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Massart A, Hunt DP. Management of Refractory Breathlessness: a Review for General Internists. J Gen Intern Med 2021; 36:1035-1040. [PMID: 33469757 PMCID: PMC8041955 DOI: 10.1007/s11606-020-06439-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/10/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Annie Massart
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA. .,, Atlanta, USA.
| | - Daniel P Hunt
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA
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2
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Ferry OR, Huang YC, Masel PJ, Hamilton M, Fong KM, Bowman RV, McKenzie SC, Yang IA. Diagnostic approach to chronic dyspnoea in adults. J Thorac Dis 2019; 11:S2117-S2128. [PMID: 31737340 DOI: 10.21037/jtd.2019.10.53] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Olivia R Ferry
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Yao C Huang
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Philip J Masel
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Kwun M Fong
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Rayleen V Bowman
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Scott C McKenzie
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Cardiology Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Ian A Yang
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Baille G, Chenivesse C, Perez T, Machuron F, Dujardin K, Devos D, Defebvre L, Moreau C. Dyspnea: An underestimated symptom in Parkinson's disease. Parkinsonism Relat Disord 2018; 60:162-166. [PMID: 30224267 DOI: 10.1016/j.parkreldis.2018.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/29/2018] [Accepted: 09/02/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Dyspnea is one of the least well-characterized non-motor symptoms (NMS) associated with Parkinson's disease (PD). OBJECTIVE To determine the frequency of dyspnea in a large, single-center cohort of consecutive PD patients with no history of lung or heart disease, and to compare clinical features in dyspneic vs. non-dyspneic patients. METHODS Patients with abnormal cardiovascular and pulmonary results in a clinical examination were excluded. A positive response to at least one question ("In the last month, have you suffered from breathlessness?" and "In the last month, have you had trouble breathing normally?") was considered to signify the experience of dyspnea. MDS-UPDRS, global cognitive performance, non-motor symptoms and quality of life were assessed. RESULTS In the cohort of 153 non-demented PD patients (mean age ± standard deviation: 63.9 ± 7.4; mean disease duration: 9.2 ± 6.1 years), the mean [95% confidence interval (CI)] frequency of dyspnea was 39.2% (31.5-47). After adjustment for disease severity, PD patients with dyspnea had a significantly higher Movement Disorders Society Unified Parkinson's Disease Rating Scale part I, II and IV scores, a higher HAD anxiety and depression scores and a significantly higher 8-item Parkinson's Disease Questionnaire. CONCLUSION Dyspnea is a frequent NMS in PD. Its pathophysiology and prognostic value need more investigation.
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Affiliation(s)
- Guillaume Baille
- Department of Neurology, Expert Center for Parkinson's Disease, INSERM UMRS_1171, Lille University Medical Center, LICEND COEN Center, Lille, F-59000 France.
| | - Cécile Chenivesse
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Univ. Lille, INSERM U1019, CIIL, Institut Pasteur de Lille, F-59000 Lille, France
| | - Thierry Perez
- CHU Lille, Service de Pneumologie et Immuno-Allergologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Univ. Lille, INSERM U1019, CIIL, Institut Pasteur de Lille, F-59000 Lille, France
| | - François Machuron
- Univ. Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Department of Biostatistics, F-59000 Lille, France
| | - Kathy Dujardin
- Department of Neurology, Expert Center for Parkinson's Disease, INSERM UMRS_1171, Lille University Medical Center, LICEND COEN Center, Lille, F-59000 France
| | - David Devos
- Department of Neurology, Expert Center for Parkinson's Disease, INSERM UMRS_1171, Lille University Medical Center, LICEND COEN Center, Lille, F-59000 France
| | - Luc Defebvre
- Department of Neurology, Expert Center for Parkinson's Disease, INSERM UMRS_1171, Lille University Medical Center, LICEND COEN Center, Lille, F-59000 France
| | - Caroline Moreau
- Department of Neurology, Expert Center for Parkinson's Disease, INSERM UMRS_1171, Lille University Medical Center, LICEND COEN Center, Lille, F-59000 France
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Monahan M, Barton P, Taylor CJ, Roalfe AK, Hobbs FDR, Cowie M, Davis R, Deeks J, Mant J, McCahon D, McDonagh T, Sutton G, Tait L. MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care. Int J Cardiol 2017; 241:255-261. [PMID: 28366472 PMCID: PMC5483229 DOI: 10.1016/j.ijcard.2017.02.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Detection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital. DESIGN A decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. METHODS Data from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective. RESULTS The current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a "do nothing" strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses. CONCLUSIONS This represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.
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Affiliation(s)
- Mark Monahan
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Pelham Barton
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom
| | - Andrea K Roalfe
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, OX2 6GG, United Kingdom.
| | - Martin Cowie
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals, Lyndon, West Bromwich, West Midlands B71 4HJ, United Kingdom
| | - Jon Deeks
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Jonathan Mant
- Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge CB1 8RN, United Kingdom
| | - Deborah McCahon
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - George Sutton
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Lynda Tait
- School of Health Sciences, University of Nottingham, B Floor, South Block Link, Queen's Medical Centre, Nottingham NG7 2HA, United Kingdom
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Vogel-Claussen J, Elshafee AS, Kirsch J, Brown RK, Hurwitz LM, Javidan-Nejad C, Julsrud PR, Kramer CM, Krishnamurthy R, Laroia AT, Leipsic JA, Panchal KK, Shah AB, White RD, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Dyspnea—Suspected Cardiac Origin. J Am Coll Radiol 2017; 14:S127-S137. [DOI: 10.1016/j.jacr.2017.01.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/17/2022]
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Taylor CJ, Hobbs FDR, Marshall T, Leyva-Leon F, Gale N. From breathless to failure: symptom onset and diagnostic meaning in patients with heart failure-a qualitative study. BMJ Open 2017; 7:e013648. [PMID: 28283487 PMCID: PMC5353318 DOI: 10.1136/bmjopen-2016-013648] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- C J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F D R Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - T Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - F Leyva-Leon
- Aston Medical Research Insitutue, Aston Medical School, Birmingham, UK
| | - N Gale
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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