Reliability and validity of the multidimensional dyspnea profile

Use of Ecological Momentary Assessment to Measure Dyspnea in COPD

Dyspnea is an unpredictable and distressing symptom of chronic obstructive pulmonary disease (COPD). Dyspnea is challenging to measure due to the heterogeneity of COPD and recall bias associated with retrospective reports. Ecological Momentary Assessment (EMA) is a technique used to collect symptoms in real-time within a natural environment, useful for monitoring symptom trends and risks of exacerbation in COPD. EMA can be integrated into mobile health (mHealth) platforms for repeated data collection and used alongside physiological measures and behavioral activity monitors. The purpose of this paper is to discuss the use of mHealth and EMA for dyspnea measurement, consider clinical implications of EMA in COPD management, and identify needs for future research in this area.

A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service

Breathlessness support services have demonstrated benefits for breathlessness mastery, quality of life and psychosocial outcomes for people living with breathlessness. However, these services have predominantly been implemented in hospital and home care contexts. This study aims to evaluate the adaptation and implementation of a hospice-based outpatient Multidisciplinary Breathlessness Support Service (MBSS) in Ireland. A sequential explanatory mixed methods design guided this study. People with chronic breathlessness participated in longitudinal questionnaires (n = 10), medical record audit (n = 14) and a post-discharge interview (n = 8). Caregivers (n = 1) and healthcare professionals involved in referral to (n = 2) and delivery of (n = 3) the MBSS participated in a cross-sectional interview. Quantitative and qualitative data were integrated deductively via the pillar integration process, guided by the RE-AIM framework. Integration of mixed methods data enhanced understanding of factors influencing the reach, adoption, implementation and maintenance of the MBSS, and the potential outcomes that were most meaningful for service users. Potential threats to the sustainability of the MBSS related to potential preconceptions of hospice care, the lack of standardized discharge pathways from the service and access to primary care services to sustain pharmacological interventions. This study suggests that an adapted multidisciplinary breathlessness support intervention is feasible and acceptable in a hospice context. However, to ensure optimal reach and maintenance of the intervention, activities are required to ensure that misconceptions about the setting do not influence willingness to accept referral to MBSS services and integration of services is needed to enable consistency in referral and discharge processes.

Barriers and Best Practices for the Use of Patient-Reported Outcome Measures in Emergency Medicine

Patient-reported outcome measures are commonly used in clinical trials and have been incorporated into routine clinical care in select specialties but have not been widely implemented in emergency medicine research and clinical care. We describe measurement-related barriers to patient-reported outcome measure use in the emergency department; administrative and practical considerations; implications of developing novel emergency medicine-specific patient-reported outcome measures; and key considerations for the use of patient-reported outcome measures in emergency medicine research and clinical care. Despite the unique barriers of the ED environment, potential solutions include the use of ED-validated patient-reported outcome measures when available; adapting existing short-form, multidimensional patient-reported outcome measures previously validated in diverse populations, ideally using computer-adapted testing; and collecting responses during anticipated wait times. With this work, we aim to inform barriers and best practices to the use of patient-reported outcome measures in emergency medicine research and clinical care to support future, more widespread implementation of patient-reported outcome measures within emergency care. The successful adoption of patient-reported outcome measures for diverse ED patient populations within the unique constraints of the acute care environment may help researchers, clinicians, and policymakers improve the quality and patient-centeredness of acute care.

[The role of the physiotherapist in the assessment and management of dyspnea]

The role of the physiotherapist in the assessment and management of dyspnea. Dyspnea is the most common symptom in cardio-respiratory diseases. Recently improved comprehension of dyspnea mechanisms have underlined the need for three-faceted assessment. The three key aspects correspond to the "breathing, thinking, functioning" clinical model, which proposes a multidimensional - respiratory, emotional and functional - approach. Before initiating treatment, it is essential for several reasons to assess each specific case, determining the type of dyspnea affecting the patient, appraising the impact of shortness of breath, and estimating the effectiveness of the treatment applied. The physiotherapist has a major role to assume in the care of dyspneic patients, not only in assessment followed by treatment but also as a major collaborator in a multidisciplinary team, especially with regard to pulmonary rehabilitation. The aim of this review is to inventory the existing assessment tools and the possible physiotherapies for dyspnea, using a holistic approach designed to facilitate the choice of techniques and to improve quality of care by fully addressing the patient's needs.

Automated Oxygen Administration Alleviates Dyspnea in Patients Admitted with Acute Exacerbation of COPD: A Randomized Controlled Trial

Objective

Devices for Automated Oxygen Administration (AOA) have been developed to optimize the therapeutic benefit of oxygen supplementation. We aimed to investigate the effect of AOA on multidimensional aspects of dyspnea and as-needed consumption of opioids and benzodiazepines, as opposed to conventional oxygen therapy, in hospitalized patients with Acute Exacerbation of COPD (AECOPD).

Method and Patients

A multicenter randomized controlled trial across five respiratory wards in the Capital Region of Denmark. Patients admitted with AECOPD (n=157) were allocated 1:1 to either AOA (O2matic Ltd), a closed loop device automatically delivering oxygen according to the patient's peripheral oxygen saturation (SpO₂), or conventional nurse-administered oxygen therapy. Oxygen flows and SpO₂ levels were measured by the O2matic device in both groups, while dyspnea, anxiety, depression, and COPD symptoms were accessed by Patient Reported Outcomes.

Results

Of the 157 randomized patients, 127 had complete data for the intervention. The AOA reduced patients' perception of overall unpleasantness significantly on the Multidimensional Dyspnea Profile (MDP) with a difference in medians of -3 (p=0.003) between the intervention group (n=64) and the control group (n=63). The AOA also provided a significant between group difference in all single items within the sensory domain of the MDP (all p-values≤0.05) as well as in the Visual Analogue Scale - Dyspnea (VAS-D) within the past three days (p=0.013). All between group differences exceeded the Minimal Clinical Important Difference of the MDP and VAS-D, respectively. AOA did not seem to have an impact on the emotional response domain of the MDP, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, or use of as-needed opioids and/or benzodiazepines (all p-values>0.05).

Conclusion

AOA reduces both breathing discomfort and physical perception of dyspnea in patients admitted with AECOPD but did not seem to impact the emotional status or other COPD symptoms.

The effect of trait self-control on dyspnoea and tolerance to a CO2 rebreathing challenge in healthy males and females

BACKGROUND

High trait self-control is associated with greater tolerance of unpleasant sensations including effort and pain. Dyspnoea and pain have several commonalities and this study aimed to investigate for the first time whether trait self-control influences responses to a hypercapnic rebreathing challenge designed to induce dyspnoea. As sex also influences tolerance to dyspnoea, we also sought to investigate whether this moderated the role of trait self-control.

METHODS

Participants (n = 65, 32 females) scoring high or low for trait self-control, performed a standardised rebreathing challenge, in which inspired carbon dioxide (CO₂) gradually increased over a period of 6 min or until an intolerable level of dyspnoea. Air hunger (AH) intensity - a distinctive quality of dyspnoea, was measured every 30 s. The multidimensional dyspnoea profile (MDP) was completed after the rebreathing challenge for a more complete overview of breathing discomfort.

RESULTS

Males high in trait self-control (SCHIGH) (302 ± 42 s), tolerated the rebreathing challenge for longer than males low in self-control (SCLOW) (252 ± 66 s, P = 0.021), experienced slower increases in AH intensity during the rebreathing challenge (0.03 ± 0.01 cm^.s ^- 1 vs. 0.04 ± 0.01 cm^.s ^- 1,P = 0.045) and reported lower perceived mental effort on the MDP (4.94 ± 2.46 vs. 7.06 ± 1.60, P = 0.007). There was no difference between SCHIGH and SCLOW females for challenge duration. However, SCHIGH females (9.29 ± 0.66 cm) reported greater air hunger at the end of the challenge than SCLOW females (7.75 ± 1.75 cm, P = 0.003). It is possible that SCLOW females were unwilling to tolerate the same perceptual intensity of AH as the SCHIGH females.

CONCLUSIONS

These results indicate that individuals high in trait self-control are more tolerant of dyspnoea during a CO₂ rebreathing challenge than low self-control individuals. Tolerance of the stimulus was moderated by the sex of the participant, presenting an interesting opportunity for future research.

Natural, longitudinal recovery of adults with COVID-19 using standardized rehabilitation measures

Background

While studies recommend rehabilitation following post-hospitalization recovery from COVID-19, few implement standardized tools to assess continued needs. The aim of this study was to identify post-hospitalization recommendations using an interdisciplinary needs assessment with standardized rehabilitation measures. A secondary aim was to use these tools to measure recovery over a 30-day period.

Materials and methods

Using a 30-day longitudinal design, we completed weekly rapid needs assessments in this convenience sample of 20 people diagnosed with COVID-19 discharged from the hospital to home. We computed summary statistics and used the Wilcoxon Signed Rank Test to assess change over the 4-week course of the study with alpha level = 0.05.

Results

Our sample (65% male, 47% over 50 years of age, 35% White, 37% with a confirmed diagnosis of diabetes, and 47% obese) included no patients who had required mechanical ventilation. Initial assessments demonstrated the majority of our participants were at an increased risk of falls, had disability in activities of daily living (ADL) and instrumental activities of daily living (IADL), mild cognitive impairment, and dyspnea. At the 30-day follow-up, most were independent in mobility and basic ADLs, with continued disability in IADLs and cognitive function.

Discussion

In this sample of patients who were not mechanically-ventilated, early and individualized rehabilitation was necessary. The results of this study suggest patients would benefit from a multi-disciplinary team needs assessment after medical stabilization to minimize fall risk and disability, and to prevent secondary complications resulting from post-hospital deconditioning due to COVID-19.

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.

Physical and affective components of dyspnoea are improved by pulmonary rehabilitation in COPD

Background

Dyspnoea is a multidimensional experience of breathing discomfort, but its affective dimension is unfrequently assessed in people with chronic obstructive pulmonary disease (COPD). We evaluated the effectiveness of a home-based pulmonary rehabilitation (PR) programme on the physical and affective components of dyspnoea assessed by the Dyspnoea-12 (D-12) questionnaire. We also determined the baseline characteristics that contributed to the change in D-12 scores.

Methods

In this retrospective study, 225 people with COPD (age, 65±11 years; forced expiratory volume in 1 s (FEV₁), 35±15% of predicted value) were enrolled into a person-centric home-based PR, consisting of a weekly supervised 90 min home session during 8 weeks. D-12 questionnaire, health status, anxiety and depressive symptoms, exercise tolerance and general fatigue were assessed at baseline (M0), at the end of PR programme (M2), and 8 (M8) and 14 months (M14) after M0. Multivariable analysis of covariance (ANCOVA) models were performed to identify the baseline characteristics that contributed to the change in D-12 scores.

Results

Both physical and affective components of dyspnoea and all the other outcome measures were improved at M2, M8 and M14 compared with baseline (p<0.05). Baseline body mass index was the only significant independent predictor of the changes in physical dyspnoea score, while the change in the affective dimension of dyspnoea after PR was associated with FEV₁, anxiety symptoms and exercise tolerance (6 min stepper test). However, since these variables had only a small impact on the changes in D-12 questionnaire scores, results from the ANCOVA analysis should be taken cautiously.

Conclusion

Both physical and affective components of dyspnoea were improved, at short term and long term, by 8 weeks of individualised home-based PR. The present results support the importance of assessing dyspnoea as a multidimensional experience during PR, warranting replication by robustly designed randomised and controlled studies.

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.

Research policy in supportive care and palliative care for cancer dyspnea

BACKGROUND

Dyspnea is a common and distressing symptom in patients with cancer. To improve its management, multicenter confirmatory studies are necessary. Research policy would be useful in conducting these studies. Here, we propose a new research policy for the management of dyspnea in patients with cancer.

METHODS

The first draft was developed by a policy working group of 11 specialists in the field of supportive care or palliative care for dyspnea. Then, a provisional draft was developed after review by a research support group (the Japanese Supportive, Palliative and Psychosocial Care Study Group) and five Japanese scientific societies (Japanese Association of Supportive Care in Cancer, Japanese Society of Medical Oncology, Japanese Society of Palliative Medicine, Japanese Association of Rehabilitation Medicine and Japanese Society of Clinical Oncology), and receipt of public comments.

RESULTS

The policy includes the following components of research policy on dyspnea: (i) definition of dyspnea, (ii) scale for assessment of dyspnea, (iii) reason for dyspnea or factors associated with dyspnea and (iv) treatment effectiveness outcomes/adverse events. The final policy (Ver1.0) was completed on 1 March 2021.

CONCLUSIONS

This policy could help researchers plan and conduct studies on the management of cancer dyspnea.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ISRCTN14483247.

The role of personality traits in inpatient pulmonary rehabilitation response in patients with chronic obstructive pulmonary disease

BACKGROUND

The effectiveness of pulmonary rehabilitation (PR) is a critical issue for chronic obstructive pulmonary disease (COPD) patients. However, PR response is marked by a strong heterogeneity, partially unexplained to date. We hypothesized that personality traits defined by the Five-Factor Model could modulate the effect of inpatient-PR.

OBJECTIVE

The aim was to assess the associations between these five personality traits and PR outcomes.

METHODS

74 persons with COPD admitted for a 5-week inpatient PR program had a personality assessment at the start of the program (T1). Exercise capacity, quality of life, sensory and affective dyspnea dimensions were assessed at T1 and at the end of the program (T2). Their evolution was evaluated using the delta score between T2 and T1. PR response was defined using the minimal clinically important change score for each of them. A composite response was established distinguishing the poor responders' group, made of patients who responded to 0, 1 or 2 parameters and the good responders' group, with patients who responded on 3 or 4 indicators.

RESULTS

Logistic regressions analyses highlighted that those with a high level of openness [OR = 0.36, 95% CI = 0.15-0.74, p < 0.01] were less likely to respond on quality of life, controlling for socio-demographic factors and the severity of the disease.

CONCLUSION

This study shows that the investigation of the personality constitutes an interesting perspective for better understanding the interindividual differences observed between patients in the PR response. Tailoring clinical intervention to the patient's personality could be a promising prospect for optimizing PR effectiveness.

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.

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.

Effect of different form of upper limb muscles training on dyspnea in chronic obstructive pulmonary disease: A study protocol

INTRODUCTION

In activities involving upper limbs, patients with chronic obstructive pulmonary disease (COPD) report an increase in dyspnea. For this reason, the authors of the recommendations about pulmonary rehabilitation propose to perform upper limbs muscle strengthening in patients with COPD. However, the modalities of strengthening are not clearly established.The aim of this study is to compare the effects of upper limbs endurance strengthening versus upper limbs force strengthening, in patients with COPD during a pulmonary rehabilitation program.

METHODS

This study is a randomized, open-label, bi-center controlled trial in parallel groups distributed in a ratio (1:1) comparing upper limbs force strengthening (group F) to the upper limbs endurance strengthening (group E) during a pulmonary rehabilitation program in patients with COPD stages 2 to 4 (A-D).After randomization, patients will be allocated to follow: A 4 weeks pulmonary rehabilitation program with upper limbs resistance strengthening (group F). A 4 weeks pulmonary rehabilitation program with upper limbs endurance strengthening (group E).The primary outcome is dyspnea measured with the London Chest Activity of daily Living questionnaire. The secondary outcomes are dyspnea (using Modified Medical Research Council dyspnea Scale, dyspnea-12 questionnaire, multidimensional dyspnea profile questionnaire), upper limb exercise capacity (using the 6-minute Peg Board and Ring Test), Maximal voluntary strength of deltoid, biceps, and brachial triceps.The sample size calculated is 140 patients per group, or 280 in total.

DISCUSSION

The modalities of upper limb strengthening are not very well known, and evidence based is lacking to recommend endurance or resistance upper limb strengthening.We anticipate that the results of this study will be of relevance to clinical practice. They will bring information about the best modality of upper limb strengthening to use during a pulmonary rehabilitation program.

TRIAL REGISTRATION

IdRCB n°2018-A00955-50; V1.1 du 11/07/2018; REHABSUP, clinical trial.gov (NCT03611036), registered August 02, 2018, https://clinicaltrials.gov/ct2/show/NCT03611036.

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.

Experimental dyspnoea interferes with locomotion and cognition: a randomised trial

BACKGROUND

Chronic respiratory diseases are associated with cognitive dysfunction, but whether dyspnoea by itself negatively impacts on cognition has not been demonstrated. Cortical networks engaged in subjects experiencing dyspnoea are also activated during other tasks that require cognitive input and this may provoke a negative impact through interference with each other.

METHODS

This randomised, crossover trial investigated whether experimentally-induced dyspnoea would negatively impact on locomotion and cognitive function among 40 healthy adults. Crossover conditions were unloaded breathing or loaded breathing using an inspiratory threshold load. To evaluate locomotion, participants were assessed by the Timed Up and Go (TUG) test. Cognitive function was assessed by categorical and phonemic verbal fluency tests, the Trail Making Tests (TMTs) A and B (executive function), the CODE test from the Wechsler Adult Intelligence Scale (WAIS)-IV (processing speed) and by direct and indirect digit span (working memory).

RESULTS

The mean time difference to perform the TUG test between unloaded and loaded breathing was -0.752 s (95% CI -1.012 to -0.492 s) (p<0.001). Executive function, processing speed and working memory performed better during unloaded breathing, particularly for subjects starting first with the loaded breathing condition.

CONCLUSION

Our data suggest that respiratory threshold loading to elicit dyspnoea had a major impact on locomotion and cognitive function in healthy adults.

Outcome measures in a combined exercise rehabilitation programme for adults with COPD and chronic heart failure: A preliminary stakeholder consensus event

Combined exercise rehabilitation for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) is potentially attractive. Uncertainty remains as to the baseline profiling assessments and outcome measures that should be collected within a programme. Current evidence surrounding outcome measures in cardiac and pulmonary rehabilitation were presented by experts at a stakeholder consensus event and all stakeholders (n = 18) were asked to (1) rank in order of importance a list of categories, (2) prioritise outcome measures and (3) prioritise baseline patient evaluation measures that should be assessed in a combined COPD and CHF rehabilitation programme. The tasks were completed anonymously and related to clinical rehabilitation programmes and associated research. Health-related quality of life, exercise capacity and symptom evaluation were voted as the most important categories to assess for clinical purposes (median rank: 1, 2 and 3 accordingly) and research purposes (median rank; 1, 3 and 4.5 accordingly) within combined exercise rehabilitation. All stakeholders agreed that profiling symptoms at baseline were ‘moderately’, ‘very’ or ‘extremely’ important to assess for clinical and research purposes in combined rehabilitation. Profiling of frailty was ranked of the same importance for clinical purposes in combined rehabilitation. Stakeholders identified a suite of multidisciplinary measures that may be important to assess in a combined COPD and CHF exercise rehabilitation programme.

Randomized Controlled Study Evaluating Efficiency of Low Intensity Transcranial Direct Current Stimulation (tDCS) for Dyspnea Relief in Mechanically Ventilated COVID-19 Patients in ICU: The tDCS-DYSP-COVID Protocol

The severe respiratory distress syndrome linked to the new coronavirus disease (COVID-19) includes unbearable dyspneic suffering which contributes to the deterioration of the prognosis of patients in intensive care unit (ICU). Patients are put on mechanical ventilation to reduce respiratory suffering and preserve life. Despite this mechanical ventilation, most patients continue to suffer from dyspnea. Dyspnea is a major source of suffering in intensive care and one of the main factors that affect the prognosis of patients. The development of innovative methods for its management, especially non-drug management is more than necessary. In recent years, numerous studies have shown that transcranial direct current stimulation (tDCS) could modulate the perception of acute or chronic pain. In the other hand, it has been shown that the brain zones activated during pain and dyspnea are close and/or superimposed, suggesting that brain structures involved in the integration of aversive emotional component are shared by these two complex sensory experiences. Therefore, it can be hypothesized that stimulation by tDCS with regard to the areas which, in the case of pain have activated one or more of these brain structures, may also have an effect on dyspnea. In addition, our team recently demonstrated that the application of tDCS on the primary cortical motor area can modulate the excitability of the respiratory neurological pathways. Indeed, tDCS in anodal or cathodal modality reduced the excitability of the diaphragmatic cortico-spinal pathways in healthy subjects. We therefore hypothesized that tDCS could relieve dyspnea in COVID-19 patients under mechanical ventilation in ICU. This study was designed to evaluate effects of two modalities of tDCS (anodal and cathodal) vs. placebo, on the relief of dyspnea in COVID-19 patients requiring mechanical ventilation in ICU. Trial Registration: This protocol is derived from the tDCS-DYSP-REA project registered on ClinicalTrials.gov NCT03640455. It will however be registered under its own NCT number.

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.

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.

A breath of fresh air: Validity and reliability of a Portuguese version of the Multidimensional Dyspnea Profile for patients with COPD

Aim

To provide a Portuguese version of the Multidimensional Dyspnea Profile (MDP), investigating its validity and reliability in Brazilian patients with COPD.

Methods

This was a cross-sectional study for translation and linguist validation of the Portuguese MDP version for patients with COPD. The process occurred according to the protocol of Mapi Research Trust, Lyon, France. Three scores of MDP were used for the analysis: the immediate unpleasantness of dyspnea (A1); the “immediate perception domain” (S) (sum of A1 plus the sensory descriptors) and the “emotional response domain” (A2) (sum of the emotional descriptors). The questionnaires COPD assessment Test (CAT), Hospital Anxiety and Depression scale (HADS) and Medical Research Council scale (MRC) were used as anchors to investigate MDP’s validity. Internal consistency was assessed with Cronbach’s alpha. Test–retest reliability was assessed with intraclass correlation coefficient (ICC) and concurrent validity was assessed with Spearman correlation coefficients.

Results

Thirty patients with moderate-severe COPD were studied for MDP’s validation analysis (43% male, 63±8years, body mass index [BMI] 27±6Kg/m², forced expiratory volume in the first second [FEV₁] 48±15%predicted, six-minute walking test [6MWT] 464±84m and 84±16%predicted), whereas 10 patients were excluded from the test-retest reliability analysis due to missing data, resulting in a sample of 20 subjects for this purpose (50% male, 62±8years, BMI 27±6Kg/m², FEV₁ 48±15%predicted, 6MWT 452±93m and 82±19%predicted). Both samples were similar regarding general characteristics (P>0,05 for all variables). MDP presented strong correlations, i.e., ICC intra-rater: A1: 0.77 (0.48–0.90), S: 0.78 (0.52–0.91), and A2: 0.85 (0.66–0.94), with high internal consistency (Cronbach's α 0.86, 0.88 and 0.92 respectively); and ICC inter-rater: A1: 0.74 (0.46–0.89), S: 0.75 (0.48–0.89) and A2: 0.91 (0.78–0.96) with Cronbach's α 0.85, 0.86 and 0.95 respectively.

Conclusion

The Portuguese version of the MDP is the first valid and reliable instrument to assess dyspnea multidimensionally in Portuguese-speaking patients with COPD.

Sarcopenia in patients with malignant pleural effusion: impact on symptoms, health status, and response to hospitalization

BACKGROUND

Malignant pleural effusion (MPE) refers to the presence of neoplastic cells in the pleural fluid and was previously associated with lung cancer, breast cancer, and lymphoma. Patients with MPE effusion have significant symptoms, diminishing their overall quality of life but little is known about the influence sarcopenia may have on their clinical presentation.

PURPOSE

To examine the prevalence of sarcopenia in patients with MPE and its relationship with symptoms, health status, and the response to hospitalization.

METHODS

Seventy-four patients with MPE underwent measurements of symptoms, health-related quality of life, and functional status upon admission, discharge, and 3 months after hospital discharge.

RESULTS

Patients with MPE and sarcopenia were symptomatic during hospitalization and at discharge. Additionally, health-related quality of life and functional status were worse in patients with MPE and sarcopenia. All measures of patients with MPE and sarcopenia were significantly poorer 3 months after hospital discharge.

CONCLUSIONS

Sarcopenia is a clinical characteristic with substantial negative effects in patients with MPE. Specific interventions may need to be provided, designed, and offered in the clinical setting.

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.

Ventilatory response to CO2 in patients with epilepsy

OBJECTIVE

Severe periictal respiratory depression is thought to be linked to risk of sudden unexpected death in epilepsy (SUDEP) but its determinants are largely unknown. Interindividual differences in the interictal ventilatory response to CO₂ (hypercapnic ventilatory response [HCVR] or central respiratory CO₂ chemosensitivity) may identify patients who are at increased risk for severe periictal hypoventilation. HCVR has not been studied previously in patients with epilepsy; therefore we evaluated a method to measure it at bedside in an epilepsy monitoring unit (EMU) and examined its relationship to postictal hypercapnia following generalized convulsive seizures (GCSs).

METHODS

Interictal HCVR was measured by a respiratory gas analyzer using a modified rebreathing technique. Minute ventilation (V_E ), tidal volume, respiratory rate, end tidal (ET) CO₂ and O₂ were recorded continuously. Dyspnea during the test was assessed using a validated scale. The HCVR slope (ΔV_E /ΔETCO₂ ) for each subject was determined by linear regression. During the video-electroencephalography (EEG) study, subjects underwent continuous respiratory monitoring, including measurement of chest and abdominal movement, oronasal airflow, transcutaneous (tc) CO₂ , and capillary oxygen saturation (SPO₂ ).

RESULTS

Sixty-eight subjects completed HCVR testing in 151 ± (standard deviation) 58 seconds, without any serious adverse events. HCVR slope ranged from -0.94 to 5.39 (median 1.71) L/min/mm Hg. HCVR slope correlated with the degree of unpleasantness and intensity of dyspnea and was inversely related to baseline ETCO₂ . Both the duration and magnitude of postictal tcCO₂ rise following GCSs were inversely correlated with HCVR slope.

SIGNIFICANCE

Measurement of the HCVR is well tolerated and can be performed rapidly and safely at the bedside in the EMU. A subset of individuals has a very low sensitivity to CO₂ , and this group is more likely to have a prolonged increase in postictal CO₂ after GCS. Low interictal HCVR may increase the risk of severe respiratory depression and SUDEP after GCS and warrants further study.

Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights

Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.

The Pathophysiology of Respiratory Failure: Control of Breathing, Respiratory Load, and Muscle Capacity

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.

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.

Effects of inspiratory muscle training on dyspnoea in severe COPD patients during pulmonary rehabilitation: controlled randomised trial

The benefit of inspiratory muscle training (IMT) combined with a pulmonary rehabilitation programme (PRP) is uncertain. We aimed to demonstrate that, in severe and very severe chronic obstructive pulmonary disease (COPD) patients, IMT performed during a PRP is associated with an improvement of dyspnoea.In a single-blind randomised controlled trial, 150 severe or very severe COPD patients were allocated to follow PRP+IMT versus PRP alone. The evaluations were performed at inclusion and after 4 weeks. The primary outcome was the change in dyspnoea using the Multidimensional Dyspnoea Profile questionnaire at the end of a 6-min walk test (6MWT) at 4 weeks. Secondary outcomes were changes in dyspnoea using the Borg (end of the 6MWT) and modified Medical Research Council scales and in functional parameters (maximal inspiratory pressure (P_Imax), inspiratory capacity, 6MWT and quality of life). All analyses were performed on an intention-to-treat basis.Dyspnoea decreased significantly in both groups; however, the improvement of dyspnoea was not statistically different between the two groups. We only found a statistically significant greater increase of P_Imax after IMT+PRP than after PRP alone.In this trial including severe or very severe COPD patients, we did not find a significant benefit of IMT during PRP+IMT as compared to PRP alone on dyspnoea, despite a significantly higher improvement of P_Imax in the IMT group.

The Impact of Listening to Music During a High-Intensity Exercise Endurance Test in People With COPD

BACKGROUND

In people with COPD, dyspnea is the primary symptom limiting exercise tolerance. One approach to reducing dyspnea during exercise is through music listening. A constant speed endurance test reflects a high-intensity aerobic exercise training session, but whether listening to music affects endurance time is unknown. This study aimed to determine the effects of listening to music during a constant speed endurance test in COPD.

METHODS

Participants with COPD completed two endurance walk tests, one with and one without listening to self-selected music throughout the test. The primary outcome was the difference in endurance time between the two conditions. Heart rate, percutaneous oxygen saturation, dyspnea, and rate of perceived exertion were measured before and after each test.

RESULTS

Nineteen participants (mean [SD]: age, 71 [8] years; FEV₁, 47 [19] % predicted) completed the study. Endurance time was greater (1.10 [95% CI, 0.41-1.78] min) while listening to music (7.0 [3.1] min) than without (5.9 [2.6] min), and reduced end-test dyspnea (1.0 [95% CI, -2.80 to -1.80] units) (with music, 4.6 [1.7] units; vs without music, 5.6 [1.4] units, respectively). There was not a significant difference in heart rate, percutaneous oxygen saturation, or leg fatigue. There were no adverse events under either condition.

CONCLUSIONS

In COPD, dyspnea was less while listening to music and was accompanied by an increased tolerance of high-intensity exercise demonstrated by greater endurance time. Practically, the effect was modest but may represent an aid for exercise training of these patients.

TRIAL REGISTRY

Australian New Zealand Clinical Trials Registry; No. ACTRN12617001217392.

Interferences between breathing, experimental dyspnoea and bodily self-consciousness

Dyspnoea, a subjective experience of breathing discomfort, is a most distressing symptom. It implicates complex cortical networks that partially overlap with those underlying bodily self-consciousness, the experience that the body is one's own within a given location (self-identification and self-location, respectively). Breathing as an interoceptive signal contributes to bodily self-consciousness: we predicted that inducing experimental dyspnoea would modify or disrupt this contribution. We also predicted that manipulating bodily self-consciousness with respiratory-visual stimulation would possibly attenuate dyspnoea. Twenty-five healthy volunteers were exposed to synchronous and asynchronous respiratory-visual illumination of an avatar during normal breathing and mechanically loaded breathing that elicited dyspnoea. During normal breathing, synchronous respiratory-visual stimulation induced illusory self-identification with the avatar and an illusory location of the subjects' breathing towards the avatar. This did not occur when respiratory-visual stimulation was performed during dyspnoea-inducing loaded breathing. In this condition, the affective impact of dyspnoea was attenuated by respiratory-visual stimulation, particularly when asynchronous. This study replicates and reinforces previous studies about the integration of interoceptive and exteroceptive signals in the construction of bodily self-consciousness. It confirms the existence of interferences between experimental dyspnoea and cognitive functions. It suggests that respiratory-visual stimulation should be tested as a non-pharmacological approach of dyspnoea treatment.

Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series "Exertional dyspnoea" Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni

Asthma is a heterogeneous condition, with dyspnoea during exercise affecting individuals to a variable degree. This narrative review explores the mechanisms and measurement of exertional dyspnoea in asthma and summarises the available evidence for the efficacy of various interventions on exertional dyspnoea. Studies on the mechanisms of dyspnoea in asthma have largely utilised direct bronchoprovocation challenges, rather than exercise, which may invoke different physiological mechanisms. Thus, the description of dyspnoea during methacholine challenge can differ from what is experienced during daily activities, including exercise. Dyspnoea perception during exercise is influenced by many interacting variables, such as asthma severity and phenotype, bronchoconstriction, dynamic hyperinflation, respiratory drive and psychological factors. In addition to the intensity of dyspnoea, the qualitative description of dyspnoea may give important clues as to the underlying mechanism and may be an important endpoint for future interventional studies. There is currently little evidence demonstrating whether pharmacological or non-pharmacological interventions specifically improve exertional dyspnoea, which is an important area for future research.

[Dyspnea]

Dyspnea represents one of the most frequent cardinal symptoms in general practice and interdisciplinary emergency care across all sectors. Due to its subjective character, dyspnea is described by patients in many different ways, including "shortness of breath, difficulty of breathing, feeling of chest tightness, etc". The spectrum of differential diagnoses is broad, including in particular pulmonary and cardiovascular diseases. In addition to an evaluation of severity and an assessment of temporal, situation-related, and causal classification criteria, a structured process of multiple diagnostic steps in both primary and emergency care is a prerequisite for fast and correct diagnosis. In this context, it is of crucial importance to identify life-threatening diseases according to defined criteria and thus initiate adequate emergency measures. Further treatment options at the interface between primary and clinical care can be based on the German Appropriate Evaluation Protocol (G-AEP) criteria.

Chronic Pain in People With Chronic Obstructive Pulmonary Disease: Prevalence, Clinical and Psychological Implications

Background: Although pain is a common symptom in chronic obstructive pulmonary disease (COPD), pain characteristics such as frequency, duration and type are unclear. The primary study aim was to identify these pain characteristics in individuals with COPD versus healthy control participants. The secondary aim was to explore the clinical and psychological associations with pain in those with COPD. Methods: Participants with COPD and age and gender-matched, healthy controls completed questionnaires to elicit pain characteristics. Those with COPD also had assessments of dyspnea, health-related quality of life, psychological associations (anxiety and depression) and physical activity. Results: Sixty-four participants with COPD (mean [standard deviation (SD)] age 71[10] , forced expiratory volume in 1 second [FEV1] 38% predicted) and 64 control participants (mean [SD] age 67 [13] , FEV1 91% predicted) were included. Chronic pain was more prevalent in individuals with COPD compared to control participants (41% versus 29%, p=0.03). The pain was more prevalent in the chest and upper back (p=0.04). COPD participants with chest or upper back pain had a higher total lung capacity (mean difference 2.0L, 95% confidence interval [CI] 0.6 to 3.0L) compared to COPD participants without pain. Greater dyspnea (p<0.001), more depression (p=0.02) and lower physical activity levels (p=0.03) were also present in people with COPD experiencing pain. Conclusions: Chronic pain is common in COPD. It is associated with higher dyspnea and depression and lower physical activity.

Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research

BACKGROUND

Symptom assessment in critically ill patients is challenging because many cannot provide a self-report.

OBJECTIVES

To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non-vocal ICU patients.

METHODS

This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non-vocal ICU patients.

RESULTS

Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self-report measures (e.g., 0-10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical-Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population.

CONCLUSION

Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.