Prevalence and burden of breathlessness in Australian adults: The National Breathlessness Survey-a cross-sectional web-based population survey

BACKGROUND AND OBJECTIVE

Chronic respiratory symptoms (in particular, breathlessness and cough) can cause physical, social and emotional distress, and may indicate the presence of an underlying disease that presages future poor health outcomes. Our aim was to investigate the burden of breathlessness in Australian adults, including breathlessness that may be undiagnosed, unlabelled or untreated.

METHODS

The National Breathlessness Survey was a cross-sectional, web-based survey conducted in October 2019. Australian adults were randomly selected from a large web-based survey panel with recruitment stratified by age-group, gender and state of residence according to national population data. The main outcome measures were modified Medical Research Council (mMRC) dyspnoea scale, EuroQol visual analog scale, Dyspnoea-12 score and 4-item Patient Health Questionnaire (PHQ-4).

RESULTS

Among all respondents (n = 10,072; 51.1% female; median age group 40-49 years), 9.5% reported clinically important breathlessness (mMRC dyspnoea grade ≥ 2, 2 = 'I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level'). Among those with clinically important breathlessness, 49.1% rated their general health as fair or poor and 44.2% had at least moderate depression or anxiety symptoms (PHQ ≥ 6) but over half (50.8%) did not report a current respiratory or heart condition diagnosis.

CONCLUSION

Breathlessness is common among Australian adults, and is associated with a substantial burden of ill health, including among people without a diagnosed respiratory or heart condition. The extent of underdiagnosis of these conditions or alternative causes of breathlessness requires further investigation.

Management of Refractory Breathlessness: a Review for General Internists

Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.

Research and Healthcare Priorities of Individuals Living with COPD

This study describes the research and healthcare priorities of individuals living with COPD. On an online survey, individuals living with COPD assigned a percentage of funding to 22 research priorities and a percentage of time spent communicating with a healthcare provider to 24 healthcare priorities, indicating which topics were most important. For each research and healthcare priority, we examined the selection frequency of the priority and used chi-square analyses to examine differences in priority selection by quartiles of airflow obstruction (percent predicted forced expiratory volume in 1-sec (FEV₁%predicted)) and breathlessness burden and exacerbation risk. Based on participants' responses (N = 148, 47% women; Mean ± Standard Deviation age = 68 ± 9 yrs) relief of breathlessness was the most often selected research (76% of respondents) and healthcare priority (61% of respondents). It was selected most often, regardless of disease severity or breathlessness burden and exacerbation risk. We found differences for disease severity and breathlessness burden and exacerbation risk in some research priorities (e.g., to improve the maximal amount of exercise of adults living with COPD in and out of the home (χ²₍₃₎ = 9.97, Cramer's V =.28) and healthcare priorities (e.g., increase your ability to exercise (χ²₍₃₎ = 9.72, Cramer's V =.27)). This study provides empirical evidence that relief of breathlessness is a top research and healthcare priority for individuals living with COPD. Future healthcare and research activities should align with the priorities of individuals with COPD to improve their care by minimizing disease/symptom burden and optimizing health-related quality of life.

Corticosteroids and pulmonary rehabilitation reducing long-term morbidity in a patient with post-COVID-19 pneumonitis: A case study

Background

Whilst research efforts have focussed on treatment during the acute phase, little work has focussed on the long‐term sequelae of COVID‐19 infection. This case described a patient who remained symptomatic several weeks after discharge from hospital with what was diagnosed as a COVID‐19 infection. There were significant deficits shown in his functional exercise testing, his pulmonary functions testing and there was evidence of fibrotic changes on his radiology.

Methods

As part of a multidisciplinary clinic, he was started on steroids and a tailored pulmonary rehabilitation course over a course of 6–8 weeks. Thereafter, his exercise testing, pulmonary function tests and radiology were all repeated to see progress.

Results

On completing the course of corticosteroids and concurrent personalised pulmonary rehabilitation, there was a dramatic improvement in the patient's symptom severity, radiology and pulmonary function. The most significant improvement noted was in his exercise testing, namely a 6‐min walk test and 1 min of sit‐to‐stands. Before treatment, he had a Medical Reserch Council (MRC) score of 2, and after it returned to his baseline of 0.

Discussion

Using corticosteroids and exercise training that allowed quantitative evaluation throughout the stages of recovery was a valuable tool to gauge progress and response to treatment. These therapies present opportunity to prevent the development of irreversible pulmonary fibrosis that could prove to be a major breakthrough in reducing long‐term morbidity and improving the quality of life of those affected.

The impact of unpredictability of dyspnea offset on dyspnea perception, fear, and respiratory neural gating

Dyspnea is a debilitating and threatening symptom in various diseases. Affected patients often report the unpredictability of dyspnea episodes being particularly anxiety-provoking and amplifying the perception of dyspnea. Experimental studies testing dyspnea unpredictability together with related neural processes, physiological fear responses, and dyspnea-related personality traits are sparse. Therefore, we investigated the impact of unpredictability of dyspnea offset on dyspnea perception and fear ratings, respiratory neural gating and physiological fear indices, as well as the influence of interindividual differences in fear of suffocation (FoS). Forty healthy participants underwent a task manipulating the offset predictability of resistive load-induced dyspnea including one unloaded safety condition. Respiratory variables, self-reports of dyspnea intensity, dyspnea unpleasantness, and fear were recorded. Moreover, respiratory neural gating was measured in a paired inspiratory occlusion paradigm using electroencephalography, while electrodermal activity, startle eyeblink, and startle probe N100 were assessed as physiological fear indices. Participants reported higher dyspnea unpleasantness and fear when dyspnea offset was unpredictable compared to being predictable. Individuals with high levels of FoS showed the greatest increase in fear and overall higher levels of fear and physiological arousal across all conditions. Respiratory neural gating, startle eyeblink, and startle probe N100 showed general reductions during dyspnea conditions but no difference between unpredictable and predictable dyspnea conditions. Together, the current results suggest that the unpredictable offset of dyspnea amplifies dyspnea perception and fear, especially in individuals with high levels of FoS. These effects were unrelated to respiratory neural gating or physiological fear responses, requiring future studies on underlying mechanisms.

COVID-19: Symptoms in Dying Residents of Nursing Homes and in Those Admitted to Hospitals

Objective: To compare symptom prevalence and relief in residents who died in nursing homes with residents who were acutely referred to hospitals. Design: Data on symptoms during the last week of life from the Swedish Register of Palliative Care (SRPC). Setting and Subjects: Nursing homes (n = 1903 deaths) and hospitals in Sweden (n = 202 nursing home residents who were admitted to hospital before death). Data were retrieved on August 24, 2020. Results: Residents who died in hospitals had more breakthrough symptoms of breathlessness (60% vs. 31%, p < 0.0001) and delirium (41% vs. 25%, p < 0.0001) than those who died in nursing homes. When symptoms were present, complete symptom relief was seen less often in hospitals compared with nursing homes (breathlessness, 28% vs. 47%, p < 0.001; delirium, 10% vs. 35%, p < 0.0001; respiratory secretions, 30% vs. 55%, p < 0.0001). Conclusion: Despite access to oxygen and pharmacologic/nonpharmacologic therapies in hospitals, symptom relief in dying nursing home residents acutely admitted to hospitals was lower compared with those who died in nursing homes, possibly because of differences in patient characteristics.

Breathlessness Predicts Survival in Patients With Malignant Pleural Effusions: Meta-analysis of Individual Patient Data From Five Randomized Controlled Trials

BACKGROUND

Patients with malignant pleural effusions (MPEs) experience breathlessness and poor survival. Breathlessness is associated with poor survival in other conditions.

RESEARCH QUESTION

Is breathlessness, measured using a visual analog scale for dyspnea (VASD), associated with survival in patients with MPE?

STUDY DESIGN AND METHODS

Individual patient data from five randomized controlled trials of 553 patients undergoing interventions for MPE were analyzed. VASD was recorded at baseline and daily after intervention. Patients were followed up until death or end of trial. Univariate and multivariable Cox regression were used to identify factors associated with survival.

RESULTS

Baseline VASD was significantly associated with worse survival, with a hazard ratio of 1.10 (95% CI, 1.06-1.15) for a 10-mm increase in VASD. On multivariable regression, it remained a significant predictor of survival. Mean 7-day VASD and mean total VASD were also predictors of survival (mean 7-day VASD: hazard ratio [HR], 1.26 [95% CI, 1.19-1.34]; total VASD: HR, 1.25 [95% CI, 1.15-1.37]). Other predictors of survival were serum C-reactive protein level and tumor type. Previous treatment with chemotherapy, performance status, pleural fluid lactate dehydrogenase, serum albumin, hemoglobin, serum neutrophil:lymphocyte ratio, and size of effusion were associated with survival on univariate but not multivariable analysis.

INTERPRETATION

Breathlessness, measured using VASD at baseline and postprocedure, is a predictor of survival in patients with MPE.

Effectiveness and implementation of palliative care interventions for patients with chronic obstructive pulmonary disease: A systematic review

BACKGROUND

Although guidelines recommend palliative care for patients with chronic obstructive pulmonary disease, there is little evidence for the effectiveness of palliative care interventions for this patient group specifically.

AIM

To describe the characteristics of palliative care interventions for patients with COPD and their informal caregivers and review the available evidence on effectiveness and implementation outcomes.

DESIGN

Systematic review and narrative synthesis (PROSPERO CRD42017079962).

DATA SOURCES

Seven databases were searched for articles reporting on multi-component palliative care interventions for study populations containing ⩾30% patients with COPD. Quantitative as well as qualitative and mixed-method studies were included. Intervention characteristics, effect outcomes, implementation outcomes and barriers and facilitators for successful implementation were extracted and synthesized qualitatively.

RESULTS

Thirty-one articles reporting on twenty unique interventions were included. Only four interventions (20%) were evaluated in an adequately powered controlled trial. Most interventions comprised of longitudinal palliative care, including care coordination and comprehensive needs assessments. Results on effectiveness were mixed and inconclusive. The feasibility level varied and was context-dependent. Acceptability of the interventions was high; having someone to call for support and education about breathlessness were most valued characteristics. Most frequently named barriers were uncertainty about the timing of referral due to the unpredictable disease trajectory (referrers), time availability (providers) and accessibility (patients).

CONCLUSION

Little high-quality evidence is yet available on the effectiveness and implementation of palliative care interventions for patients with COPD. There is a need for well-conducted effectiveness studies and adequate process evaluations using standardized methodologies to create higher-level evidence and inform successful implementation.

Acute Pulmonary Embolism in the COVID-19 Era: The Experience of a Ghanaian Patient

The coronavirus pandemic has resulted in profound changes in healthcare delivery, some based on official reforms and others driven by healthcare professionals' fear of exposure to coronavirus disease (COVID-19). Many patients require screening tests of one form or the other before being attended to in hospitals. The protean clinical manifestations of this highly transmissible infection require that a high index of suspicion be maintained. Pulmonary embolism is a potentially fatal emergency whose presentation is mimicked by COVID-19. Delays in ruling out COVID-19 may result in undue delays in initiating treatment for pulmonary embolism, potentially resulting in significant morbidity and mortality. This article presents a patient whose treatment for acute pulmonary embolism was forestalled by delays in getting the polymerase chain reaction test for COVID-19 done. It reiterates the need for physicians to test promptly in order to allow early focus on differential diagnoses which were routinely being investigated promptly prior to the COVID-19 pandemic.

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

The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.

Transmucosal Buprenorphine in the Treatment of Dyspnea: Case Series and Review of the Literature

Full μ-opioid agonists are commonly employed in advanced disease to relieve dyspnea of various etiologies. Although there are ongoing debates and studies regarding the relative efficacy of different agents, a factor limiting more general use is a concern about side effects, in particular respiratory depression. Buprenorphine is a partial μ receptor agonist and a κ-opioid receptor antagonist, with a better safety profile than full μ receptor agonists. We conducted a literature search, which did not reveal any studies looking at the use of buprenorphine to treat dyspnea. We also report a case series of three patients with dyspnea of various etiologies treated with buprenorphine, with an apparent excellent response of dyspnea to treatment, without any significant side effects. Given those results, as well as the potential impact of κ-opioid receptor antagonism on dyspnea-associated anxiety, we conclude that there is a need for controlled studies of buprenorphine against full μ-opioid agonists for the symptomatic treatment of dyspnea in palliative care.

Early experiences of rehabilitation for individuals post-COVID to improve fatigue, breathlessness exercise capacity and cognition - A cohort study

Individuals with lasting symptoms of COVID-19 should be offered a comprehensive recovery programme. 30 individuals (mean[SD] age 58[16]) that completed a 6 week, twice supervised rehabilitation programme demonstrated statistically significant improvements in exercise capacity, respiratory symptoms, fatigue and cognition. Participants improved by 112 m on the Incremental Shuttle Walking Test and 544 seconds on the Endurance Shuttle Walking Test. There were no serious adverse events recorded, and there were no dropouts related to symptom worsening. COVID-19 rehabilitation appears feasible and significantly improves clinical outcomes.

Breathlessness and cough in the acute setting

The symptom of breathlessness is well recognized as part of the presentation of a wide range of medical conditions. It can be a manifestation of a life-threatening emergency. In acute medical settings, the priority is to quickly recognize patients who are critically unwell and require emergency treatment. For these patients, rapid initial assessment and immediate treatment are essential. However, once symptoms have stabilized or in less acute settings, a more thorough assessment is required. Cough is a common respiratory symptom, often part of a symptom complex, which is troublesome for the patient. It is important to recognize worrying associated features to prompt further investigation. In late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection emerged from a zoonotic source, resulting in many cases of infection, hospitalizations and deaths, and has since spread in a pandemic across every continent. A substantial percentage of patients with COVID-19 develop an acute respiratory illness requiring hospital care. Cough and acute breathlessness are two of the most prevalent symptoms in this infection; any patient presenting to an acute setting should currently be assumed to have this infection and immediately tested with a viral swab from the upper airway to guide management.

'To more than I can be': A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease

Anecdotal experience and qualitative accounts suggest that singing groups, classes or choirs specifically for people with COPD (henceforth referred to as COPD-SGs) are effective in improving health. However, this is not reflected in the quantitative evidence. This meta-ethnography deployed phenomenological methods to explore this discrepancy. Analysis identified the phenomena of being together, being uplifted and being involved as central benefits of COPD-SGs. When viewed through the phenomenological lens of body-social as distinct from body-subject and body-object, findings demonstrated that the qualitative effectiveness of COPD-SGs is greatest on a collective basis. Qualitative research into the effectiveness of COPD-SGs offers more favourable results because phenomenological approaches can identify collective benefits that quantitative methods cannot. COPD-SGs should seek to maximise these collective benefits by rediscovering their cultural and artistic heritage within the national and global Arts in Health (AiH) movement, which has long emphasised the radical creative and healing power of group activity.

Clinical and Scientific Rationale for the "MATH+" Hospital Treatment Protocol for COVID-19

In December 2019, COVID-19, a severe respiratory illness caused by the new coronavirus SARS-CoV-2 (COVID-19) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies' recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working," the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically. The review concludes with a comparison of published multi-national mortality data with MATH+ center outcomes.

Personal Growth and Associated Factors Among Patients with Chronic Obstructive Pulmonary Disease in China: A Cross-Sectional Study

Purpose

This cross-sectional study aimed to describe personal growth and to analyze its associated factors among patients with chronic obstructive pulmonary disease (COPD) in China.

Patients and Methods

A total of 364 Chinese COPD hospitalized patients were included in the study between November 2016 and April 2018. Participants provided demographic information and completed the Growth Through Uncertainty Scale (GTUS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the modified Medical Research Council dyspnoea scale (mMRC).

Results

The mean total score on the GTUS was 142.34 (SD = 7.61). The multiple linear regression analysis showed that factors including educational level, average monthly income, social support, and breathlessness can influence personal growth (R² = 0.427, F = 44.420, p < 0.001), explaining 42.7% of the variance.

Conclusion

COPD patients tend to report a moderate level of personal growth in China. Educational level, average monthly income, social support, and breathlessness were significant factors associated with personal growth. Medical workers should be aware of the level of personal growth among COPD patients and make tailored interventions to facilitate COPD patients’ personal growth, such as increasing social support and decrease breathlessness.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Minimal Clinically Important Difference in Barthel Index Dyspnea in Patients with COPD

Background

The Barthel Index dyspnea (BId) is responsive to physiological changes and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, the minimum clinically important difference (MCID) has not been established yet.

Aim

To identify the MCID of BId in patients with COPD stratified according to the presence of chronic respiratory failure (CRF) or not.

Materials and Methods

Using the Medical Research Council (MRC) score as an anchor, receiver operating characteristic curves and quantile regression were retrospectively evaluated before and after pulmonary rehabilitation in 2327 patients with COPD (1151 of them with CRF).

Results

The median post-rehabilitation changes in BId for all patients were −10 (interquartile range = −17 to −3, p<0.001), correlating significantly with changes in MRC (r = 0.57, 95% CI = 0.53 to 0.59, p<0.001). Comparing different methods of assessment, the MCID ranged from −6.5 to −9 points for patients without and −7.5 to −12 points for patients with CRF.

Conclusion

The most conservative estimate of the MCID is −9 points in patients with COPD, without and −12 in those with CRF. This estimate may be useful in the clinical interpretation of data, particularly in response to intervention studies.

Effectiveness of inspiratory muscle training on respiratory fitness and breathlessness in chronic renal failure: A randomized control trial

BACKGROUND

People with chronic renal failure (CRF) show decreased respiratory fitness and poor quality of life (QOL). Exercise during hemodialysis has been suggested to improve the cardio-respiratory fitness. However, results of effects of respiratory muscle (RM) training on respiratory fitness and QOL are inconsistent. In addition, very few studies explored the association between inspiratory muscle (IM) training and sensation of breathlessness.

OBJECTIVES

To examine the effects of IM training in hemodialysis patients on respiratory fitness QOL and breathlessness.

METHOD

A randomized control trial with 50 CRF, who underwent hemodialysis (25 individuals in each group; IM training and sham group) was designed. Pulmonary function, RM strength, QOL (measured by Kidney Disease Quality of Life-36), and sensation of breathlessness were measured before and after an 8-week intervention.

RESULTS

Compared to the sham group, the IM strength increased in the intervention group after an 8-week program (Δ25.92 ± 8.73 cmH₂ O, p = 0.005). Significantly increased IM and forced vital capacity values in training groups was observed after an 8-week intervention (Δ12.44 ± 3.07 cmH₂ O and Δ0.097 ± 0.046 L, respectively), but not the sham group. Neither, the training group, nor the sham group were significantly different in the QOL. However, feeling of shortness of breath improved after the training program among inspiratory muscle training group, but not the sham group.

CONCLUSION

IM training during hemodialysis could lead to an improvement of respiratory fitness and reduce breathlessness in people with CRF who are receiving hemodialysis. However, QOL was not different after the training program. The study suggests that after 8-week intervention program, IM training (loading exercise) could improve IM strength, pulmonary function without any complications during the intervention program within 1-2 h.

Patients' and caregivers' experiences of driving with chronic breathlessness before and after regular low-dose sustained-release morphine: A qualitative study

BACKGROUND

Chronic breathlessness is a disabling syndrome that profoundly impacts patients' and caregivers' lives. Driving is important for most people, including those with advanced disease. Regular, low-dose, sustained-release morphine safely reduces breathlessness, but little is known about its impact on driving.

AIM

To understand patients' and caregivers' (1) perspectives and experiences of driving with chronic breathlessness; and (2) perceived impact of regular, low-dose, sustained-release morphine on driving.

DESIGN

A qualitative study embedded in a pragmatic, phase III, randomised, placebo-controlled trial of low-dose, sustained-release morphine (⩽32 mg/24 h) for chronic breathlessness. Semi-structured interviews were conducted immediately after participants withdrew or completed the randomised, placebo-controlled trial. Informed by grounded theory, a constant comparative approach to analysis was adopted.

SETTING/PARTICIPANTS

Participants were recruited from an outpatients palliative care service in Adelaide, Australia. Participants included patients (n = 13) with severe breathlessness associated with chronic obstructive pulmonary disease and their caregivers (n = 9).

RESULTS

Participants were interviewed at home. Eleven received morphine 8-32 mg. Three themes emerged: (1) independence; (2) breathlessness' impact on driving; and (3) driving while taking regular, low-dose, sustained-release morphine.

CONCLUSION

Driving contributed to a sense of identity and independence. Being able to drive increased the physical and social space available to patients and caregivers, their social engagement and well-being. Patients reported breathlessness at rest may impair driving skills, while the introduction of sustained-release morphine seemed to have no self-reported impact on driving. Investigating this last perception objectively, especially in terms of safety, is the subject of ongoing work.

Activities Forgone because of Chronic Breathlessness: A Cross-Sectional Population Prevalence Study

Background: Chronic breathlessness is a prevalent disabling syndrome affecting many people for years. Identifying the impact of chronic breathlessness on people's activities in the general population is pivotal for designing symptom management strategies.

Objective: This study aimed to evaluate the association between chronic breathlessness and activities respondents identify can no longer be undertaken (“activities forgone”).

Design: This population-based cross-sectional online survey used a market research company's database of 30,000 registrants for each sex, generating the planned sample size—3000 adults reflecting Australia's 2016 Census by sex, age group, state of residence, and rurality.

Setting/Subjects: The population of focus (n = 583) reported a modified Medical Research Council (mMRC) breathlessness scale ≥1 and experienced this breathlessness for ≥3 months.

Measurements: Activities forgone were categorized by mMRC using coding derived from the Dyspnea Management Questionnaire domains. Activities were classified as “higher/lower intensity” using Human Energy Expenditure scale.

Results: Respondents were male 50.3%; median age 50.0 (IQR 29.0); with 66% living in metropolitan areas; reporting 1749 activities forgone. For people with mMRC 1 (n = 533), 35% had not given up any activity, decreasing to 9% for mMRC 2 (n = 38) and 3% for mMRC 3–4 (n = 12). Intense sport (e.g., jogging and bike riding) was the top activity forgone: 42% (mMRC 1), 32% (mMRC 2), and 36% (mMRC 3–4). For respondents with mMRC 3–4, the next most prevalent activities forgone were “sexual activities” (14%), “lower intensity sports” (11%), and “other activities” (11%).

Conclusions: People progressively reduce a wide range of activities because of their chronic breathlessness.

Effective management of adult patients with asthma

Asthma is a chronic respiratory condition that can affect people of all ages. Globally, asthma is one of the most common non-communicable diseases and is associated with significant personal, financial and societal costs. In some cases, asthma can be fatal, although many fatalities would have been preventable with appropriate management. People with asthma often underestimate the effects of their symptoms, and nurses should develop their knowledge and skills so that they can provide appropriate management advice. This article outlines the causes of asthma and its symptoms. It also explains the interventions used in the management of this condition, including medicines, patient education, appropriate lifestyle changes and referral to specialist services.

Availability of Internationally Controlled Essential Medicines in the COVID-19 Pandemic

Section 2 of the 2019 World Health Organization Model List of Essential Medicines includes opioid analgesics formulations commonly used for the control of pain and respiratory distress, as well as sedative and anxiolytic substances such as midazolam and diazepam. These medicines, essential to palliative care, are regulated under the international drug control conventions overseen by United Nations specialized agencies and treaty bodies and under national drug control laws. Those national laws and regulations directly affect bedside availability of Internationally Controlled Essential Medicines (ICEMs). The complex interaction between national regulatory systems and global supply chains (now impacted by COVID-19 pandemic) directly affects bedside availability of ICEMs and patient care. Despite decades of global civil society advocacy in the United Nations system, ICEMs have remained chronically unavailable, inaccessible, and unaffordable in low- and-middle-income countries, and there are recent reports of shortages in high-income countries as well. The most prevalent symptoms in COVID-19 are breathlessness, cough, drowsiness, anxiety, agitation, and delirium. Frequently used medicines include opioids such as morphine or fentanyl and midazolam, all of them listed as ICEMs. This paper describes the issues related to the lack of availability and limited access to ICEMs during the COVID-19 pandemic in both intensive and palliative care patients in countries of all income levels and makes recommendations for improving access.