Association of inadequate social support and clinical outcomes in patients with chronic obstructive pulmonary disease - A cross-sectional study

INTRODUCTION

In patients with chronic obstructive pulmonary disease (COPD), loneliness and social isolation are associated with increased morbidity and decreased mobility, self-reliance, and health-related quality of life. Social support has been shown to improve these outcomes.

AIMS

This cross-sectional study aimed to investigate the level of experienced social support and the clinical outcomes associated with inadequate social support among patients with COPD with a resident loved one.

METHODS

Level of social support was assessed with the Medical Outcomes Study - Social Support Survey (MOS-SSS) in patients with COPD with a resident loved one. Patients were sub-grouped into adequate or inadequate social support. Multiple clinical outcomes were assessed, including lung function, degree of dyspnoea, health status, symptoms of anxiety and depression, the degree of care dependency, functional status, and mobility.

RESULTS

The study included 191 Dutch patients with COPD (53.4% men, age: 65.6 ± 8.9 years, FEV1: 47.3 ± 17.7% predicted). Eighteen percent of the patients reported inadequate social support. Patients with inadequate social support reported a significantly symptom severity of COPD (p = 0.004), a higher care dependency level (p = 0.04) and a higher level of depression (p = 0.004) compared to patients with adequate social support. Other traits were comparable for both groups.

CONCLUSION

Patients with COPD with a resident loved one who perceive an inadequate level of social support are more likely to report a higher impact of COPD, a higher care dependency and symptoms of depression. Other characteristics are comparable with patients who perceive adequate social support.

Do guidelines influence breathlessness management in advanced lung diseases? A multinational survey of respiratory medicine and palliative care physicians

BACKGROUND

Respiratory medicine (RM) and palliative care (PC) physicians' management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey.

METHODS

A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists.

RESULTS

450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018).

CONCLUSIONS

These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.

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.

Dyspnea

The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.

Association between symptoms, affect and heart rhythm in patients with persistent or paroxysmal atrial fibrillation: an ambulatory pilot study

Symptoms in atrial fibrillation are generally assumed to correspond to heart rhythm; however, patient affect - the experience of feelings, emotion or mood - is known to frequently modulate how patients report symptoms but this has not been studied in atrial fibrillation. In this study, we investigated the relationship between affect, symptoms and heart rhythm in patients with paroxysmal or persistent atrial fibrillation. We found that presence of negative affect portended reporting of more severe symptoms to the same or greater extent than heart rhythm.

Voice-related quality of life: Relation to objective spirometry measures in subglottic stenosis

OBJECTIVES

The current study seeks to identify the correlation between in-office spirometry data and voice-related quality of life in patients with subglottic stenosis (SGS).

METHODS

Patients with SGS of any etiology were included when in-office spirometric data was available in addition to voice-related patient-reported outcomes (PROM) data in the form of the Voice Handicap Index-10 (VHI-10) and/or the Voice-Related Quality of Life (V-RQOL) survey. Overall survey scores and individual question responses were assessed for degree of correlation to spirometric data.

RESULTS

Twenty-nine patients were included in the final analysis. Overall mean total VHI-10 scores totaled 7.15 (SD 9.11), while mean overall V-RQOL scores totaled 78.41 (SD 16.45). Both PEF and PIF rates correlated to total scores on the VHI and V-RQOL surveys. This correlation was stronger with PIF than with PEF, and with the V-RQOL than with the VHI. Questions related to breathlessness most closely correlated with spirometric data.

CONCLUSION

Voice-related QOL is impacted in patients with SGS in a predictable way. Breathlessness while speaking may be more impactful than inability to produce speech in this population.

Posttraumatic Stress Disorder Is Associated With a Decrease in Anaerobic Threshold, Oxygen Pulse, and Maximal Oxygen Uptake

BACKGROUND

Posttraumatic stress disorder (PTSD) has been linked to respiratory symptoms and functional limitations, but the mechanisms leading to this association are poorly defined.

RESEARCH QUESTION

What is the relationship between PTSD, lung function, and the cardiopulmonary response to exercise in combat veterans presenting with chronic respiratory symptoms?

STUDY DESIGN AND METHODS

This study prospectively enrolled military service members with respiratory symptoms following deployment to southwest Asia. All participants underwent a comprehensive evaluation that included pulmonary function testing and cardiopulmonary exercise testing. Pulmonary function test variables and cardiopulmonary response to exercise were compared in subjects with and without PTSD by using multivariable linear regression to adjust for confounders.

RESULTS

A total of 303 participants were included (PTSD, n = 70; non-PTSD, n = 233). Those with PTSD had a greater frequency of current respiratory symptoms. There were no differences in measures for airway disease or lung volumes, but patients with PTSD had a reduction in diffusing capacity that was eliminated following adjustment for differences in hemoglobin levels. Participants with PTSD had a lower anaerobic threshold (23.9 vs 26.4 cc/kg per minute; P = .004), peak oxygen pulse (19.7 vs 18.5 cc/beat; P = .03), and peak oxygen uptake (34.5 vs 38.8 cc/kg per minute; P < .001). No significant difference was observed in gas exchange, respiratory reserve, or effort at peak exercise between participants with and without PTSD.

INTERPRETATION

A diagnosis of PTSD was associated with a reduced anaerobic threshold, oxygen pulse, and peak oxygen uptake. This objective reduction in cardiopulmonary work is independent of baseline lung function, was not associated with abnormalities in gas exchange or respiratory reserve, and may be related to deconditioning.

Managing the experience of breathlessness with Tai Chi: A qualitative analysis from a randomized controlled trial in COPD

PURPOSE

Chronic obstructive pulmonary disease (COPD) is associated with dyspnea, decreased physical activity, and reduced quality-of-life. While pulmonary rehabilitation is helpful, maintenance of physical activity afterwards is problematic. We sought to explore qualitatively the multi-dimensional, biopsychosocial experience of patients with COPD who participated in Tai Chi (TC) vs. group walking to facilitate physical activity after pulmonary rehabilitation).

METHODS

We analyzed semi-structured qualitative exit interviews (N = 81) from a randomized controlled trial comparing 6-months TC with a time-matched group walking intervention and usual care control (UC). Transcripts were reviewed by at least 2 independent reviewers utilizing a social constructivist framework and theoretical sampling approach. An in-depth analysis of an exemplar subset was performed to thematic saturation and captured emergent themes within and between groups.

RESULTS

Focused analysis was conducted on 54 transcripts (N = 21 TC, N = 16 Walking, N = 17 UC). Participants were characterized by mean age 68.5 (±8.3) years, GOLD Stage = 3.0 (IQR 2.0-3.0), baseline FEV1 percent predicted 48.8% (±16.4), and 48.2% female. We identified predominant themes of breathlessness, and associated fear and embarrassment that limited physical activity across all groups. In both TC and walking, participants reported improvements in energy and endurance. Those in TC additionally shared improvements in breathing, mobility, and capacity for daily activities facilitated by body and breath awareness, emotional control and regulation of breathing, and an adaptive reframing of breathlessness.

CONCLUSION

TC promoted physical and mental wellbeing by diminishing fear and embarrassment associated with breathlessness. Results highlight the multimodal characteristics of TC that may facilitate continued physical activity and improvement in quality of life.

Pharmacologic Interventions for Breathlessness in Patients With Advanced Cancer: A Systematic Review and Meta-analysis

IMPORTANCE

Improved survival in patients with advanced cancer has increased the need for better understanding of how to manage common symptoms that they may experience, such as breathlessness.

OBJECTIVE

To assess the benefits and harms associated with pharmacologic interventions for breathlessness in adults with advanced cancer.

DATA SOURCES

PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published from database inception through May 31, 2020, using predefined eligibility criteria within a PICOTS (population, intervention, comparator, outcome, timing, setting) format.

STUDY SELECTION

Randomized clinical trials (RCTs), non-RCTs, and observational studies with a comparison group that evaluated benefits and/or harms and cohort studies that reported harms were selected.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened studies for eligibility, serially abstracted data, independently assessed risk of bias, and graded strength of evidence (SOE).

MAIN OUTCOMES AND MEASURES

Benefits and harms of pharmacologic interventions were compared, focusing on breathlessness, anxiety, exercise capacity, and health-related quality of life. When possible, meta-analyses were conducted and standardized mean differences (SMDs) calculated.

RESULTS

In this systematic review and meta-analysis, a total of 7729 unique citations were identified, of which 19 studies (17 RCTs and 2 retrospective studies) that included a total of 1424 patients assessed the benefits of medications for management of breathlessness in advanced cancer or reported harms. The most commonly reported type of cancer was lung cancer. Opioids were not associated with more effectiveness than placebo for improving breathlessness (SMD, -0.14; 95% CI, -0.47 to 0.18) or exercise capacity ( SMD, 0.06; 95% CI, -0.43 to 0.55) (SOE, moderate); most studies examined exertional breathlessness. Specific dose and/or route of administration of opioids did not differ in effectiveness for breathlessness (SMD, 0.15; 95% CI, -0.22 to 0.52) (SOE, low). Anxiolytics were not associated with more effectiveness than placebo for breathlessness or anxiety (reported mean between-group difference, -0.52; 95% CI, -1.045 to 0.005) (SOE, low). Evidence for other pharmacologic interventions was limited. Pharmacologic interventions demonstrated some harms compared with usual care, but dropout attributable to adverse events was minimal in these short-term studies (range 3.2%-16%).

CONCLUSIONS AND RELEVANCE

Evidence did not support the association of opioids or other pharmacologic interventions with improved breathlessness. Given that studies had many limitations, pharmacologic interventions should be considered in selected patients but need to be considered in the context of potential harms and evidence of an association of nonpharmacologic interventions with improved breathlessness.

Mechanisms underlying the sensation of dyspnea

Dyspnea is defined as a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. It is a common symptom among patients with respiratory diseases that reduces daily activities, induces deconditioning, and is self-perpetuating. Although clinical interventions are needed to reduce dyspnea, its underlying mechanism is poorly understood depending on the intertwined peripheral and central neural mechanisms as well as emotional factors. Nonetheless, experimental and clinical observations suggest that dyspnea results from dissociation or a mismatch between the intended respiratory motor output set caused by the respiratory neuronal network in the lower brainstem and the ventilatory output accomplished. The brain regions responsible for detecting the mismatch between the two are not established. The mechanism underlying the transmission of neural signals for dyspnea to higher sensory brain centers is not known. Further, information from central and peripheral chemoreceptors that control the milieu of body fluids is summated at higher brain centers, which modify dyspneic sensations. The mental status also affects the sensitivity to and the threshold of dyspnea perception. The currently used methods for relieving dyspnea are not necessarily fully effective. The search for more effective therapy requires further insights into the pathophysiology of dyspnea.

Repurposing chlorpromazine to treat COVID-19: The reCoVery study

OBJECTIVES

The ongoing COVID-19 pandemic has caused approximately 2,350,000 infections worldwide and killed more than 160,000 individuals. In Sainte-Anne Hospital (GHU PARIS Psychiatrie & Neuroscience, Paris, France) we have observed a lower incidence of symptomatic forms of COVID-19 among patients than among our clinical staff. This observation led us to hypothesize that psychotropic drugs could have a prophylactic action against SARS-CoV-2 and protect patients from the symptomatic and virulent forms of this infection, since several of these psychotropic drugs have documented antiviral properties. Chlorpromazine (CPZ), a phenothiazine derivative, is also known for its antiviral activity via the inhibition of clathrin-mediated endocytosis. Recentin vitro studies have reported that CPZ exhibits anti-MERS-CoV and anti-SARS-CoV-1 activity.

METHODS

In this context, the ReCoVery study aims to repurpose CPZ, a molecule with an excellent tolerance profile and a very high biodistribution in the saliva, lungs and brain. We hypothesize that CPZ could reduce the unfavorable course of COVID-19 infection among patients requiring respiratory support without the need for ICU care, and that it could also reduce the contagiousness of SARS-CoV-2. For this purpose, we plan a pilot, multicenter, randomized, single blind, controlled, phase III therapeutic trial (standard treatment vs. CPZ+standard treatment).

CONCLUSION

This repurposing of CPZ for its anti-SARS-CoV-2 activity could offer an alternative, rapid strategy to alleviate infection severity. This repurposing strategy also avoids numerous developmental and experimental steps, and could save precious time to rapidly establish an anti-COVID-19 therapy with well-known, limited and easily managed side effects.

Percutaneous Closure of PFO in Patients with Reduced Oxygen Saturation at Rest and during Exercise: Short- and Long-Term Results

BACKGROUND

A patent foramen ovale (PFO) is a rare cause of hypoxemia and clinical symptoms of dyspnea. Due to a right-to-left shunt, desaturated blood enters the systemic circulation in a subset of patients resulting in dyspnea and a subsequent reduction in quality of life (QoL). Percutaneous closure of PFO is the treatment of choice.

OBJECTIVES

This retrospective multicentre study evaluates short- and long-term results of percutaneous closure of PFO in patients with dyspnea and/or reduced oxygen saturation.

METHODS

Patients with respiratory symptoms were selected from databases containing all patients percutaneously closed between January 2000 and September 2018. Improvement in dyspnea, oxygenation, and QoL was investigated using pre- and postprocedural lung function parameters and two postprocedural questionnaires (SF-36 and PFSDQ-M).

RESULTS

The average follow-up period was 36 [12-43] months, ranging from 0 months to 14 years. Percutaneous closure was successful in 15 of the 16 patients. All patients reported subjective improvement in dyspnea immediately after device deployment, consistent with their improvement in oxygen saturation (from 90 ± 6% to 94 [92-97%] on room air and in upright position) (p < 0.05). Both questionnaires also indicated an improvement of dyspnea and QoL after closure. The two early and two late deaths were unrelated to the procedure.

CONCLUSION

PFO-related dyspnea and/or hypoxemia can be treated successfully with a percutaneous intervention with long-lasting benefits on oxygen saturation, dyspnea, and QoL.

The Effects of Acupressure on Quality of Life and Dyspnea in Lung Cancer: A Randomized, Controlled Trial

CONTEXT

Dyspnea is the most common symptom of lung cancer. Acupressure is an important application in the management of dyspnea for lung cancer patients. High-powered, well-planned work is needed on the topic.

OBJECTIVES

The study was conducted to determine the effects of acupressure on quality of life and dyspnea level for individuals with lung cancer.

DESIGN

The study was a randomized, controlled, single-blinded trial.

SETTING

The study took place in the Oncology Day Treatment Unit of a university hospital in Turkey.

PARTICIPANTS

Participants were patients in the unit who were receiving chemotherapy and had experienced dyspnea.

INTERVENTION

Patients were divided into 2 groups: (1) an intervention group receiving acupressure, and (2) a control group receiving standard care. The P6-Lu1-Lu10 acupuncture points in the hand, forearm, and chest were used, with acupressure being applied 2 times per day for 4 wk, for a total of 56 sessions.

OUTCOME MEASURES

Data were collected at baseline and postintervention. Sociodemographic and disease-related data were collected using the Patient Identification Form. Quantitative data were collected with the Modified Borg Dyspnea Scale (Borg scale) and the St George's Respiratory Questionnaire and through measurements of participants' heart rates, respiratory rates, oxygen saturation, and walking distance before and after the 6-mile walk test. Qualitative data were collected using the semistructured "Patients' Views Form on Acupressure Experience."

RESULTS

The 4-wk acupressure intervention demonstrated a significant reduction in the participants' levels of dyspnea, and at the same time, significant increases in their quality of life. The quantitative findings of this study were supported with qualitative findings.

CONCLUSIONS

Acupressure can be a helpful adjunct treatment that enhances the quality of life and reduces dyspnea in individuals with lung cancer. It is an easily applicable method without serious side effects.

Study protocol of coaching end-of-life palliative care for advanced heart failure patients and their family caregivers in rural appalachia: a randomized controlled trial

BACKGROUND

Heart failure (HF) afflicts 6.5 million Americans with devastating consequences to patients and their family caregivers. Families are rarely prepared for worsening HF and are not informed about end-of-life and palliative care (EOLPC) conservative comfort options especially during the end stage. West Virginia (WV) has the highest rate of HF deaths in the U.S. where 14% of the population over 65 years have HF. Thus, there is a need to investigate a new family EOLPC intervention (FamPALcare), where nurses coach family-managed advanced HF care at home.

METHODS

This study uses a randomized controlled trial (RCT) design stratified by gender to determine any differences in the FamPALcare HF patients and their family caregiver outcomes versus standard care group outcomes (N = 72). Aim 1 is to test the FamPALcare nursing care intervention with patients and family members managing home supportive EOLPC for advanced HF. Aim 2 is to assess implementation of the FamPALcare intervention and research procedures for subsequent clinical trials. Intervention group will receive routine standard care, plus 5-weekly FamPALcare intervention delivered by community-based nurses. The intervention sessions involve coaching patients and family caregivers in advanced HF home care and supporting EOLPC discussions based on patients' preferences. Data are collected at baseline, 3, and 6 months. Recruitment is from sites affiliated with a large regional hospital in WV and community centers across the state.

DISCUSSION

The outcomes of this clinical trial will result in new knowledge on coaching techniques for EOLPC and approaches to palliative and end-of-life rural home care. The HF population in WV will benefit from a reduction in suffering from the most common advanced HF symptoms, selecting their preferred EOLPC care options, determining their advance directives, and increasing skills and resources for advanced HF home care. The study will provide a long-term collaboration with rural community leaders, and collection of data on the implementation and research procedures for a subsequent large multi-site clinical trial of the FamPALcare intervention. Multidisciplinary students have opportunity to engage in the research process.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153890, Registered on 4 November 2019.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Differences between experienced and recalled breathlessness: a review

PURPOSE OF REVIEW

Experienced breathlessness and recalled breathlessness are two different entities, which may be associated with different factors and might have different impacts on function for the individual. The aim was to review the knowledge from the last 2 years concerning experienced breathlessness and recalled breathlessness and related factors.

RECENT FINDINGS

Experienced breathlessness was most often induced or measured during exercise testing in a lab environment using a modified Borg scale. It was associated with both psychological factors, such as social rejection, presence of others, psychosocial stress and prenatal exposure to stress, as well as physical factors, such as hypoxia and frequent exacerbations.Recalled breathlessness was most often measured in epidemiological studies, most commonly using the modified Medical Research Council scale. It was associated with lung volumes, overweight, exercise training, frailty, smoking, personality traits, behavior and marital and occupational status.

SUMMARY

No studies during the review period had directly compared experienced breathlessness and recalled breathlessness. Several factors were related to either experienced breathlessness or recalled breathlessness but no clear differences between factors were found in this review. There is a need for comparative studies using the same measurement methods and in the same settings in order to examine their relation.

The Effect of Pulmonary Rehabilitation on Non-chronic Obstructive Pulmonary Disease Patients

BACKGROUND

Pulmonary rehabilitation has shown significant benefit for patients with chronic obstructive pulmonary disease (COPD). The effect on non-COPD pulmonary patients is less well established.

OBJECTIVES

To determine whether pulmonary rehabilitation is also beneficial for non-COPD pulmonary patients.

METHODS

Clinical and demographic data on non-COPD pulmonary patients who participated in our institutional pulmonary rehabilitation program between January 2009 and December 2016 were collected. Participants engaged in a 60-minute, twice-weekly, ambulatory hospital-based program lasting 12 to 24 sessions. Sessions included both endurance and muscle training as well as healthy lifestyle educational activities. The six-minute walk test (6MWT) and the St. George's Respiratory Questionnaire (SGRQ) were conducted before and after the rehabilitation program.

RESULTS

We recruited 214 non-COPD patients, of whom 153 completed at least 12 sessions. Of these, 59 presented with interstitial lung disease (ILD), 18 with non-ILD restrictive lung defects, 25 with asthma, 30 with lung cancer, and 21 with other conditions (e.g., pulmonary hypertension, bronchiectasis) The groups demonstrated significant improvement in 6MWT and in SGRQ scores. Non-COPD patients gained a 61.9 meter (19%) improvement in the 6MWT (P < 0.0001) and 8.3 point reduction in their SGRQ score (P < 0.0001).

CONCLUSIONS

Pulmonary rehabilitation is effective in non-COPD pulmonary patients. As such, it should be an integral part of the treatment armament provided to the vast majority of those suffering from chronic respiratory disease.

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.

Weight loss reduces dyspnea on exertion and unpleasantness of dyspnea in obese men

We hypothesized that weight loss would ameliorate dyspnea on exertion (DOE) and feelings of unpleasantness related to the DOE in obese men. Eighteen men (34 ± 7yr, 35 ± 4 kg/m2 BMI, mean ± SD) participated in a 12-week weight loss program. Body composition, pulmonary function, cardiorespiratory measures, DOE, and unpleasantness (visual analog scale) were assessed before and after weight loss. Subjects were grouped by Ratings of Perceived Breathlessness (RPB, Borg 0-10 scale) during submaximal cycling: Ten men rated RPB ≥ 4 (+DOE), eight rated RPB ≤ 2 (-DOE). Subjects lost 10.3 ± 5.6 kg (9.2 ± 4.5%) of body weight (n = 18). RPB during submaximal cycling was significantly improved in both groups (+DOE: 4.1 ± 0.3-2.8 ± 1.1; -DOE: 1.3 ± 0.7 to 0.8 ± 0.6, p < 0.001). Several submaximal exercise variables (e.g., V˙O2, V˙E) were decreased similarly in both groups (p < 0.01). Unpleasantness associated with the DOE was reduced (p < 0.05). The improved RPB was not significantly correlated with changes in body weight or cardiopulmonary exercise responses (p > 0.05). Moderate weight loss appears to be an effective option to ameliorate DOE and unpleasantness related to DOE in obese men.

Control and Context Are Central for People With Advanced Illness Experiencing Breathlessness: A Systematic Review and Thematic Synthesis

CONTEXT

Breathlessness is common and distressing in advanced illness. It is a challenge to assess, with few effective treatment options. To evaluate new treatments, appropriate outcome measures that reflect the concerns of people experiencing breathlessness are needed.

OBJECTIVES

The objective of this study was to systematically review and synthesize the main concerns of people with advanced illness experiencing breathlessness to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.

METHODS

This is a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. MEDLINE (1946-2017), PsycINFO (1806-2017), and EMBASE (1974-2017), as well as key journals, gray literature, reference lists, and citation searches, identified qualitative studies exploring the concerns of people living with breathlessness. Included studies were quality-assessed using the Critical Appraisal Skills Program checklist and analyzed using thematic synthesis.

RESULTS

We included 38 studies with 672 participants. Concerns were identified across six domains of "total" breathlessness: physical, emotional, spiritual, social, control, and context (chronic and episodic breathlessness). Four of these have been previously identified in the concept of "total dyspnea." Control and context have been newly identified as important, particularly in their influence on coping and help-seeking behavior. The importance of social participation, impact on relationships, and loss of perceived role within social and spiritual domains also emerged as being significant to individuals.

CONCLUSION

People with advanced illness living with breathlessness have concerns in multiple domains, supporting a concept of "total breathlessness." This adapted model can help to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.

Personalized Goal for Dyspnea and Clinical Response in Advanced Cancer Patients

BACKGROUND

The clinical response after comprehensive symptom management is difficult to determine in terms of a clinically important difference. Moreover, therapies should try to reach the threshold perceived by the individual patient for the determination of a favorable response to a treatment.

MEASURES

The Edmonton Symptom Assessment Score (ESAS) was measured at admission (T0), and seven days after starting palliative care (T7). Patient Global Impression and Goal Response after one week of palliative care and its relation with the Personalized Dyspnea Goal were measured at T7.

INTERVENTION

Patients admitted to palliative care units underwent a comprehensive symptom assessment by a specialist palliative care team. At T0, patients were asked about their Personalized Dyspnea Intensity Goal on ESAS. One week later (T7), after a comprehensive palliative care treatment, Personalized Dyspnea Intensity Goals were measured again. Patients were considered to have achieved a Patient Dyspnea Goal Response if dyspnea intensity (measured at T7) was equal or less than their expected Personalized Dyspnea Intensity Goal. At the same interval (T7), Patient Global Impression (improvement or deterioration) was measured.

OUTCOMES

279 patients were analyzed in this study. The mean Personalized Dyspnea Intensity Goal at T0 and T7 were 0.97 (SD 1.3), and 0.71 (SD 2.1), respectively. 263 patients (94.2%) indicated a Personalized Dyspnea Intensity Goal of ≤3 as a target at T0. Patients perceived a bit better, a better improvement, and a much better improvement with a mean decrease in dyspnea intensity of -2.1, -3.5, and -4.3 points on the dyspnea intensity scale, respectively. In 60 patients (21.5%), dyspnea intensity did not change, and in 4.7%, dyspnea intensity worsened. Patients perceived a Minimal Clinically Important Difference (little worse) with a mean increase in dyspnea intensity of 0.10, and they perceived a worse with a mean increase of 1.7 points. Higher dyspnea intensity at T0 and lower dyspnea intensity at T7 were independently related to Patient Global Impression. At T7, 93 (33.3%) patients achieved their Personalized Goal Response, based on Personalized Dyspnea Intensity. Patient Dyspnea Goal Response was associated with Memorial Delirium Assessment Scale score and Personalized Dyspnea Intensity Goal at T0, and inversely associated with dyspnea intensity at T0 and T7, and lower Karnofsky level. For Patient Dyspnea Goal Response, no significant differences among categories of dyspnea intensity were found (P>0.05).

CONCLUSION

Patient Dyspnea Goal Response and Patient Global Impression seem to be relevant for evaluating the effects of a comprehensive management of symptoms, including dyspnea, assisting decision making process. Some factors may be implicated in determining the individual target and clinical response. A personalized symptom goal may translate in terms of therapeutic intervention, according to the achievement of the patients' expectations. High values of dyspnea intensity, a lower Karnofsky level, as well as high level of Dyspnea Intensity Goal (that is less patients' expectations) favor the achievement of the target.

The interrelations among aspects of dyspnea and symptoms of depression in COPD patients - a network analysis

BACKGROUND

Depression is a frequent comorbidity in COPD. COPD symptoms such as dyspnea may play an important role in the causal relationship between COPD and depression. We investigated the interrelations among different aspects of dyspnea and other COPD parameters and symptoms of depression in COPD patients.

METHODS

This is a secondary analysis of N = 590 COPD patients. At the beginning (T0) and the end (T1) of a 3-week inpatient pulmonary rehabilitation, dyspnea aspects intensity (BORG scale), frequency (2 CCQ items), functioning (CCQ-function) and cognitive/emotional response (2 SGRQ items) as well as cough (2 CCQ items), functional capacity (6MWD), lung function (FEV1) and symptoms of depression (PHQ-9) were assessed. Regression analyses with PHQ-9 sum score as dependent variable as well as network analysis using PHQ-9 single items were performed. Structural invariance over time was examined.

RESULTS

Dyspnea frequency, function, and cognitive/emotional response showed conditional independent relationships with PHQ-9 sum score. Network analysis showed that dyspnea frequency and dyspnea functioning were primarily associated with somatic depression symptoms (for example, sleep problems, loss of energy), while cognitive/emotional response was primarily related to cognitive-affective depression symptoms (for example, feeling down/depressed/hopeless). Regression parameters, network structure and network global strength did not differ between T0 and T1.

LIMITATIONS

Models are based on between-person relationships. Results should be confirmed using time-series data.

CONCLUSIONS

Dyspnea and depression seem to be interrelated through a variety of different and complex pathways in COPD patients. Results may be used to explain intervention effects and develop new intervention strategies to reduce depression in COPD.

Age and mini-mental state examination score can predict poor-quality spirometry in the elderly: a cross-sectional study

OBJECTIVES

The goal was to identify predictors of poor-quality spirometry in community-dwelling older adults and their respective cutoffs.

METHODS

This was a cross-sectional population-based study involving 245 elderly subjects (age≥60 years). The spirometric data were categorized as good or poor quality, and cognitive status was assessed using an adapted version (scaled to have a maximum of 19 points) of the Mini-Mental State Examination. Multivariate analysis was used to assess the association between poor-quality spirometry and sociodemographic, behavioral and health characteristics. The best cutoff points for predicting poor-quality spirometry were evaluated by the receiver operating characteristic curve.

RESULTS

In this population, 61 (24.9%) subjects with poor-quality spirometry were identified. After multiple logistic regression analysis, only age and Mini-Mental State Examination score were still associated with poor-quality spirometry (p≤0.05). The cutoff for the Mini-Mental State Examination score was 15 points, with an area under the receiver operating characteristic curve of 0.628 (p=0.0017), sensitivity of 74.5% and specificity of 49.5%; for age, the cutoff was 78 years, with an area under the receiver operating characteristic curve of 0.718 (p=0.0001), sensitivity of 57.4% and specificity of 79.9%.

CONCLUSION

Age and Mini-Mental State Examination score together are good predictors of poor-quality spirometry and can contribute to the screening of community-dwelling older adults unable to meet the minimum quality criteria for a spirometric test.

Psychometric properties of the German version of the Leicester Cough Questionnaire in sarcoidosis

Background

Cough is one of the most common symptoms in general and pulmonary medicine with profound negative impact on health-related quality of life (HRQL). The Leicester Cough Questionnaire (LCQ) is a validated HRQL questionnaire, yet a validated German version of the LCQ is not available and it has never been tested in a cohort with sarcoidosis.

Objectives

To translate the LCQ into German and determine its psychometric properties.

Methods

The LCQ was translated in a forward-backward approach. Structured interviews in sarcoidosis patients were performed. Subsequently, sarcoidosis patients were asked to answer the German LCQ and comparative questionnaires. Distribution properties, item difficulty, concurrent validity, Rasch model fit and internal consistency of the German LCQ were determined.

Results

200 patients with sarcoidosis were included. We provide evidence for reliability, unidimensionality and internal consistency. However, only a moderate correlation with general and respiratory-specific HRQL questionnaires, no Rasch model fit could be shown. Skewed responses caused by floor effects were detected.

Conclusion

We demonstrate that the German LCQ is valid and reliable and its psychometric properties fulfil the standards required for its use in clinical settings as well as in interventional trials.

Randomized Controlled Trial of Health Coaching for Vulnerable Patients with Chronic Obstructive Pulmonary Disease

RATIONALE

Socioeconomically disadvantaged patients with chronic obstructive pulmonary disease (COPD) often face barriers to evidence-based care that are difficult to address in public care settings with limited resources.

OBJECTIVES

To determine the benefit of health coaching for patients with moderate to severe COPD relative to usual care.

METHODS

We conducted a randomized controlled trial of 9 months of health coaching versus usual care for English- or Spanish-speaking patients at least 40 years of age with moderate to severe COPD. Primary outcomes were COPD-related quality of life and the dyspnea subscale of the Chronic Respiratory Disease Questionnaire. Secondary outcomes were self-efficacy for managing COPD, exercise capacity (6-min walk test), and number of COPD exacerbations. Additional outcomes were COPD symptoms, lung function (forced expiratory volume in 1 s percent predicted), smoking status, bed days owing to COPD, quality of care (Patient Assessment of Chronic Illness Care), COPD knowledge, and symptoms of depression (Patient Health Questionnaire). Outpatient visits, emergency department visits, and hospitalizations were assessed by review of medical records. Generalized linear modeling was used to adjust for baseline values and account for clustering by clinic.

RESULTS

Of 192 patients enrolled, 158 (82%) completed 9 months of follow-up. There were no significant differences between study arms for the primary or secondary outcomes. At 9 months, patients in the coached group reported better quality of care (mean Patient Assessment of Chronic Illness Care score, 3.30 vs. 3.18; adjusted P = 0.02) and were less likely to report symptoms of moderate to severe depression (Patient Health Questionnaire score, ≥15) than those in the usual care arm (6% vs. 20%; adjusted P = 0.01). During the study, patients in the coaching arm had 48% fewer hospitalizations related to COPD (0.27/patient/yr vs. 0.52/patient/yr), but this difference was not significant in the adjusted analysis.

CONCLUSIONS

These results help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. They may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Clinical trial registered with www.clinicaltrials.gov (NCT02234284).

Impact of Sleep Quality on the Health-Related Quality of Life of Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Impaired sleep is reportedly common in chronic obstructive pulmonary disease (COPD) and the impact of quality of sleep on health-related quality of life (HRQL) has been documented. Although factors affecting HRQL have been investigated in various studies, the impact of sleep quality on HRQL has not been previously investigated among patients with COPD in Nigeria. The purpose of this study was to determine the contribution of sleep quality as a factor affecting HRQL. We hypothesized that sleep quality is a determinant of HRQL.

METHODOLOGY

Sixty patients with COPD were evaluated. HRQL was assessed using COPD Assessment Test (CAT). Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Lung function was assessed by spirometry, severity of dyspnea by the Modified Medical Research Council (MMRC) scale, and functional exercise capacity by the Six-Minute Walk Test (6MWT). In all the statistical tests, a p value of <0.05 was considered significant.

RESULTS

The mean age of the study population was 70±8years. Forty-nine patients (81.7%) had poor quality of sleep (PSQI > 5). The mean CAT score of the study population was 19.40±7.5. Bivariate correlation shows that HRQL reduces with worsening sleep quality (r=0.705, p=<0.001). HRQL was also associated with COPD severity (P = 0.001), severity of dyspnea, exercise capacity and frequency of exacerbation (P = <0.001). Multiple regression analysis showed that quality of sleep was the best independent predictor of HRQL in our patients (p= <0.001).

CONCLUSION

Results from this study suggest that health status is generally poor in patients with COPD and quality of sleep is a significant determinant of their HRQL.

Visual analogue scales for interstitial lung disease: a prospective validation study

BACKGROUND

Visual analogue scales (VAS) are simple symptom assessment tools which have not been validated in interstitial lung disease (ILD). Simple measures of ILD disease burden would be valuable for non-specialist clinicians monitoring disease away from ILD specialist centres.

OBJECTIVE

To validate VAS to assess change in dyspnoea, cough and fatigue in ILD, and to define the minimal clinically important difference (MCID) for change in these.

METHODS

Patients of 64 with ILD completed VAS for dyspnoea, cough and fatigue. Baseline King's Brief ILD questionnaire (K-BILD) scores, lung function and 6-min walk test results were collected. Tests were repeated 3-6 months later, in addition to a seven-point Likert scale. The MCID was estimated using median change in VAS in patients who reported 'small but just worthwhile change' in symptoms at follow-up. Methods were repeated in a validation cohort of 31 ILD patients to confirm findings.

RESULTS

VAS scores were significantly higher for patients who reported a 'small but just worthwhile change' in symptoms vs. 'no change' or 'not worthwhile change' (P < 0.01). The MCID for VAS Dyspnoea was estimated as 22.0 mm and 14.5 mm for VAS Fatigue. These results were reproducible in the validation cohort. Results were not significant for VAS Cough. Change in VAS Dyspnoea correlated with change in K-BILD (r = -0.51, P < 0.01), forced vital capacity (r = -0.32, P = 0.01) and 6-min walking distance (r = -0.37, P = 0.01).

CONCLUSION

The VAS is valid for assessing change in dyspnoea and fatigue in ILD. The MCID is estimated as 22.0 mm for dyspnoea and 14.5 mm for fatigue. This could be used to monitor disease in settings away from ILD specialist review.

MESH DESCRIPTORS

Lung Diseases, Interstitial, Dyspnoea, Fatigue, Cough.

A qualitative exploration of distress associated with episodic breathlessness in advanced lung cancer

PURPOSE

Breathlessness is a distressing symptom, particularly common in those with advanced lung cancer. Previous research has identified the symptom occurrence of episodic breathlessness, identifying average frequency, duration and severity of episodes, but has not explored the distress specifically associated with these episodes. This study explored the distress associated with episodic breathlessness for adults with advanced cancer and the relative impact of three elements; frequency, duration or severity.

METHODS

Semi-structured interviews were conducted with four participants with advanced lung cancer. Analysis adopted an interpretative phenomenological approach.

RESULTS

A complex relationship existed between distress caused by episodic breathlessness and its frequency, duration and severity for study participants. Episodic breathlessness had a significant impact on participant's perceptions of self and previous experience effected how distressed they were by their breathlessness. The emotional work created by the symptom was considerable for individuals.

CONCLUSION

The study highlights the importance of recognizing symptoms as a combination of different experiences that may each cause different levels of distress. Initial evidence is provided that the emotional work involved for patients to self-manage each separate element of breathlessness should be considered in its treatment.

Retrospective memory for symptoms in patients with medically unexplained symptoms

OBJECTIVE

Clinical assessment and diagnostic processes heavily rely on memory-based symptom reports. The current study investigated memory for symptoms and the peak-end effect for dyspnea in patients with medically unexplained symptoms and healthy participants.

METHODS

Female patients with medically unexplained dyspnea (MUD) (n=22) and matched healthy controls (n=22) participated in two dyspnea induction trials (short, long). Dyspnea ratings were collected: (1) continuously during symptom induction (concurrent with respiratory measures), (2) immediately after the experiment, and (3) after 2weeks. Symptoms, negative affect, and anxiety were assessed at baseline and after every trial. The mediating role of state anxiety in symptom reporting was assessed. The peak-end effect was tested with forced-choice questions measuring relative preference for the trials.

RESULTS

Compared to controls, dyspnea induction resulted in higher levels of symptoms, anxiety, concurrent dyspnea ratings, and minute ventilation in the patient group. In both groups, immediate retrospective ratings were higher than averaged concurrent ratings. No further increase in dyspnea ratings was observed at 2-week recall. Retrospective dyspnea ratings were mediated by both state anxiety and concurrent dyspnea ratings. Patients did not show a peak-end effect, whereas controls did.

CONCLUSION

The findings show that patients' experience of a dyspneic episode is subject to immediate memory bias, but does not change over a longer time period. The results also highlight the importance of affective state during symptom experience for both symptom perception and memory.

Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department 'near miss' for breathlessness: a strengths-based qualitative study

OBJECTIVES

Breathlessness 'crises' in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED 'near misses' where they considered going to the ED but successfully self-managed instead.

DESIGN AND METHODS

A qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen's Transactional Model of Stress and Coping informed interpretive themes.

RESULTS

Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services.

CONCLUSIONS

In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients' generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

Translation and Validation of the Multidimensional Dyspnea-12 Questionnaire

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unpredictable episodic breathlessness in patients with advanced chronic obstructive pulmonary disease and lung cancer: a qualitative study

PURPOSE

The internationally consented definition and categorization describe two categories of episodic breathlessness: predictable (with known triggers) and unpredictable. The link of known triggers only to predictable episodes can be read that unpredictable episodes have none known trigger. Our aim was to illuminate patients' experiences with episodes of unpredictable breathlessness, to collect descriptions of the episodes' impact on the patients' lives, and, in turn, the patients' individual coping strategies in this connection.

DESIGN

Qualitative study using semi-structured in-depth interviews with patients suffering from unpredictable episodes of breathlessness and chronic obstructive pulmonary disease (COPD; Global Initiative for Obstructive Lung Disease III and IV) or lung cancer (all stages). Interviews were audio-recorded, transcribed verbatim, and analyzed using Framework Analysis.

RESULTS

One hundred one patients were screened in a large university hospital; ten participants fulfilled the inclusion criteria and provided consent. The experienced episodes were evaluated as unpleasant and with higher intensity compared to predictable episodes. Non-pharmacological interventions were identified as useful coping strategies. Interestingly, although patients experienced the episodes in an unpredictable manner, a trigger could be detected retrospectively for the majority of cases (mostly emotions (especially panic) and, occasionally, physical exertion). Unpredictable episodes are less frequent than previously assumed.

CONCLUSION

The unpredictability of unpredictable breathless episodes refers to the patients' experience that these episodes occur "out-of-the-blue." However, a known trigger can be identified for the majority of unpredictable breathless episodes. These are therefore triggered as well. Further research needs to describe more possible triggers, to inquire the prevalence of unpredictable episodic breathlessness, and to develop effective management strategies.

Personality and Lung Function in Older Adults

OBJECTIVES

Lung disease is a leading cause of disability and death among older adults. We examine whether personality traits are associated with lung function and shortness of breath (dyspnea) in a national cohort with and without chronic obstructive pulmonary disease (COPD).

METHOD

Participants (N = 12,670) from the Health and Retirement Study were tested for peak expiratory flow (PEF) and completed measures of personality, health behaviors, and a medical history.

RESULTS

High neuroticism and low extraversion, openness, agreeableness, and conscientiousness were associated with lower PEF, and higher likelihood of COPD and dyspnea. Conscientiousness had the strongest and most consistent associations, including lower risk of PEF less than 80% of the predicted value (OR = 0.67; 0.62-0.73) and dyspnea (OR = 0.52; 0.47-0.57). Although attenuated, the associations remained significant when accounting for smoking, physical activity, and chronic diseases including cardiovascular and psychiatric disorders. The associations between personality and PEF or dyspnea were similar among those with or without COPD, suggesting that psychological links to lung function are not disease dependent. In longitudinal analyses, high neuroticism (β = -0.019) and low conscientiousness (β = 0.027) predicted steeper declines in PEF.

DISCUSSION

A vulnerable personality profile is common among individuals with limited lung function and COPD, predicts shortness of breath and worsening lung function.

Understanding the determinants of health-related quality of life in rheumatoid arthritis-associated interstitial lung disease

RATIONALE

Health-related quality of life (HRQL) is impaired among patients with interstitial lung disease (ILD). Little is understood about HRQL in specific subtypes of ILD.

OBJECTIVES

The aim of this study was to characterize and identify clinical determinants of HRQL among patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and compare them to patients with idiopathic pulmonary fibrosis (IPF).

METHODS

We identified patients with a diagnosis of RA-ILD and IPF from an ongoing longitudinal cohort of ILD patients. HRQL was measured at their baseline visit using the Short Form Health Survey (SF-36), versions 1 and 2. Regression models were used to characterize and understand the relationship between selected baseline clinical covariates, the physical component score (PCS) and mental component score (MCS) of the SF-36.

MEASUREMENTS AND MAIN RESULTS

RA-ILD patients (n = 50) were more likely to be younger and female compared to IPF patients (n = 50). After controlling for age and pulmonary function, RA-ILD patients had a lower HRQL compared to IPF patients, as measured by the PCS (P = 0.03), with significant differences in two of four PCS domains - bodily pain (P < 0.01) and general health (P = 0.01). Clinical covariates most strongly associated with a lower PCS in RA-ILD patients compared to IPF patients were the presence of joint pain or stiffness and dyspnea severity (P < 0.01). Mental and emotional health, as measured by the MCS, was similar between RA-ILD and IPF patients.

CONCLUSION

The physical components of HRQL appear worse in RA-ILD patients compared to IPF patients as measured by the PCS of the SF-36. Differences in the PCS of the SF-36 can be explained in part by dyspnea severity and joint symptoms among patients with RA-ILD.

From breathless to failure: symptom onset and diagnostic meaning in patients with heart failure-a qualitative study

OBJECTIVES

To explore 2 key points in the heart failure diagnostic pathway-symptom onset and diagnostic meaning-from the patient perspective.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from a secondary care clinic in central England following referral from primary care.

PARTICIPANTS

Over age 55 years with a recent (<1 year) diagnosis of heart failure confirmed by a cardiologist following initial presentation to primary care.

METHODS

Semistructured interviews were carried out with 16 participants (11 men and 5 women, median age 78.5 years) in their own homes. Data were audio-recorded and transcribed. Participants were asked to describe their diagnostic journey from when they first noticed something wrong up to and including the point of diagnosis. Data were analysed using the framework method.

RESULTS

Participants initially normalised symptoms and only sought medical help when daily activities were affected. Failure to realise that anything was wrong led to a delay in help-seeking. Participants' understanding of the term 'heart failure' was variable and 1 participant did not know he had the condition. The term itself caused great anxiety initially but participants learnt to cope with and accept their diagnosis over time.

CONCLUSIONS

Greater public awareness of symptoms and adequate explanation of 'heart failure' as a diagnostic label, or reconsideration of its use, are potential areas of service improvement.

Opioid suppression of conditioned anticipatory brain responses to breathlessness

Opioid painkillers are a promising treatment for chronic breathlessness, but are associated with potentially fatal side effects. In the treatment of breathlessness, their mechanisms of action are unclear. A better understanding might help to identify safer alternatives. Learned associations between previously neutral stimuli (e.g. stairs) and repeated breathlessness induce an anticipatory threat response that may worsen breathlessness, contributing to the downward spiral of decline seen in clinical populations. As opioids are known to influence associative learning, we hypothesized that they may interfere with the brain processes underlying a conditioned anticipatory response to breathlessness in relevant brain areas, including the amygdala and the hippocampus.

Healthy volunteers viewed visual cues (neutral stimuli) immediately before induction of experimental breathlessness with inspiratory resistive loading. Thus, an association was formed between the cue and breathlessness. Subsequently, this paradigm was repeated in two identical neuroimaging sessions with intravenous infusions of either low-dose remifentanil (0.7 ng/ml target-controlled infusion) or saline (randomised).

During saline infusion, breathlessness anticipation activated the right anterior insula and the adjacent operculum. Breathlessness was associated with activity in a network including the insula, operculum, dorsolateral prefrontal cortex, anterior cingulate cortex and the primary sensory and motor cortices.

Remifentanil reduced breathlessness unpleasantness but not breathlessness intensity. Remifentanil depressed anticipatory activity in the amygdala and the hippocampus that correlated with reductions in breathlessness unpleasantness. During breathlessness, remifentanil decreased activity in the anterior insula, anterior cingulate cortex and sensory motor cortices. Remifentanil-induced reduction in breathlessness unpleasantness was associated with increased activity in the rostral anterior cingulate cortex and nucleus accumbens, components of the endogenous opioid system known to decrease the perception of aversive stimuli.

These findings suggest that in addition to effects on brainstem respiratory control, opioids palliate breathlessness through an interplay of altered associative learning mechanisms. These mechanisms provide potential targets for novel ways to develop and assess treatments for chronic breathlessness.

•

The mechanisms of how low-dose opioids relieve breathlessness are unknown.

•

We tested whether low-dose opioids affect conditioned anticipation and perception of breathlessness.

•

Low-dose opioids reduced unpleasantness, but not intensity of breathlessness.

•

Reduced breathlessness unpleasantness was associated with activation of the endogenous opioid system.

•

Breathlessness relief was predicted by decreased anticipatory activity in amygdala/hippocampus.

Six key topics informal carers of patients with breathlessness in advanced disease want to learn about and why: MRC phase I study to inform an educational intervention

INTRODUCTION

Breathlessness is a common symptom of advanced disease placing a huge burden on patients, health systems and informal carers (families and friends providing daily help and support). It causes distress and isolation. Carers provide complex personal, practical and emotional support yet often feel ill-prepared to care. They lack knowledge and confidence in their caring role. The need to educate carers and families about breathlessness is established, yet we lack robustly developed carer-targeted educational interventions to meet their needs.

METHODS

We conducted a qualitative interview study with twenty five purposively-sampled patient-carer dyads living with breathlessness in advanced disease (half living with advanced cancer and half with advanced chronic obstructive pulmonary disease (COPD). We sought to identify carers' educational needs (including what they wanted to learn about) and explore differences by diagnostic group in order to inform an educational intervention for carers of patients with breathlessness in advanced disease.

RESULTS

There was a strong desire among carers for an educational intervention on breathlessness. Six key topics emerged as salient for them: 1) understanding breathlessness, 2) managing anxiety, panic and breathlessness, 3) managing infections, 4) keeping active, 5) living positively and 6) knowing what to expect in the future. A cross-cutting theme was relationship management: there were tensions within dyads resulting from mismatched expectations related to most topics. Carers felt that knowledge-gains would not only help them to support the patient better, but also help them to manage their own frustrations, anxieties, and quality of life. Different drivers for education need were identified by diagnostic group, possibly related to differences in caring role duration and resulting impacts.

CONCLUSION

Meeting the educational needs of carers requires robustly developed and evaluated interventions. This study provides the evidence-base for the content of an educational intervention for carers of patients with breathlessness in advanced disease.

Patient confidence and quality of life in idiopathic pulmonary fibrosis and sarcoidosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) and sarcoidosis impact significantly on health-related quality of life (HRQOL). There are few studies on the impact of patient confidence on HRQOL in these conditions.

OBJECTIVES

1. To investigate whether patient confidence is associated with HRQOL, anxiety, depression, dyspnoea or fatigue. 2. To assess if patient confidence is associated with inpatient admissions, access to community healthcare and, for IPF patients, mortality and disease severity.

METHODS

Study participants self-completed seven questionnaires: Hospital Anxiety and Depression Scale, EuroQol 5D (EQ5D), King's Brief Interstitial Lung Disease questionnaire, St George's Respiratory Questionnaire, MRC dyspnoea scale, Fatigue Assessment Scale and a non-validated questionnaire assessing patient confidence, symptom duration and access to community healthcare. Lung function and follow-up data were collected from hospital electronic databases. Spearman's rank correlation coefficients were calculated to assess for correlation between patient confidence, questionnaire variables and inpatient admissions. Chi-square tests were performed to assess for association between patient confidence, mortality and disease severity.

RESULTS

75 IPF patients and 69 sarcoidosis patients were recruited to the study. Patient confidence in IPF was significantly negatively correlated with depression and fatigue, and significantly positively correlated with EQ5D scores, but not healthcare outcomes. No associations were found between confidence and any of the variables assessed in sarcoidosis.

CONCLUSIONS

Lower levels of confidence in IPF patients are associated with higher levels of depression and fatigue and worse HRQOL. Efforts should be made to improve patient confidence to assess the impact on HRQOL.

[COPD ASSESSMENT TEST (CAT) IN PULMONARY REHABILITATION – OUR EXPERIENCE]

Introduction: Development of COPD Assessment Test (CAT) has enabled quick, reliable and valid measurement of the impact of the disease on the quality of life. The aim of this study is to establish whether the CAT questionnaire may be useful in evaluation of the quality of life in patients with COPD before and after pulmonary rehabilitation. Method: This study was conducted on 47 patients. Patients have completed the CAT questionnaire before and after rehabilitation. Efficiency analysis of rehabilitation procedures included measuring FEV1 – physiological measure of disease severity and MRC dyspnoea scale. Results: There was a difference in most items of the CAT questionnaire, total score (before rehabilitation 19, after rehabilitation 12) and MRC scale, indicating a better quality of life after rehabilitation. The difference in FEV1 was not statistically significant. There was a significant positive correlation between the CAT score and MRC scale and between the CAT score and duration of rehabilitation. The correlation between the FEV1 and CAT score was negative and not statistically significant. Conclusion: The CAT questionnaire is simple and applicable in the evaluation of the quality of life in patients with COPD, as well as a useful outcome measure for the evaluation of efficiency for pulmonary rehabilitation.

OPTIMUM: a protocol for a multicentre randomised controlled trial comparing Out Patient Talc slurry via Indwelling pleural catheter for Malignant pleural effusion vs Usual inpatient Management

INTRODUCTION

The development of malignant pleural effusion (MPE) results in disabling breathlessness, pain and reduced physical capability with treatment a palliative strategy. Ambulatory management of MPE has the potential to improve quality of life (QoL). The OPTIMUM trial is designed to determine whether full outpatient management of MPE with an indwelling pleural catheter (IPC) and pleurodesis improves QoL compared with traditional inpatient care with a chest drain and talc pleurodesis. OPTIMUM is currently open for any centres interested in collaborating in this study.

METHODS AND ANALYSIS

OPTIMUM is a multicentre non-blinded randomised controlled trial. Patients with a diagnosis of MPE will be identified and screened for eligibility. Consenting participants will be randomised 1:1 either to an outpatient ambulatory pathway using IPCs and talc pleurodesis or standard inpatient treatment with chest drain and talc pleurodesis as per British Thoracic Society guidelines. The primary outcome measure is global health-related QoL at 30 days measured using the EORTC QLQ-C30 questionnaire. Secondary outcome measures include breathlessness and pain measured using a 100 mm Visual Analogue Scale and health-related QoL at 60 and 90 days. A sample size of 142 patients is needed to demonstrate a clinically significant difference of 8 points in global health status at 30 days, for an 80% power and a 5% significance level.

ETHICS AND DISSEMINATION

The study has been approved by the NRES Committee South East Coast-Brighton and Sussex (reference 15/LO/1018). The trial results will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBERS

UKCRN19615 and ISRCTN15503522; Pre-results.

Dignity Through Integrated Symptom Management: Lessons From the Breathlessness Support Service

CONTEXT

Dignity is poorly conceptualized and little empirically explored in end-of-life care. A qualitative evaluation of a service offering integrated palliative and respiratory care for patients with advanced disease and refractory breathlessness uncovered an unexpected outcome, it enhanced patients' dignity.

OBJECTIVES

To analyze what constitutes dignity for people suffering from refractory breathlessness with advanced disease, and its implications for the concept of dignity.

METHODS

Qualitative study of cross-sectional interviews with 20 patients as part of a Phase III evaluation of a randomized controlled fast-track trial. The interviews were transcribed verbatim, imported into NVivo, and analyzed through constant comparison. The findings were compared with Chochinov et al.'s dignity model. The model was adapted with the themes and subthemes specific to patients suffering from breathlessness.

RESULTS

The findings of this study underscore the applicability of the conceptual model of dignity for patients with breathlessness. There were many similarities in themes and subthemes. Differences specifically relevant for patients suffering from severe breathlessness were as follows: 1) physical distress and psychological mechanisms are interlinked with the disability and dependence breathlessness causes, in the illness-related concerns, 2) stigma is an important component of the social dignity inventory, 3) conditions and perspectives need to be present to practice self-care in the dignity-conserving repertoire.

CONCLUSION

Dignity is an integrated concept and can be affected by influences from other areas such as illness-related concerns. The intervention shows that targeting the symptom holistically and equipping patients with the means for self-care realized the outcome of dignity.

Inspiring change: humanities and social science insights into the experience and management of breathlessness

PURPOSE OF REVIEW

Breathlessness can be debilitating for those with chronic conditions, requiring continual management. Yet, the meaning of breathlessness for those who live with it is poorly understood in respect of its subjective, cultural, and experiential significance. This article discusses a number of current issues in understanding the experience of breathlessness.

RECENT FINDINGS

Effective communication concerning the experience of breathlessness is crucial for diagnosis, to identify appropriate treatment, and to provide patients with the capacity to self-manage their condition. However, there is an evident disconnect between the way breathlessness is understood between clinical and lay perspectives, in terms of awareness of breathlessness, the way symptoms are expressed, and acknowledgement of how it affects the daily lives of patients.

SUMMARY

The review highlights the need for integrated multidisciplinary work on breathlessness, and suggests that effective understanding and management of breathlessness considers its wider subjective and social significance.

Documentation of Patients’ Participation in Care at the End of Life

The aim of this study was to describe how patients’ participation in the care they received was documented in their health care records during the last three months of their lives. Two hundred and twenty-nine deceased adult persons were randomly identified from 12 municipalities in a Swedish county and their records were selected from different health care units. Content analysis was used to analyse the text. Four categories of patient participation were described: refusing offered care and treatments; appealing for relief; desire for everyday life; and making personal decisions. The most common way for these patients to be involved in their care at the end of their life was by refusal of the treatment and care offered. Characteristic of the different ways of participation were the diverse activities represented. The description of patients’ involvement in their life situation at this time indicated their dissociation from the health care offered more than consenting to it.

Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer

CONTEXT

Verbal descriptors are important in understanding patients' experience of breathlessness.

OBJECTIVES

The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness.

METHODS

We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis.

RESULTS

Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness.

CONCLUSION

The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.

Gender Makes a Difference in the Description of Dyspnoea in Patients with Chronic Heart Failure

Background: Dyspnoea is a common symptom of chronic heart failure (CHF). In the community setting, patients with CHF are most often women.

Aim: To examine the impact of gender on the description of dyspnoea and to explore which clinical variables support a diagnosis of CHF.

Methods: From four primary health care centres, 158 patients with CHF were included. Patients were examined with echocardiography and a cardiologist assessed the diagnosis of CHF. The patients filled in a questionnaire containing 11 descriptors of dyspnoea.

Results: A diagnosis of CHF was confirmed in 87 (55%) patients (47 males and 40 females). One descriptor, I feel that I am suffocating, was significantly scored higher in CHF patients ( p=0.014) as compared to non-CHF patients. Three descriptors, My breath does not go in all the way ( p=0.006), I feel that I am suffocating ( p=0.040), and I cannot get enough air ( p=0.0327) were significantly scored higher among men with CHF, compared to no descriptor among women with CHF. Being male (OR=2.7; CI: 1.3–5.6, p=0.008), having diabetes (OR=5.6; CI: 1.7–18.2, p=0.004), IHD (OR=3.3; CI: 1.3–8.5, p=0.014), and a borderline significance for age (OR=1.04; CI: 0.99–1.08, p=0.058) predicted a confirmed diagnosis of CHF.

Conclusion: Three descriptors of dyspnoea were associated with CHF among men, whereas no such association was found among women. Our results suggest that gender is an important factor and should—together with age, underlying heart disease, and diabetes—be taken into account when symptoms are evaluated in the diagnosis of CHF in primary care.

Differences in Symptom Burden Among Patients With Moderate, Severe, or Very Severe Chronic Obstructive Pulmonary Disease

CONTEXT

The symptom experience of patients with chronic obstructive pulmonary disease (COPD) is extremely complex. It is characterized by multiple co-occurring symptoms. However, very few studies have described this experience in COPD patients.

OBJECTIVES

The aims of this study were to evaluate for differences in symptom occurrence rates, as well as ratings of symptom severity, frequency, and distress among patients (n = 267) with moderate, severe, and very severe COPD.

METHODS

The Memorial Symptom Assessment Scale was used to evaluate the multiple dimensions of the patient's symptom experience. Binary and ordinal logistic regression analyses with stage of disease as an ordinal predictor variable were used to evaluate for differences in symptom occurrence rates and ratings of symptom severity, frequency, and distress.

RESULTS

Regardless of the severity of their disease, patients reported an average of 12 co-occurring symptoms. Shortness of breath and lack of energy were the only two symptoms that differed significantly among the three disease severity groups in terms of occurrence, severity, frequency, and distress. Patients with very severe COPD reported the highest ratings for shortness of breath and lack of energy across all four symptom dimensions.

CONCLUSION

Regardless of stage of disease, the high symptom burden identified in this study underscores the need for COPD patients to be screened for multiple co-occurring symptoms.

Self-management and quality of life in chronic obstructive pulmonary disease (COPD): The mediating effects of positive affect

OBJECTIVE

This study aimed to increase our understanding of general self-management (SM) abilities in COPD by determining if SM can predict disease specific quality of life (QoL), by investigating whether specific SM domains are significant in COPD and by exploring the mediating effect of the positive/negative affect in the association between SM and QoL.

METHODS

Cross-sectional study based on 292 patients with COPD. Measures included demographics, lung function, gait speed, health care utilization, positive/negative affect, SM abilities, breathlessness and disease specific QoL. We performed, correlation, multiple regression models and mediation analysis (positive/negative affect being mediator between SM and QoL association).

RESULTS

After controlling for breathlessness, living alone, marital status, hospitalization history, age and lung function, SM related to QoL (p<0.0001). Investment in behaviors (hobbies and social relationships) and self-efficacy are SM domains independently related to QoL in COPD. Positivity measured by the positive/negative affect ratio completely mediates the relationship of SM with QoL.

CONCLUSION

SM is independently associated with disease specific QoL in COPD after adjustment significant covariates but positive/negative affect ratio completely mediates the relationship of SM with QoL.

PRACTICE IMPLICATIONS

Measuring positive/negative affect and addressing investment behavior and self-efficacy are important in implementing COPD-SM programs.