Predicting the rate of oxygen consumption during the 3-minute constant-rate stair stepping and shuttle tests in people with chronic obstructive pulmonary disease

Background

The 3-minute constant-rate stair stepping (3-min CRSST) and constant-speed shuttle tests (3-min CSST) were developed to assess breathlessness in response to a standardized exercise stimulus. Estimating the rate of oxygen consumption (V’O₂) during these tests would assist clinicians to relate the stepping/shuttle speeds that elicit breathlessness to daily physical activities with a similar metabolic demand. This study: (I) developed equations to estimate the V’O₂ of these tests in people with chronic obstructive pulmonary disease (COPD); and (II) compared the newly developed and American College of Sports Medicine (ACSM) metabolic equations for estimating the V’O₂ of these tests.

Methods

This study was a retrospective analysis of people with COPD who completed a 3-min CRSST (n=98) or 3-min CSST (n=69). Multivariate linear regression estimated predictors (alpha <0.05) of V’O₂ to construct COPD-specific metabolic equations. The mean squared error (MSE) of the COPD-specific and ACSM equations was calculated and compared. Bland-Altman analyses evaluated level of agreement between measured and predicted V’O₂ using each equation; limits of agreement (LoA) and patterns of bias were compared.

Results

Stepping rate/shuttle speed and body mass were identified as significant predictors of V’O₂. The MSE of the COPD-specific equations was 0.05 L·min⁻¹ for both tests. Mean difference between measured and predicted V’O₂ was 0.00 L·min⁻¹ (95% LoA −0.46, 0.46) and 0.00 L·min⁻¹ (95% LoA −0.44, 0.44) for the 3-min CRSST and 3-min CSST, respectively. For the ACSM metabolic equations, the MSE was 0.10 L·min⁻¹ and 0.18 L·min⁻¹ for the 3-min CRSST and 3-min CSST, respectively. The ACSM metabolic equations underestimated V’O₂ of the 3-min CRSST by −0.18 L·min⁻¹ (95% LoA −0.68, 0.32), and overestimated V’O₂ of the 3-min CSST by 0.35 L·min⁻¹ (95% LoA −0.14, 0.84).

Conclusions

This study presents metabolic equations to predict V’O2 of the 3-min CRSST and 3-min CSST for people with COPD that are more accurate than the ACSM metabolic equations.

Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis

CONTEXT

Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment.

OBJECTIVE

The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings.

METHODS

This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma.

RESULTS

Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care.

CONCLUSION

Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.

Cardiopulmonary exercise test in myocardial ischemia detection

Exercise electrocardiography has low sensitivity for detection of myocardial ischemia. However, when combined with cardiopulmonary exercise testing (CPEX), the sensitivity and specificity of ischemia detection improves significantly. CPEX offers unique advantages over imaging techniques in tricky situations such as balanced ischemia. Early abnormal oxygen uptake would point toward profound coronary stenosis that could be missed in perfusion imaging. CPEX could be an invaluable tool in asymptomatic left bundle branch block pattern, without exposing patients to the risks of computerized tomography or invasive coronary angiography. Normal oxygen uptake curves would rule out significant coronary stenosis as the cause of left bundle branch block pattern. Elseways, abnormal oxygen uptake in patients with normal coronary arteries could indicate microvascular angina. Furthermore, exercise capacity is an excellent predictor of cardiovascular risk in those with and without heart disease. Using two clinical cases we introduce the concept of gas-exchange and hemodynamic changes encountered in ischemic heart disease.

A Cross-Sectional Study in Patients with Severe COPD to Assess the Perception of Symptom Variability (COPVAR) in the Middle East and Africa

Purpose

This study was performed to assess symptom variability and its impact on morning activities in stable patients with severe COPD in the Middle East and Africa (MEA) countries.

Patients and methods

Non-interventional, cross-sectional study (NCT03425760) in patients with severe COPD (GOLD 2015, C, or D categories). Symptom variability was assessed directly by interviewing the patient and using the Global Chest Symptoms Questionnaire (GCSQ). The impact on morning activities was assessed using the Capacity of Daily Living during the Morning (CDLM) and the Morning Activities and Symptoms Questionnaire (MASQ).

Results

A total of 3253 patients (mean±SD age: 64.1±9.5 years, 90.3% males) were enrolled. Overall, 81.6% and 83.4% of patients reported weekly and daily symptom variability, respectively. The number of exacerbations in the previous year, smoking cessation, and COPD GOLD D were the most consistent factors associated with symptom variability. The GCSQ score was significantly higher (p<0.001) in GOLD D than in GOLD C patients at each time during the day. In GOLD D, the mean (±SD) GCSQ score was higher at night (1.6±1.2, p<0.001) and in the morning (1.5±1.0, p<0.001) than in the afternoon (1.3±0.9), suggesting daytime variability of breathlessness and chest tightness. Overall, 60.0% of GOLD D patients (versus 13.6% GOLD C, p<0.0001) had difficulty getting out of bed due to COPD. Patients with symptom variability had significantly more difficulty to get out of bed, especially patients with chest tightness variability (p<0.0001) and wheezing variability (p<0.0001). The CDLM global score was significantly lower (p<0.0001) in GOLD D than in GOLD C patients (3.5±1.1 and 4.6 ± 3.5, respectively). Daily variability in chest tightness and wheezing was also significantly associated with CDLM scores (p<0.0001).

Conclusion

In MEA countries, patients with severe stable COPD reported significant daily and weekly symptom variability which affects morning activities, particularly in GOLD D patients.

The effect of inspiratory muscle training on swimming performance, inspiratory muscle strength, lung function, and perceived breathlessness in elite swimmers: a randomized controlled trial

Background:

According to studies performed on terrestrial sports athletes, inspiratory muscle training (IMT) may improve athletes’ performance. However, evidence of its effects in elite swimmers is lacking. Therefore, we aimed to assess the effect of 12-week IMT on swimming performance, inspiratory muscle strength, lung function, and perceived breathlessness in elite swimmers.

Methods:

Elite swimmers from the main FC Porto swimming team (in competitive training for a minimum period of 3 years) were invited to participate and were randomly allocated into intervention or control groups. The intervention group performed 30 inspiratory efforts, twice a day, 5 times a week, against a pressure threshold load equivalent to 50% of maximal inspiratory pressure, whereas the control group performed inspiratory efforts at the same frequency but against a 15% load. Swimming performance was assessed through time trials, converted into points according to International Swimming Federation Points Table. Outcomes were evaluated before and following the 12-week study period.

Results:

A total of 32 participants (22 girls) were included. The median age was 15 and 14 years old for the intervention (n = 17) and control (n = 12) groups, respectively. No differences were found in swimming performance (P = .271), inspiratory muscle strength (P = .914), forced vital capacity (P = .262), forced expiratory volume in 1st second (P = .265), peak expiratory flow (P = .270), and perceived breathlessness (P = .568) between groups after 12 weeks of intervention.

Conclusion:

Twelve weeks of IMT had no effect on swimming performance, lung function, and perceived breathlessness in elite swimmers. These results may be related to swimming-specific factors and/or an applied load insufficient to achieve training overload that could induce further improvements.

Symptoms and exacerbations in asthma: an apparent paradox?

Background:

There is a dearth of data on prospectively recorded symptoms in patients with uncontrolled asthma. Asthma symptoms and exacerbation rate are commonly thought to be associated. The aim of this study was to analyse asthma symptoms of cough, wheeze, chest tightness and breathlessness in an uncontrolled asthma cohort. We also examined the effect of maintenance and reliever therapy (MART) on these symptoms and its effect on exacerbation rate.

Methods:

Adults with uncontrolled asthma electronically recorded their asthma symptom severity scores twice-daily over a period of 48 weeks following randomisation to beclometasone/formoterol twice daily plus pro re nata (prn) salbutamol or MART. Subjects with symptom scores of ⩾2 (ranging from 0 to 3 for each symptom) were considered more symptomatic, whereas those below a score of 2 were considered less severe. The influence treatment on exacerbation frequency and symptom profiles were then correlated.

Results:

Of the 1701 subjects in the analyses, 1403 were symptomatic with ⩾100 symptom episodes for one symptom. The remaining 298 subjects were classified as pauci-symptomatic. There was poor association between the frequency and symptom severity score for each symptom. Surprisingly, wheeze was the least reported symptom. Females were more likely to be polysymptomatic. MART compared with prn salbutamol markedly attenuated severe asthma exacerbations. This effect was most notable in subjects with fewer symptoms.

Conclusions:

In uncontrolled asthma, there is a poor correlation between reported symptoms and exacerbation frequency. This post hoc analysis suggests that MART should not be reserved for symptomatic subjects but achieves the greatest benefit in pauci-symptomatic patients with asthma.

Trial registration:

ClinicalTrials.gov identifier: NCT00861926

Diagnostic approach to chronic dyspnoea in adults

Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

Introduction

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

Methods

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

Results

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

Discussion

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

Breathlessness and the brain: the role of expectation

PURPOSE OF REVIEW

Breathlessness debilitates countless people with a wide range of common diseases. For some people, the experience of breathlessness is poorly explained by the findings of medical tests. This disparity complicates diagnostic and treatment options and means that disease-modifying treatments do not always have the expected effect upon symptoms. These observations suggest that brain processing of respiratory perceptions may be somewhat independent of disease processes. This may help to explain the dissonance observed in some patients between physical disease markers and the lived experience of breathlessness.

RECENT FINDINGS

A body of breathlessness research using functional neuroimaging has identified a relatively consistent set of brain areas that are associated with breathlessness. These areas include the insula, cingulate and sensory cortices, the amygdala and the periaqueductal gray matter. We interpret these findings in the context of new theories of perception that emphasize the importance of distributed brain networks. Within this framework, these perceptual networks function by checking an internal model (a set of expectations) against peripheral sensory inputs, instead of the brain acting as a passive signal transducer. Furthermore, other factors beyond the physiology of breathlessness can influence the system.

SUMMARY

A person's expectations and mood are major contributors to the function of the brain networks that generate perceptions of breathlessness. Breathlessness, therefore, arises from inferences made by the brain's integration of both expectations and sensory inputs. By better understanding individual differences across these contributing perceptual factors, we will be better poised to develop targeted and individualized treatments for breathlessness that could complement disease-modifying therapies.

Disrupted breath, songlines of breathlessness: an interdisciplinary response

Health research is often bounded by disciplinary expertise. While cross-disciplinary collaborations are often forged, the analysis of data which draws on more than one discipline at the same time is underexplored. Life of Breath, a 5-year project funded by the Wellcome Trust to understand the clinical, historical and cultural phenomenology of the breath and breathlessness, brings together an interdisciplinary team, including medical humanities scholars, respiratory clinicians, medical anthropologists, medical historians, cultural theorists, artists and philosophers. While individual members of the Life of Breath team come together to share ongoing work, collaborate and learn from each other's approach, we also had the ambition to explore the feasibility of integrating our approaches in a shared response to the same piece of textual data. In this article, we present our pluralistic, interdisciplinary analysis of an excerpt from a single cognitive interview transcript with a patient with chronic obstructive pulmonary disease. We discuss the variation in the responses and interpretations of the data, why research into breathlessness may particularly benefit from an interdisciplinary approach, and the wider implications of the findings for interdisciplinary research within health and medicine.

Fan Therapy for the Treatment of Dyspnea in Adults: A Systematic Review

CONTEXT

The use of a handheld or electric fan has been proposed as one component of the complex clinical interventions used in the relief of dyspnea; however, there is a lack of consensus regarding its efficacy.

OBJECTIVES

We performed a systematic review to determine the effectiveness of fan therapy for the treatment of dyspnea.

METHODS

We searched the Medline, EMBASE, Web of Science, Scopus, CINAHL, PsycInfo, and Cochrane Library databases to identify all fan therapy studies published from January 1, 1946 to September 31, 2018. The search terms included "dyspnea," "dysponea," "dyspneic," "short of breath," "shortness of breath," "breathless," "breathlessness," "breathing difficulty," "labored breathing," and "fan." Searches were limited to articles in English or Chinese. The bibliographies of identified articles were also manually searched. Three authors independently assessed papers for inclusion.

RESULTS

Ten of the 92 unique records identified met the inclusion criteria (nine randomized controlled trials and one cohort study). Most studies (80%) were conducted in the hospital setting, and none were double blinded. Nearly half (159 [46%]) of the 344 total subjects had cancer. The most common nonmalignant disease was chronic obstructive pulmonary disease. The most common duration of fan therapy was five minutes. Six studies (60%) reported a significant improvement in dyspnea with fan therapy. There are two ongoing trials being conducted based on a search of trial registries.

CONCLUSION

Limited direct evidence from randomized controlled trials indicates that fan therapy may effectively alleviate dyspnea. Additional trials are warranted to confirm this finding and explore the use of fan therapy for the treatment of dyspnea in more diverse populations and settings.

Symptoms and perception of airway obstruction in asthmatic patients: Clinical implications for use of reliever medications

BACKGROUND

Asthma causes the unpleasant sensation of breathlessness (dyspnea) caused by airway obstruction. Patients with poor perception of airway obstruction are at risk of delay in seeking medical attention and undertreatment, which can lead to avoidable deaths. Conversely, those with heightened perception are at risk of overtreatment and iatrogenic adverse effects with reliever medications, anxiety, and unnecessary use of health care resources.

OBJECTIVE

We sought to review evidence about symptom misperception in asthmatic patients and how to identify and manage affected patients, particularly with regard to reliever medications.

METHODS

We conducted a systematic literature search for studies of perception of airway function in asthmatic patients. We searched the OVID (Medline and Medline [R] in process [PubMed]), Embase, and Adisearch/Odyssey databases, restricting our search to human studies published in English from 1990-2018, with no restrictions on age, sex, or racial origin.

RESULTS

We found that both underperception and overperception assessed during induced bronchoconstriction or bronchodilation or during changes in airway resistance were common across all age groups and that aging, disease severity, smoking, sex, ethnicity, psychologic factors, and medication are all associated with differences in perception. Importantly, airway inflammation was associated with impaired perception and a history of severe or near-fatal asthma. We also identified knowledge gaps, such as whether an individual patient's perception varies over time and the influence perception has on patients' use of reliever medication.

CONCLUSION

We found that abnormal perception of airway obstruction has important clinical implications for the management of patients with asthma.

Selective Type 2 Respiratory Failure Followed by Ocular Myasthenia Gravis Diagnosed by Ice Pack Test: A Case Report

Myasthenia gravis is an autoimmune neuromuscular disorder that can present with skeletal muscle involvement, ocular muscles involvement and can progress to respiratory muscle paralysis. Here, we present a unique case of type 2 respiratory failure due to myasthenia gravis with the delayed ocular presentation. A 46-year-old female patient presented to the outpatient clinic with complaints of dyspnea. On further evaluation, she was found to be hypercapnic on arterial blood gas analysis with no muscular weakness in any of the limbs. The patient further progressed to ocular symptoms. With the use of an ice pack test, a bedside test for improvement of ptosis, the patient was diagnosed with myasthenic ptosis preventing further progression of type 2 respiratory failure and intubation. With this case report, we emphasize the critical role of such simple bedside test in timely diagnosis and management of myasthenia gravis while awaiting the final results.

The roles of dispositional coping style and social support in helping people with respiratory disease cope with a breathlessness crisis

AIM

To explore the role of coping moderators in self-management of breathlessness crises by people with advanced respiratory disease.

DESIGN

A secondary analysis of semi-structured interview data.

METHODS

Interviews with patients who had advanced respiratory disease, chronic breathlessness and at least one experience where they considered presenting to Emergency but self-managed instead (a "near miss"). Participants were recruited from New South Wales, Queensland, Victoria, South Australia or Tasmania. Eligible caregivers were those who contributed to Emergency-related decision-making. Interviews were coded inductively and then deductively against the coping moderators social support and dispositional coping style, defined by the Transactional Model of Stress and Coping.

RESULTS

Interviews were conducted between October 2015 - April 2016 with 20 patients and three caregivers. Social networks offered emotional and practical support but also had potential for conflict with patients' 'hardy' coping style. Patient hardiness (characterized by a sense of 'commitment' and 'challenge') promoted a proactive approach to self-management but made some patients less willing to accept support. Information-seeking tendencies varied between patients and were sometimes shared with caregivers. An optimistic coping style appeared to be less equivocally beneficial.

CONCLUSION

This study shows that social support and coping style may influence how people self-manage through their breathlessness crises and identified ways coping moderators can facilitate or hinder effective self-management.

IMPACT

This study confers insights into how social-support and coping style can be supported and optimized to facilitate breathlessness self-management. Acknowledging coping moderator interactions is beneficial for developing resources and strategies that recognise patient mastery.

The Effects of Repeated Dyspnea Exposure on Response Inhibition

In order to treat dyspnea (=breathlessness) successfully, response inhibition (RI) as a major form of self-regulation is a premise. This is supported by research showing that self-regulation is associated with beneficial behavioral changes supporting treatment success in patients. Recent research showed that dyspnea has an impairing effect on RI, but the effects of repeated dyspnea exposure on RI remain unknown. Therefore, the present study tested the effects of repeated resistive load-induced dyspnea on RI over a 5-day period. Healthy volunteers (n = 34) performed the standard version of the Stroop task during baseline and dyspnea conditions on the first and fifth testing day and underwent an additional dyspnea exposure phase on each testing day. Variables of interest to investigate RI were reaction time, accuracy as well as the event-related potentials late positive complex (LPC) and N400 in the electroencephalogram. Reduced accuracy for incongruent compared to congruent stimuli during the dyspnea condition on the first testing day were found (p < 0.001). This was paralleled by a reduced LPC and an increased N400 for incongruent stimuli during the induction of dyspnea (p < 0.05). After undergoing dyspnea exposure, habituation of dyspnea intensity was evident. Importantly, on the fifth testing day, no differences between baseline, and dyspnea conditions were found for behavioral and electrophysiological measures of RI. These findings demonstrate that the impairing effect of dyspnea on RI disappeared after repeated dyspnea exposure in healthy participants. Translated to a clinical sample, it might cautiously be suggested that dyspnea exposure such as dyspnea perceived during physical exercise could reduce the impairing effect of dyspnea on RI which might have the potential to help increase self-regulation abilities and subsequent treatment efforts in dyspneic patients.

Trapped in my lungs and fighting a losing battle. A phenomenological study of patients living with chronic obstructive and pulmonary disease

Chronic obstructive and pulmonary disease (COPD) has detrimental effects on individuals with the disease. COPD causes breathlessness, morbidity and associated psychosocial distress. This study was guided by the phenomenological question what is it like to have COPD and situated in Van Manen's phenomenology of practice. Experiential material was gathered through phenomenological interviews. Four themes emerged from the lived experiences of patients living with COPD: breath as a possibility; being vigilant; fighting a losing battle; and feeling isolated from others. For patients with COPD, breathing becomes ever-present and shifts from the invisible background of daily living to the central activity around which everyday life is organised. COPD patients always monitor their own breath and scrutinise the environment on possible dangers that can affect their breathing. Whenever moving or being involved in an activity, a part of their mind is preoccupied with the breathing. Although COPD patients realise that no amount of good behaviour will matter and that the decline of their lungs is inevitable, they make every effort to take good care of their body. They anticipate and avoid triggers of breathlessness isolating them from social interactions and activities. The appearance of the body as a source of social embarrassment also has an isolating effect. This study shows that breathlessness is a constant horizon that frames the experience of COPD patients. It is a limiting factor and determines their entire life. A more profound understanding of these experiences in healthcare professionals will contribute to person-centred care for COPD patients.

Battery operated fan and chronic breathlessness: does it help?

OBJECTIVES

To examine whether use of a hand-held fan ('fan') improves breathlessness and increases physical activity.

METHODS

A secondary exploratory analysis using pooled data from the fan arms of two feasibility randomised controlled trials in people with chronic breathlessness: (1) fan and activity advice vs activity advice, (2) activity advice alone or with the addition or the 'calming hand', or the fan, or both. Descriptive statistics and regression analysis to explore patient characteristics associated with benefit (eg age, sex, diagnosis, general self-efficacy).

RESULTS

Forty-one participants were allocated the fan (73 years (IQR 65-76, range 46-88), 59% male, 20 (49%) chronic obstructive pulmonary disease (COPD), three (7%) heart failure, three (7%) cancer). Thirty-five (85%) reported that the fan helped breathing, and 22 (54%) reported increased physical activity.Breathlessness benefit was more likely in older people, those with COPD and those with a carer. However, due to the small sample size none of these findings were statistically significant. Those with COPD were more likely to use the fan than people with other diagnoses (OR 5.94 (95% CI 0.63 to 56.21, p=0.120)).

CONCLUSIONS

These exploratory data support that the fan helps chronic breathlessness in most people and adds new data to indicate that the fan is perceived to increase people's physical activity. There is also a signal of possible particular benefits in people with COPD which is worthy of further study.

Modern Innovative Solutions to Improve Outcomes in Asthma, Breathlessness, and Chronic Obstructive Pulmonary Disease (MISSION ABC): Protocol for a Mixed-Methods Study

BACKGROUND

A high proportion of the costs for respiratory diseases are generated by a relatively small group of patients with severe disease (recognized or unrecognized) or complex problems that include multimorbidity, at-risk behaviors, and socioeconomic disadvantage. These patients often struggle to engage with the structured, proactive, care approaches for chronic disease management advocated for asthma and chronic obstructive pulmonary disease (COPD), resulting in repeated emergency use of both primary and secondary health care. An integrated approach for the management of complex patients, incorporating both specialist and primary care teams' expertise, may be effective in improving outcomes for such high-risk patients. However, the evidence is mixed, and there is a need for evaluation of models of integrated care in routine "real-world" clinical settings.

OBJECTIVE

This mixed-methods protocol examines the implementation of a novel integrated care model for patients with airways disease and undifferentiated breathlessness by using both quantitative and qualitative evaluation of processes, patient and health care professional experiences, and clinical outcomes throughout the clinic cycles. It aims to establish whether Modern Innovative Solutions to Improve Outcomes in Asthma, Breathlessness, and Chronic Obstructive Pulmonary Disease (MISSION ABC), including innovative diagnostic and self-management tools, can deliver improvements in health service use and clinical outcomes for the different patient groups (asthma, breathlessness, and COPD) and compares the 12-month period prior to the first patient visit and the 6-month period following the last visit.

METHODS

A combination of study designs is required to evaluate all aspects of the service: participatory action research approach, involving real-time evaluation at each clinic to inform subsequent clinics; before-and-after study for patient outcomes before and after clinic attendance; and qualitative methods (interviews and focus groups).

RESULTS

The results will be compiled and published in April 2019.

CONCLUSIONS

Evaluation of the clinic cycles will include consideration of qualitative data from patients, carers, and health care professionals in addition to quantitative outcomes for service implementation and patient factors. The long-term impact of the service will be evaluated using clinical and health service outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/9228.

Assessment of breath volatile organic compounds in acute cardiorespiratory breathlessness: a protocol describing a prospective real-world observational study

INTRODUCTION

Patients presenting with acute undifferentiated breathlessness are commonly encountered in admissions units across the UK. Existing blood biomarkers have clinical utility in distinguishing patients with single organ pathologies but have poor discriminatory power in multifactorial presentations. Evaluation of volatile organic compounds (VOCs) in exhaled breath offers the potential to develop biomarkers of disease states that underpin acute cardiorespiratory breathlessness, owing to their proximity to the cardiorespiratory system. To date, there has been no systematic evaluation of VOC in acute cardiorespiratory breathlessness. The proposed study will seek to use both offline and online VOC technologies to evaluate the predictive value of VOC in identifying common conditions that present with acute cardiorespiratory breathlessness.

METHODS AND ANALYSIS

A prospective real-world observational study carried out across three acute admissions units within Leicestershire. Participants with self-reported acute breathlessness, with a confirmed primary diagnosis of either acute heart failure, community-acquired pneumonia and acute exacerbation of asthma or chronic obstructive pulmonary disease will be recruited within 24 hours of admission. Additionally, school-age children admitted with severe asthma will be evaluated. All participants will undergo breath sampling on admission and on recovery following discharge. A range of online technologies including: proton transfer reaction mass spectrometry, gas chromatography ion mobility spectrometry, atmospheric pressure chemical ionisation-mass spectrometry and offline technologies including gas chromatography mass spectroscopy and comprehensive two-dimensional gas chromatography-mass spectrometry will be used for VOC discovery and replication. For offline technologies, a standardised CE-marked breath sampling device (ReCIVA) will be used. All recruited participants will be characterised using existing blood biomarkers including C reactive protein, brain-derived natriuretic peptide, troponin-I and blood eosinophil levels and further evaluated using a range of standardised questionnaires, lung function testing, sputum cell counts and other diagnostic tests pertinent to acute disease.

ETHICS AND DISSEMINATION

The National Research Ethics Service Committee East Midlands has approved the study protocol (REC number: 16/LO/1747). Integrated Research Approval System (IRAS) 198921. Findings will be presented at academic conferences and published in peer-reviewed scientific journals. Dissemination will be facilitated via a partnership with the East Midlands Academic Health Sciences Network and via interaction with all UK-funded Medical Research Council and Engineering and Physical Sciences Research Council molecular pathology nodes.

TRIAL REGISTRATION NUMBER

NCT03672994.

Approaches to palliative oxygen therapy in chronic obstructive pulmonary disease: a multi-national survey of specialists

As palliative oxygen therapy (POT) is beneficial only to a minority of patients with chronic breathlessness, it is no longer routinely recommended. This multi-national, online survey of respiratory and palliative medicine specialists, with 440 participants, identified that prescription of POT has decreased over the past decade; however a sizeable proportion of doctors, particularly within palliative care, still support and recommend POT. Further education and research regarding the optimal management of chronic breathlessness are required.

Relating Experienced To Recalled breathlessness Observational (RETRO) study: a prospective study using a mobile phone application

Background

Breathlessness, the subjective sensation of breathing discomfort, is common and appears in the daily life of people with cardiorespiratory diseases. Physicians often rely on patient's history based on symptom recall. The relation between recalled and experienced breathlessness is still poorly understood. This paper presents the protocol for a study primarily aimed at evaluating the relationship between experienced breathlessness and (1) recalled breathlessness and (2) predicted future breathlessness.

Methods

A mobile phone application will be used to collect data during daily life. Medically stable participants, ≥18 years of age with mean daily breathlessness of Numerical Rating Scale (NRS) 3/10 and able to use a mobile phone with internet will rate their breathlessness intensity on a 0-10 NRS prompted the user several times daily for 1 week. Participants will recall their breathlessness each day and week. Multivariable random effects regression models will be used for statistical analyses.

Results

Results of the study will be submitted for publication in peer-reviewed journals and presented at relevant conferences.

Discussion

This protocol describes a study aimed at investigating previously unknown areas of the experience and recall of breathlessness using a new method of data collection.

Registration details

Prospectively registered with ClinicalTrials.gov (Nr: NCT03468205).

Ethics and dissemination

The study has received ethical approval from the Regional Ethical Review Board Lund (DNr 2017/149). After a general study information including that participation is entirely voluntary, participants will answer the eligibility criteria and be asked to consent to participate before entering the study questions. Written informed consent to participate will be obtained for participants in the clinical sub-cohort. Participation can be discontinued at the discretion of the participant in which case no further data will be collected.

Recommendations for services for people living with chronic breathlessness in advanced disease: Results of a transparent expert consultation

Chronic breathlessness is highly distressing for people with advanced disease and their informal carers, yet health services for this group remain highly heterogeneous. We aimed to generate evidence-based stakeholder-endorsed recommendations for practice, policy and research concerning services for people with advanced disease and chronic breathlessness. We used transparent expert consultation, comprising modified nominal group technique during a stakeholder workshop, and an online consensus survey. Stakeholders, representing multiple specialities and professions, and patient/carers were invited to participate. Thirty-seven participants attended the stakeholder workshop and generated 34 separate recommendations, rated by 74 online survey respondents. Seven recommendations had strong agreement and high levels of consensus. Stakeholders agreed services should be person-centred and flexible, should cut across multiple disciplines and providers and should prioritize breathlessness management in its own right. They advocated for wide geographical coverage and access to expert care, supported through skills-sharing among professionals. They also recommended recognition of informal carers and their role by clinicians and policymakers. Overall, stakeholders' recommendations reflect the need for improved access to person-centred, multi-professional care and support for carers to provide or access breathlessness management interventions. Future research should test the optimal models of care and educational strategies to meet these recommendations.

The meaning of the name of 'pulmonary rehabilitation' and its influence on engagement with individuals with chronic lung disease

Pulmonary rehabilitation (PR) is recommended for all individuals living with a lung condition and chronic breathlessness. This article considers how adopting an interdisciplinary, medical humanities approach to the term 'pulmonary rehabilitation' might unpack some of the misconceptions, misrepresentations or negative connotations surrounding it, which have been largely overlooked in explanations of the low uptake of this programme. Taking key insights from Wellcome Trust-funded Life of Breath project, including ethnographic research in community fitness groups in North East England and the 'Breath Lab' special interest group, this article outlines how the whole-body approach of PR is not easily understood by those with lung conditions; how experience can inform breath perception through the pacing of everyday life; and how stigma can impact rehabilitation. This article highlights the value of medical humanities in working through communicative challenges evident in the translation of PR between patient and clinical contexts and sets out two arts-based approaches (Singing for Lung Health and dance movement) as potential options that could be included in the PR referral. Finally, the article outlines the need for collaborative research exploring the communication and meaning of healthcare strategies and experiences at the interface of the arts, humanities and medical practice.