Minimal clinically important differences for Dyspnea-12 and MDP scores are similar at 2 weeks and 6 months: follow-up of a longitudinal clinical study

Potential Therapeutic Role of Respiratory Muscle Training in Dyspnea Management of Cancer Survivors: A Narrative Review

Dyspnea is a disabling symptom presented in approximately half of all cancer survivors. From a clinical perspective, despite the availability of pharmacotherapies, evidence-based effective treatments are limited for relieving dyspnea in cancer survivors. Preliminary evidence supports the potential of respiratory muscle training to reduce dyspnea in cancer survivors, although large randomized controlled studies are warranted. The aims of this article were to review the relevant scientific literature on the potential therapeutic role of respiratory muscle training in dyspnea management of cancer survivor, and to identify possible mechanisms, strengths and limitations of the evidence as well as important gaps for future research directions.

Dyspnea (breathlessness) in amyotrophic lateral sclerosis/motor neuron disease: prevalence, progression, severity, and correlates

Objective: Dyspnea, or breathlessness, is an important symptom in amyotrophic lateral sclerosis/motor neuron disease (ALS/MND). We examined the measurement properties of the Dyspnea-12. Methods: Rasch analysis enabled conversion of raw Dyspnea-12 scores to interval level metric equivalents. Converted data were used to perform trajectory modeling; those following different trajectories were compared for demographic, clinical, symptom, and functioning characteristics. Logistic regression examined differences between distinct trajectories. Results: In 1022 people, at baseline, mean metric Dyspnea-12 was 7.6 (SD 9.3). 49.8% had dyspnea, severe in 12.6%. Trajectory analysis over 28 months revealed three breathlessness trajectories: group 1 reported none at baseline/follow-up (42.7%); group 2 significantly increased over time (9.4%); group 3 had a much higher level at baseline which rose over follow-up (47.9%). Group 3 had worse outcomes on all symptoms, functioning and quality of life; compared to group 1, their odds of: respiratory onset sixfold greater; King's stage ≥3 2.9 greater; increased odds of being bothered by choking, head drop, fasciculations, and muscle cramps; fatigue and anxiety also elevated (p < .01). Conclusion: Dyspnea is a cardinal symptom in ALS/MND and can be quickly measured using the Dyspnea-12. Raw scores can easily be converted to interval level measurement, for valid change scores and trajectory modeling. Dyspnea trajectories reveal different patterns, showing that clinical services must provide monitoring which is customized to individual patient need. Almost half of this large population had worsening dyspnea, confirming the importance of respiratory monitoring and interventions being integrated into routine ALS care.

Conditional in vivo deletion of LYN kinase has little effect on a BRCA1 loss-of-function-associated mammary tumour model

LYN kinase is expressed in BRCA1 loss-of-function-dependent mouse mammary tumours, in the cells of origin of such tumours, and in human breast cancer. Suppressing LYN kinase activity in BRCA1-defective cell lines as well as in in vitro cultures of Brca1-null mouse mammary tumours is deleterious to their growth. Here, we examined the interaction between LYN kinase and BRCA1 loss-of-function in an in vivo mouse mammary tumour model, using conditional knockout Brca1 and Lyn alleles. Comparison of Brca1 tumour cohorts showed little difference in mammary tumour formation between animals that were wild type, heterozygous or homozygous for the conditional Lyn allele, although this was confounded by factors including incomplete Lyn recombination in some tumours. RNA-sequencing analysis demonstrated that tumours with high levels of Lyn gene expression had a slower doubling time, but this was not correlated with levels of LYN staining in tumour cells themselves. Rather, high Lyn expression and slower tumour growth were likely a result of B-cell infiltration. The multifaceted role of LYN indicates that it is likely to present difficulties as a therapeutic target in breast cancer.

Impact of wearing a surgical facemask during exercise on dyspnea in patients with chronic pulmonary infections: A randomized crossover study

BACKGROUND

Wearing facemasks in public is effective in preventing viral transmission. However, no study has evaluated the impact of wearing facemasks during exercise on dyspnea in patients with chronic pulmonary infections from multifaceted aspects, including sensory qualities and emotional responses. The aim of this study was to evaluate facemask-related dyspnea during exercise in this patient population.

METHODS

We conducted a randomized crossover study involving adult patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD) or bronchiectasis who participated in exercise sessions, both with (mask-on) and without (mask-off) surgical facemasks. The sensory and emotional dimensions of dyspnea during each exercise session were assessed using the Multidimensional Dyspnea Profile. Statistical analyses were performed to identify factors associated with worsening scores for each dimension.

RESULTS

Thirty-four patients (mean age [standard deviation]: 71.6 [8.6] years) were included in the analysis. The median [interquartile range] total scores for the sensory and emotional dimensions of dyspnea were 3.5 [1, 9.5] (mask-off) vs. 10 [5.5, 23.8] (mask-on) (P < 0.001) and 0 [0, 5] (mask-off) vs. 3 [0.8, 10.3] (mask-on) (P = 0.115), respectively. "Air hunger" was the primary sensory descriptor of mask-related dyspnea. Vital capacity (VC) < 80% of the predicted value was a significant risk factor for worsening sensory dimension scores when wearing masks (odds ratio [95% confidence interval]: 5.5 [1.16-26.1], P = 0.038).

CONCLUSIONS

The findings of this study indicate that patients with NTM-PD or bronchiectasis, particularly those with VC <80% of the predicted value, are likely to experience the sensory dimension of dyspnea during exercise while wearing surgical facemasks.

Effectiveness of exercise training on the dyspnoea of individuals with long COVID: A randomised controlled multicentre trial

BACKGROUND

COVID-19-related acute respiratory distress syndrome (CARDS) is a severe evolution of the Sars-Cov-2 infection and necessitates intensive care. COVID-19 may subsequently be associated with long COVID, whose symptoms can include persistent respiratory symptoms up to 1 year later. Rehabilitation is currently recommended by most guidelines for people with this condition.

OBJECTIVES

To evaluate the effects of exercise training rehabilitation (ETR) on dyspnoea and health-related quality of life measures in people with continuing respiratory discomfort following CARDS.

METHODS

In this multicentre, two-arm, parallel, open, assessor-blinded, randomised controlled trial, we enroled adults previously admitted with CARDS to 3 French intensive care units who had been discharged at least 3 months earlier and who presented with an mMRC dyspnoea scale score > 1. Participants received either ETR or standard physiotherapy (SP) for 90 days. The primary outcome was dyspnoea, as measured by the Multidimensional Dyspnoea Profile (MDP), at day 0 (inclusion) and after 90 days of physiotherapy. Secondary outcomes were the mMRC and 12-item Short-Form Survey scores.

RESULTS

Between August 7, 2020, and January 26, 2022, 487 participants with CARDS were screened for inclusion, of whom 60 were randomly assigned to receive either ETR (n = 27) or SP (n = 33). Mean MDP following ETR was 42% lower than after SP (26.15 vs. 44.76); a difference of -18.61 (95% CI -27.78 to -9.44; p<10-4).

CONCLUSION

People who were still suffering from breathlessness three months after being discharged from hospital with CARDS had significantly improved dyspnoea scores when treated with ETR therapy for 90 days unlike those who only received SP. Study registered 29/09/2020 on Clinicaltrials.gov (NCT04569266).

Associations in Perceived Health and Persistent Breathlessness: A Cross-Sectional Study

Background

Persistent breathlessness is debilitating and increases in prevalence with advanced age and at end of life. This study aimed to evaluate any relationship between self-reported global impressions of change (GIC) in perceived health and breathlessness in older men.

Design

Cross-sectional study of 73-year-old Swedish men in the VAScular and Chronic Obstructive Lung disease study. A postal survey included items on perceived changes in health and breathlessness (GIC scales) and breathlessness (assessed using the modified Medical Research Council [mMRC] breathlessness scale, Dyspnea-12 and Multidimensional Dyspnea Scale) since age 65.

Results

Of 801 respondents, breathlessness (mMRC ≥2) was reported by 17.9%, worsening breathlessness by 29.1%, and worsening perceived health by 51.3%. Worsening breathlessness was strongly correlated with worsening perceived health (Pearson's correlation coefficient of 0.68 [p < 0.001] and Kendall's τ of 0.56 [p < 0.001]) and associated with more limited function (47.2% vs. 29.7%; p < 0.0001) and increased rates of anxiety/depression.

Conclusion

The strong correlation between perceived changes in health and persistent breathlessness helps delineate a more comprehensive picture of the challenges faced by older adults living with this disabling symptom.

Persisting breathlessness and activities reduced or ceased: a population study in older men

Introduction

Breathlessness is debilitating and increases in prevalence with age, with people progressively reducing their everyday activities to ‘self-manage’ it. This study aimed to evaluate the impact of breathlessness on function in terms of activities that have been reduced or ceased (‘compromised’) in older men.

Methods

A cross-sectional postal survey of Swedish 73-year-old man in the VAScular and Chronic Obstructive Lung disease study self-reporting on demographics, breathlessness (modified Medical Research Council (mMRC) scale, Dyspnoea-12, Multidimensional Dyspnea Scale) and its duration, anxiety/depression (Hospital Anxiety and Depression Scale), performance status (WHO Performance Status), everyday activities reduced/ceased and exertion.

Results

148/828 (17.9%) respondents reported breathlessness (mMRC >2), of whom 51.9% had reduced/ceased activities compared with 9.6% who did not. Physical activity was the most common activity reduced/ceased (48.0%) followed by sexual activity (41.2%) and social activities (37.8%). Of 16.0% of respondents with mMRC 3–4 talking on the phone was affected compared with only 2.9% of respondents with mMRC 2. Worsening breathlessness was associated with increasingly sedentary lifestyles and more limited function, those reporting reduced/ceased activities had an associated increase in reporting anxiety and depression. In adjusted analyses, breathlessness was associated with increased likelihood of activities being ceased overall as well as physical and sexual activities being affected separately.

Conclusion

Worsening breathlessness was associated with decreasing levels of self-reported physical activity, sexual activity and function. Overall, the study showed that people with persisting breathlessness modify their lifestyle to avoid it by reducing or ceasing a range of activities, seeking to minimise their exposure to the symptom.

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.

Prevalence and severity of differing dimensions of breathlessness among elderly males in the population

Breathlessness is common in the general population. Existing data were obtained primarily with the uni-dimensional modified Medical Research Council breathlessness scale (mMRC) that does not assess intensities of unpleasantness nor physical, emotional and affective dimensions. The aim of this research was to determine the prevalence and intensity of these dimensions of breathlessness in elderly males and any associations with their duration, change over time and mMRC grade.

We conducted a population-based, cross-sectional study of 73-year-old males in a county in southern Sweden. Breathlessness was self-reported at one time point using a postal survey including the Dyspnea-12 (D-12), the Multidimensional Dyspnea Profile (MDP) and the mMRC. Presence of an increased dimension score was defined as a score ≥minimal clinically important difference for each dimension scale. Association with the mMRC, recalled change since age 65, and duration of breathlessness were analysed with linear regression.

Among 907 men, an increased dimension score was present in 17% (D-12 total score), 33% (MDP A1 unpleasantness), 19% (D-12 physical), 17% (MDP immediate perception), 10% (D-12 affective) and 17% (MDP emotional response). The unpleasantness and affective dimensions were strongly associated with mMRC≥3. Higher MDP and D-12 scores were associated with worsening of breathlessness since age 65, and higher MDP A1 unpleasantness was associated with breathlessness of less than 1 year duration.

Increased scores of several dimensions of breathlessness are prevalent in 73-year-old males and are positively correlated with mMRC scores, worsening of breathlessness after age 65, and duration of less than 1 year.

This first epidemiological study of multidimensional breathlessness shows that unpleasant, physical, affective and emotional experiences of breathlessness are common among elderly males, and are strongly associated with mMRC ≥3https://bit.ly/3EThp5a

Agreement of the modified Medical Research Council and New York Heart Association scales for assessing the impact of self-rated breathlessness in cardiopulmonary disease

Background

The functional impact of breathlessness is assessed using the modified Medical Research Council (mMRC) scale for chronic respiratory disease and with the New York Heart Association Functional Classification (NYHA) scale for heart failure. We evaluated agreement between the scales and their concurrent validity with other clinically relevant patient-reported outcomes in cardiorespiratory disease.

Methods

Outpatients with stable chronic respiratory disease or heart failure were recruited. Agreement between the mMRC and NYHA scales was analysed using Cramér's V and Kendall's tau B tests. Concurrent validity was evaluated using correlations with clinically relevant measures of breathlessness, anxiety, depression, and health-related quality of life. Analyses were conducted for all participants and separately in chronic obstructive pulmonary disease (COPD) and heart failure.

Results

In a total of 182 participants with cardiorespiratory disease, the agreement between the mMRC and NYHA scales was moderate (Cramér's V: 0.46; Kendall's tau B: 0.57) with similar results for COPD (Cramér's V: 0.46; Kendall's tau B: 0.66) and heart failure (Cramér's V: 0.46; Kendall's tau B: 0.67). In the total population, the scales correlated in similar ways to other patient-reported outcomes.

Conclusion

In outpatients with cardiorespiratory disease, the mMRC and NYHA scales show moderate to strong correlations and similar associations with other patient-reported outcomes. This supports that the scales are comparable when assessing the impact of breathlessness on function and patient-reported outcomes.

There is moderate agreement between the mMRC and NYHA scales for assessment of functional impact of breathlessness in outpatients with COPD and heart failure.https://bit.ly/2XBPuXF