation was not studied. The aim of this study was to estimate the minimal important difference (MID) for D-12 in COPD patients undergoing a pulmonary rehabilitation programme (PRP).

METHODS

Severe or very severe COPD patients undergoing a PRP were included. Dyspnoea was assessed using D-12, MMRC dyspnoea scale, London chest of Activity of Daily Living questionnaire (LCADL). Quality of life was assessed using Saint-George respiratory questionnaire (SGRQ) and COPD assessment Test (CAT); exercise capacity using 6-Minute walk Test (6MWT) and 1-minute sit to-stand test (1STST). The MID was evaluated using distribution and anchor-based methods.

RESULTS

Sixty patients (age: 64.4 ± 8.2; FEV1 (%): 28.6 ± 8.1) were included. At the end of the PRP, patients had significantly decreased their dyspnoea measured with D-12, MMRC, LCADL (D-12:23.9 ± 8.9 to 17.6 ± 9.4; MMRC: 3 ± 0.7 to 2.2 ± 1.1, LCADL: 38 ± 13.9 to 31.6 ± 11; p < 0.0001). Using the distribution-based analysis, MID of -2.67 (standard error of measurement) or -4.45 (standard deviation) was found. According to methodology, we could only use SGRQ as anchor. With SGRQ as anchor, the receiver operating characteristic curve identified MID for the change in D-12 at -6.1 (sensibility: 58%, specificity: 79%). The correlation with SGRQ was modest (r = 0.33), so the calculated MID should be interpreted with caution.

CONCLUSION

D-12 is a good tool to assess the decrease of dyspnoea after PR. We propose MID of -6 points. However, Future estimates of MID for the D-12 should use anchors that are more strongly correlated with it.

Air Hunger: A Primal Sensation and a Primary Element of Dyspnea

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.

Validity and reliability of the Turkish version of the Multidimensional Dyspnea Profile in outpatients with respiratory disease

Background/aim

Dyspnea is the subjective feeling of breathing discomfort, which is a significant problem for patients with heart and respiratory disease and also an important determinant of exercise tolerance, quality of life, and mortality in various diseases. Most of the scales are not enough to investigate the multidimensional effects of dyspnea; therefore, the Multidimensional Dyspnea Profile (MDP) was developed and validated in many languages. This study aimed to translate and culturally adapt the MDP into Turkish and investigate the psychometric properties of this adapted version in outpatients with respiratory disease.

Materials and methods

The MDP was translated and culturally adapted into Turkish following published guidelines. A total of 170 outpatients with respiratory disease were included to assess psychometric properties. The factorial structure was investigated using a principal component analysis. Two situations were used in this study evaluating dyspnea in activity-related and resting conditions. We formulated 17 hypotheses for each MDP domain (in total 68) to assess construct validity, and correlations were investigated between the MDP and measures of body mass index, pulmonary function test, other dyspnea assessments, anxiety, depression, and health-related quality of life. To investigate the test-retest reliability, the MDP was administered again after 1-h and 1 week.

Results

Internal consistency of the MDP was excellent (Cronbach’s alpha coefficients ranged from 0.89 to 0.93). The exploratory factor analysis revealed 2 components explaining a 70% and 76% variance. Overall, 64 of the 68 predetermined hypotheses (94%) were confirmed to test construct validity. The MDP showed excellent test-retest reliability for a 1-hperiod (intraclass correlation coefficient values ranged from 0.98 to 0.99). However, test-retest reliability decreased moderate-to-high after 1 week (0.53–0.80).

Conclusion

The MDP was successfully translated and culturally adapted into Turkish and this version showed good psychometric properties including the factorial structure, internal consistency, test-retest reliability, and construct validity to assess multidimensional aspects of dyspnea.

Minimal Clinically Important Differences and Feasibility of Dyspnea-12 and the Multidimensional Dyspnea Profile in Cardiorespiratory Disease

CONTEXT

Breathlessness is a cardinal symptom in cardiorespiratory disease and consists of multiple dimensions that can be measured using the instruments Dyspnea-12 (D12) and the Multidimensional Dyspnea Profile (MDP).

OBJECTIVES

The objective of the study is to determine the minimal clinically important differences (MCIDs) of all D12 and MDP summary and subdomain scores as well as the instruments' feasibility in patients with cardiorespiratory disease.

METHODS

Prospective multicenter cohort study of outpatients with diagnosed cardiorespiratory disease and breathlessness in daily life. D12 and MDP were assessed at baseline, after 30-90 minutes and two weeks. MCIDs were calculated using anchor-based and distributional methods for summary and subdomain scores. Feasibility was assessed as rate of missing data, help required, self-reported difficulty, and completion time.

RESULTS

A total 182 outpatients (53.3% women) were included; main diagnoses were chronic obstructive pulmonary disease (COPD; 25%), asthma (21%), heart failure (19%), and idiopathic pulmonary fibrosis (19%). Anchor-based MCIDs were for D12 total score 2.83 (95% CI 1.99-3.66); D12 physical 1.81 (1.29-2.34); D12 affective 1.07 (0.64-1.49); MDP A1 unpleasantness 0.82 (0.56-1.08); MDP perception 4.63 (3.21-6.05), and MDP emotional score 2.37 (1.10-3.64). The estimates were consistent with small-to-moderate effect sizes using distributional analysis, and MCIDs were similar between COPD and non-COPD patients. The instruments were generally feasible and quick to use.

CONCLUSION

D12 and MDP are responsive to change and feasible for use for assessing multidimensional breathlessness in outpatients with cardiorespiratory disease. MCIDs were determined for use as endpoints in clinical trials.

Standardized measurement of breathlessness during exercise

PURPOSE OF REVIEW

Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion.

RECENT FINDINGS

Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time.

SUMMARY

To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus.

Clinical validation of the Swedish version of Dyspnoea-12 instrument in outpatients with cardiorespiratory disease

Introduction

Breathlessness is the cardinal symptom in both cardiac and respiratory diseases, and includes multiple dimensions. The multidimensional instrument Dyspnoea-12 has been developed to assess both physical and affective components of breathlessness. This study aimed to perform a clinical validation of the Swedish version of Dyspnoea-12 in outpatients with cardiorespiratory disease.

Methods

Stable outpatients with cardiorespiratory disease and self-reported breathlessness in daily life were recruited from five Swedish centres. Assessments of Dyspnoea-12 were performed at baseline, after 30-90 min and after 2 weeks. Factor structure was tested using confirmatory factor analysis and internal consistency using Cronbach's alpha. Test-retest reliability was analysed using intraclass correlation coefficients (ICCs). Concurrent validity at baseline was evaluated by examining correlations with lung function and several instruments for the assessment of symptoms and health status.

Results

In total, 182 patients were included: with the mean age of 69 years and 53% women. The main causes of breathlessness were chronic obstructive pulmonary disease (COPD; 25%), asthma (21%), heart failure (19%) and idiopathic pulmonary fibrosis (19%). Factor analysis confirmed the expected underlying two-component structure with two subdomains. The Dyspnoea-12 total score, physical subdomain score and affective subdomain scores showed high internal consistency (Cronbach's alpha 0.94, 0.84 and 0.80, respectively) and acceptable reliability after 2 weeks (ICC total scores 0.81, 0.79 and 0.73). Dyspnoea-12 showed concurrent validity with the instruments modified Medical Research Council scale, COPD Assessment Test, European Quality of Life-Five Dimensions-Five levels, the Functional Assessment of Chronic Illness Therapy-Fatigue, the Hospital Anxiety and Depression Scale, and with forced expiratory volume in 1 s in percentage of predicted value. The results were consistent across different cardiorespiratory conditions.

Conclusion

The Dyspnoea-12 is a valid instrument for multidimensional assessment of breathlessness in Swedish patients with cardiorespiratory diseases.

Validation of the Swedish Multidimensional Dyspnea Profile (MDP) in outpatients with cardiorespiratory disease

Introduction

Breathlessness is a cardinal symptom in cardiorespiratory disease. An instrument for measuring different aspects of breathlessness was recently developed, the Multidimensional Dyspnea Profile (MDP). This study aimed to validate the MDP in terms of the underlying factor structure, internal consistency, test-retest reliability and concurrent validity in Swedish outpatients with cardiorespiratory disease.

Methods

Outpatients with stable cardiorespiratory disease and breathlessness in daily life were recruited. Factor structure of MDP was analysed using confirmatory factor analysis; internal consistency was analysed using Cronbach's alpha; and test-retest reliability was analysed using intraclass correlation coefficients (ICCs) for patients with unchanged breathlessness between assessments (baseline, after 30-90 min and 2 weeks). Concurrent validity was evaluated using correlations with validated scales of breathlessness, anxiety, depression and health-related quality of life.

Results

In total, 182 outpatients with cardiorespiratory disease and breathlessness in daily life were included; 53.3% were women; main diagnoses were chronic obstructive pulmonary disease (24.7%), asthma (21.4%), heart failure (19.2%) and idiopathic pulmonary fibrosis (18.7%). The MDP total, immediate perception and emotional response scores, and individual item scores showed expected factor structure and acceptable measurement properties: internal consistency (Cronbach's alpha, range 0.80-0.93); test-retest reliability at 30-90 min and 2 weeks (ICC, range 0.67-0.91); and concurrent validity. There was no evidence of a learning effect. Findings were similar between diagnoses.

Discussion

MDP is a valid instrument for multidimensional measurement of breathlessness in Swedish outpatients across cardiorespiratory diseases.

Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions

Dyspnea is a distressing, debilitating, and near-ubiquitous symptom affecting patients with COPD. In addition to the functional consequences of dyspnea, which include activity limitation and reduced exercise tolerance, it is important to consider its psychological impact on patients with COPD, such as onset of depression or anxiety. Moreover, the anticipation of dyspnea itself can have a significant effect on patients' emotions and behavior, with patients frequently self-limiting physical activity to avoid what has become the hallmark symptom of COPD. Dyspnea is, therefore, a key target for COPD treatments. Pharmacologic treatments can optimize respiratory mechanics, provide symptom relief, and reduce patients' increased inspiratory neural drive to breathe. However, it is important to acknowledge the value of non-pharmacologic interventions, such as pulmonary rehabilitation and patient self-management education, which have proven to be invaluable tools for targeting the affective components of dyspnea. Furthermore, it is important to encourage maintenance of physical activity to optimize long-term patient outcomes. Here, we review the physiological and psychological consequences of activity-related dyspnea in COPD, assess the efficacy of modern management strategies in improving this common respiratory symptom, and discuss key unmet clinical and research needs that warrant further immediate attention.

A Multidimensional Profile of Dyspnea in Hospitalized Patients

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

CONTEXT

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Use of time in chronic obstructive pulmonary disease: Longitudinal associations with symptoms and quality of life using a compositional analysis approach

Background and objectives

This study explored whether, for people with chronic obstructive pulmonary disease (COPD), changes to the 24-hour composition of physical activity (PA), sedentary behaviour (SB) and sleep were associated with changes in symptoms and health-related quality of life (HRQoL); and how time re-allocations between these behaviours were associated with changes in outcomes.

Methods

This study pools data on people with COPD drawn from two previous studies: a randomised controlled trial of cognitive behavioural therapy and pulmonary rehabilitation and a usual care cohort. Participants recalled behaviours and completed symptom and HRQoL assessments at baseline (T0) and four months (T1). Linear mixed-effects models (pooled control/intervention samples) predicted changes in outcomes from T0 to T1 with a change to the 24-hour behaviour composition; compositional isotemporal substitution predicted change in outcomes when re-allocating time between behaviours.

Results

Valid data were obtained for 95 participants (forced expiratory volume in one second %predicted = 49.6±15.3) at T0 and T1. A change in the 24-hour behaviour composition was associated with a change in anxiety (p<0.01) and mastery (p<0.01), but not breathlessness, depression or fatigue. When modelling time re-allocation with compositional isotemporal substitution, more time re-allocated to higher intensity PA or sleep was associated with favourable changes in outcomes; re-allocating time to SB or light PA was associated with unfavourable changes in outcomes. The direction of association, however, could not be determined.

Conclusion

To improve the overall health and wellbeing of people with COPD, intervention approaches that optimise the composition of PA, SB and sleep may be beneficial.

European Respiratory Society International Congress 2018: Allied Respiratory Professionals' report of highlighted sessions

This article provides an overview of outstanding sessions that were supported by Assembly 9 during the recent European Respiratory Society International Congress in Paris, France. Session content was mainly targeted at allied health professionals such as respiratory physiologists, respiratory physiotherapists and respiratory nurses. Recent developments and novel findings related to pulmonary function testing, respiratory muscle function assessments and treatment, and multidimensional and multidisciplinary approaches to the assessment and management of dyspnoea were the focus of these sessions and are summarised here.

An overview of outstanding sessions that were supported by Assembly 9 during the 2018 European Respiratory Society International Congress in Paris, France.http://ow.ly/OO8P30mXs3q

Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validation of the French version of the London Chest Activity of Daily Living scale and the Dyspnea-12 questionnaire

Introduction

Eighty percent of COPD patients experience dyspnea during activities of daily life (ADL). To the best of our knowledge, the Modified Medical Research Council (MMRC) dyspnea scale is the only validated scale designed to quantify dyspnea during ADL available in the French language. Two other instruments are only available in English versions: the London Chest Activity of Daily Living (LCADL) scale that allows a specific evaluation of dyspnea during ADL and the Dyspnea-12 questionnaire that evaluates the affective (emotional) and sensory components of dyspnea in daily life. The aim of this study was to translate and validate French versions of both LCADL and Dyspnea-12 questionnaires and to determine the reliability of these versions for the evaluation of dyspnea in severe to very severe COPD patients.

Methods

Both translation and cultural adaptation were based on Beaton’s recommendations. Fifty consecutive patients completed the French version of LCADL and Dyspnea-12 and other questionnaires (MMRC, Saint George’s Respiratory Questionnaire [SGRQ], Hospital Anxiety and Depression [HAD]), at a 2-week interval. Internal consistency, validity, and reliability of LCADL and Dyspnea-12 were evaluated.

Results

The French version of LCADL and Dyspnea-12 demonstrated good internal consistency with Cronbach’s α of, respectively, 0.84 and 0.91. LCADL was correlated significantly with item activity of SGRQ (ρ=0.55, p<0.001), total score of SGRQ (ρ=0.63, p<0.001), item impact of SGRQ (ρ=0.57, p<0.001), and HAD-depression (HAD-D) (ρ=0.47, p=0.001); and Dyspnea-12 was correlated significantly with MMRC (ρ=0.39, p<0.001), HAD-anxiety (ρ=0.64, p<0.001), and HAD-D (ρ=0.64, p<0.001). The French version of LCADL and Dyspnea-12 demonstrated good test–retest reliability with, respectively, intraclass coefficient =0.84 (p<0.001) and 0.91 (p<0.001).

Conclusion

The French versions of LCADL and Dyspnea-12 questionnaires are promising tools to evaluate dyspnea in severe to very severe COPD patients.

Patterns of Time Use across the Chronic Obstructive Pulmonary Disease Severity Spectrum

Descriptions of time use patterns in people with chronic obstructive pulmonary disease (COPD) are scarce and the relationship between use-of-time and COPD severity remains unclear. This study aimed to describe a typical day for people with COPD and to explore the differences in time-use patterns across the Body Mass-Index, Airflow Obstruction, Dyspnoea and Exercise Capacity (BODE) index using compositional analyses. Using a cross-sectional design, 141 adults with clinically stable COPD had their demographics, objective measures of function (pulmonary, exercise capacity and physical activity), and self-reported COPD-related impairment recorded. Daily time-use compositions were derived from 24-h accelerometry and 24-h use-of-time recall interviews. Compositional multiple linear regression models were used to explore the relationship between the BODE index and 24-h time-use compositions. These models were used to predict daily time (min/d) that is spent in time-use components across the BODE index. The BODE index score was clearly associated with 24-h accelerometry (p < 0.0001) and 24-h use-of-time recall (p < 0.0001) compositions. Relative to the remaining time-use components, higher BODE index scores were associated with greater sedentary behaviour (p < 0.0001), Quiet time (p < 0.0001), Screen time (p = 0.001) and Self-care (p = 0.022), and less daily Chores (p < 0.0001) and Household administration (p = 0.015) time. As the BODE index scores increased, time-use predictions were strongly associated with decreases in Chores (up to 206 min/d), and increases in Screen (up to 156 min/d) and Quiet time (up to 131 min/d). Time–use patterns may provide a basis for planning interventions relative to the severity of COPD.

Translation and Validation of the Multidimensional Dyspnea-12 Questionnaire

INTRODUCTION

Dyspnea is a multidimensional symptom, but this multidimensionality is not considered in most dyspnea questionnaires. The Dyspnea-12 takes a multidimensional approach to the assessment of dyspnea, specifically the sensory and the affective response. The objective of this study was to translate into Spanish and validate the Dyspnea-12 questionnaire.

METHODS

The original English version of the Dyspnea-12 questionnaire was translated into Spanish and backtranslated to analyze its equivalence. Comprehension of the text was verified by analyzing the responses of 10 patients. Reliability and validation of the questionnaire were studied in an independent group of COPD patients attending the pulmonology clinics of Hospital Universitario Marqués de Valdecilla, diagnosed and categorized according to GOLD guidelines.

RESULTS

The mean age of the group (n=51) was 65 years and mean FEV1 was 50%. All patients understood all questions of the translated version of Dyspnea-12. Internal consistency of the questionnaire was α=0.937 and intraclass correlation coefficient was=.969; P<.001. Statistically significant correlations were found with HADS (anxiety r=.608 and depression r=.615), mMRC dyspnea (r=.592), 6MWT (r=-0.445), FEV1 (r=-0.312), all dimensions of CRQ-SAS (dyspnea r=-0.626; fatigue r=-0.718; emotional function r=-0.663; mastery r=-0.740), CAT (r=0.669), and baseline dyspnea index (r=-0.615). Dyspnea-12 scores were 10.32 points higher in symptomatic GOLD groups (B and D) (P<.001).

CONCLUSION

The Spanish version of Dyspnea-12 is a valid and reliable instrument to study the multidimensional nature of dyspnea.

Dyspnoea-12: a translation and linguistic validation study in a Swedish setting

BACKGROUND

Dyspnoea consists of multiple dimensions including the intensity, unpleasantness, sensory qualities and emotional responses which may differ between patient groups, settings and in relation to treatment. The Dyspnoea-12 is a validated and convenient instrument for multidimensional measurement in English. We aimed to take forward a Swedish version of the Dyspnoea-12.

METHODS

The linguistic validation of the Dyspnoea-12 was performed (Mapi Language Services, Lyon, France). The standardised procedure involved forward and backward translations by three independent certified translators and revisions after feedback from an in-country linguistic consultant, the developerand three native physicians. The understanding and convenience of the translated version was evaluated using qualitative in-depth interviews with five patients with dyspnoea.

RESULTS

A Swedish version of the Dyspnoea-12 was elaborated and evaluated carefully according to international guidelines. The Swedish version, 'Dyspné-12', has the same layout as the original version, including 12 items distributed on seven physical and five affective items. The Dyspnoea-12 is copyrighted by the developer but can be used free of charge after permission for not industry-funded research.

CONCLUSION

A Swedish version of the Dyspnoea-12 is now available for clinical validation and multidimensional measurement across diseases and settings with the aim of improved evaluation and management of dyspnoea.