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Bureau C, Schmidt M, Chommeloux J, Rivals I, Similowski T, Hékimian G, Luyt CE, Niérat MC, Dangers L, Dres M, Combes A, Morélot-Panzini C, Demoule A. Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study. Anesthesiology 2024; 141:87-99. [PMID: 38436930 DOI: 10.1097/aln.0000000000004962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
BACKGROUND Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive. METHODS Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles. RESULTS A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16). CONCLUSIONS In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Isabelle Rivals
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Equipe de Statistique Appliquée, ESPCI Paris, Pitié Salpêtrière Research University, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Thomas Similowski
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris University Hospital Group, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Laurence Dangers
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Médecine Intensive-Réanimation Unit, Paris, France
| | - Martin Dres
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, F-75013, Paris, France
| | - Alain Combes
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris Sorbonne, Pitié-Salpêtrière Hospital, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
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Drozdovszky O, Petzke T, Köteles F. Sensory and affective aspects of the perception of respiratory resistance. Biol Futur 2024; 75:51-59. [PMID: 37481740 DOI: 10.1007/s42977-023-00173-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023]
Abstract
Perception of airway resistance has a sensory and an affective aspect, i.e., perceived resistance and unpleasantness, respectively. The current study aimed to shed more light on the relationship of these aspects, as well as their malleability to trait-like aspects of body awareness. In a laboratory study, 71 young participants completed two respiratory resistive load discrimination tasks relying on sensory and affective evaluation, respectively, and filled out questionnaires assessing somatosensory amplification, anxiety sensitivity, somatic symptoms distress, and breath awareness. Frequentist and Bayesian statistical analysis revealed no differences in discrimination accuracy with respect to the sensory and affective aspect of perceived resistance. Psychological traits were not associated with accuracy scores. In conclusion, affective evaluation of respiratory load is as accurate as sensory evaluation. Neither sensory not affective accuracy is influenced by various aspects of body awareness.
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Affiliation(s)
- Orsolya Drozdovszky
- Institute of Health Promotion and Sport Sciences, ELTE Eötvös Loránd University, Budapest, Hungary
- Ádám György Psychophysiology Research Group, Budapest, Hungary
| | - Tara Petzke
- Psychological Institute, Johannes Gutenberg University, Wallstraße 3, 55122, Mainz, Germany.
| | - Ferenc Köteles
- Ádám György Psychophysiology Research Group, Budapest, Hungary
- Károli Gáspár University of the Reformed Church in Hungary, Budapest, Hungary
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Bureau C, Niérat MC, Decavèle M, Rivals I, Dangers L, Beurton A, Virolle S, Deleris R, Delemazure J, Mayaux J, Morélot-Panzini C, Dres M, Similowski T, Demoule A. Sensory interventions to relieve dyspnoea in critically ill mechanically ventilated patients. Eur Respir J 2024; 63:2202215. [PMID: 37678956 DOI: 10.1183/13993003.02215-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND In critically ill patients receiving mechanical ventilation, dyspnoea is frequent, severe and associated with an increased risk of neuropsychological sequelae. We evaluated the efficacy of sensory interventions targeting the brain rather than the respiratory system to relieve dyspnoea in mechanically ventilated patients. METHODS Patients receiving mechanical ventilation for ≥48 h and reporting dyspnoea (unidimensional dyspnoea visual analogue scale (Dyspnoea-VAS)) first underwent increased pressure support and then, in random order, auditory stimulation (relaxing music versus pink noise) and air flux stimulation (facial versus lower limb). Treatment responses were assessed using Dyspnoea-VAS, the Multidimensional Dyspnea Profile and measures of the neural drive to breathe (airway occlusion pressure (P 0.1) and electromyography of inspiratory muscles). RESULTS We included 46 patients (tracheotomy or intubation n=37; noninvasive ventilation n=9). Increasing pressure support decreased Dyspnoea-VAS by median 40 mm (p<0.001). Exposure to music decreased Dyspnoea-VAS compared with exposure to pink noise by median 40 mm (p<0.001). Exposure to facial air flux decreased Dyspnoea-VAS compared with limb air flux by median 30 mm (p<0.001). Increasing pressure support, but not music exposure and facial air flux, reduced P 0.1 by median 3.3 cmH2O (p<0.001). CONCLUSIONS In mechanically ventilated patients, sensory interventions can modulate the processing of respiratory signals by the brain irrespective of the intensity of the neural drive to breathe. It should therefore be possible to alleviate dyspnoea without resorting to pharmacological interventions or having to infringe the constraints of mechanical ventilation lung protection strategies by increasing ventilatory support.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Isabelle Rivals
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Equipe de Statistique Appliquée, ESPCI Paris, PSL Research University, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Laurence Dangers
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Alexandra Beurton
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Sara Virolle
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Robin Deleris
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Julie Delemazure
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Julien Mayaux
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Pneumologie (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
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4
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Burki NK. Treatment of dyspnoea. Eur Respir J 2024; 63:2301565. [PMID: 38237994 DOI: 10.1183/13993003.01565-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/02/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Nausherwan K Burki
- Dept of Medicine, University of Connecticut Health Center, Farmington, CT, USA
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5
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Luu BL, Lewis RHC, Gandevia SC, Boswell-Ruys CL, Butler JE. The detection and sensory perception of inspiratory resistive loads in people with chronic tetraplegia. J Appl Physiol (1985) 2022; 133:1192-1201. [PMID: 36107987 DOI: 10.1152/japplphysiol.00064.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
This study investigated sensations of breathing following tetraplegia. Fifteen people with chronic tetraplegia and fifteen healthy able-bodied controls matched for age, sex, height, and weight participated. Sensations of breathing were quantified by determining the threshold for detecting an added resistance during inspiration. In a separate task, the perceived magnitudes of six suprathreshold resistive loads were determined with a modified Borg scale. The detection threshold of 0.34 cmH2O/L/s [standard deviation (SD) 0.14] in the tetraplegia group was higher than the 0.23 cmH2O/L/s (SD 0.10) threshold for able-bodied controls (P = 0.004). Both participant groups perceived larger loads to be more effortful, with the Borg effort rating increasing linearly with the peak inspiratory pressure generated at each load. The relationship between Borg effort rating and peak inspiratory pressure was steeper in participants with tetraplegia than in able-bodied controls (P = 0.001), but there was no difference when pressure was divided by maximal inspiratory pressure (P = 0.95). Despite a higher detection threshold, the findings suggest that the perceived magnitude of a suprathreshold inspiratory load is not impaired in chronic tetraplegia and that load magnitude perception is related to the maximal, and not absolute, inspiratory muscle force.NEW & NOTEWORTHY Sensations of breathing are thought to be impaired following chronic tetraplegia. The detection threshold for an added resistive load during inspiration was higher in people with tetraplegia than in healthy able-bodied participants. However, for inspiratory loads above the detection threshold, the perceived magnitude of a resistive load as a function of the peak inspiratory pressure was greater in tetraplegia. Load magnitude perception was comparable between participant groups when peak pressure was divided by maximal inspiratory pressure.
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Affiliation(s)
- Billy L Luu
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - R H Chaminda Lewis
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Simon C Gandevia
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia.,Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Claire L Boswell-Ruys
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia.,Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jane E Butler
- Neuroscience Research Australia, Randwick, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Abstract
The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.
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Affiliation(s)
- Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States; Faculty of Health Sciences, Virginia Tech, Blacksburg, VA, United States.
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8
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Vinckier F, Betka S, Nion N, Serresse L, Similowski T. Harnessing the power of anticipation to manage respiratory-related brain suffering and ensuing dyspnoea: insights from the neurobiology of the respiratory nocebo effect. Eur Respir J 2021; 58:58/3/2101876. [PMID: 34556533 DOI: 10.1183/13993003.01876-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Fabien Vinckier
- Université de Paris, Paris, France.,Dept of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatry and Neurosciences, Paris, France
| | - Sophie Betka
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
| | - Nathalie Nion
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France.,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Laure Serresse
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France.,Equipe mobile de soins palliatifs, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France .,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
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9
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Lansing RW, Hoit JD. A Conceptual Framework for Understanding Speaking Dyspnea. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:844-851. [PMID: 33734811 DOI: 10.1044/2020_ajslp-20-00179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose A conceptual framework is proposed to better understand the experience of people who have dyspnea (breathing discomfort) when speaking: its nature, its physiological mechanisms, and its impacts on their lives. Method The components of the framework are presented in their natural order. They are a Speaking Domain (Speaking Activities and Speaking Variables), a Physiological Domain (Speech Breathing Variables and Physiological Mechanisms), a Perceptual Domain (Dyspnea), a Symptom Impact Domain (Emotional Responses, Immediate Behavioral Responses, and Long-Term Behavioral Response), and a Life Impact Domain (Short-Term Impacts and Long-Term Impacts). Results We discuss literature that most directly supports these components and includes findings from healthy people and those with disorders in whom speaking dyspnea was either evoked or measured. Caveats are noted where information is limited and further study is needed. A case example is provided to illustrate how to apply the framework. Conclusions This framework provides a broader view of the elements that contribute to the experience of speaking dyspnea. It is meant to guide researchers, clinicians, instructors, caregivers, and those for whom speaking dyspnea is a daily or even a life-long challenge.
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Affiliation(s)
| | - Jeannette D Hoit
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson
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10
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Abstract
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.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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Simonson TS, Baker TL, Banzett RB, Bishop T, Dempsey JA, Feldman JL, Guyenet PG, Hodson EJ, Mitchell GS, Moya EA, Nokes BT, Orr JE, Owens RL, Poulin M, Rawling JM, Schmickl CN, Watters JJ, Younes M, Malhotra A. Silent hypoxaemia in COVID-19 patients. J Physiol 2021; 599:1057-1065. [PMID: 33347610 PMCID: PMC7902403 DOI: 10.1113/jp280769] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/07/2020] [Indexed: 12/14/2022] Open
Abstract
The clinical presentation of COVID-19 due to infection with SARS-CoV-2 is highly variable with the majority of patients having mild symptoms while others develop severe respiratory failure. The reason for this variability is unclear but is in critical need of investigation. Some COVID-19 patients have been labelled with 'happy hypoxia', in which patient complaints of dyspnoea and observable signs of respiratory distress are reported to be absent. Based on ongoing debate, we highlight key respiratory and neurological components that could underlie variation in the presentation of silent hypoxaemia and define priorities for subsequent investigation.
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Affiliation(s)
- Tatum S Simonson
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Tracy L Baker
- Department of Comparative Biosciences, University of Wisconsin -, Madison, WI, USA
| | - Robert B Banzett
- Division of Pulmonary, Critical Care, & Sleep Medicine Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Tammie Bishop
- Target Discovery Institute, University of Oxford, Oxford, UK
| | - Jerome A Dempsey
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin -, Madison, WI, USA
| | - Jack L Feldman
- Department of Neurobiology, University of California, Los Angeles, CA, USA
| | - Patrice G Guyenet
- Department of Pharmacology, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Emma J Hodson
- The Francis Crick Institute, London, UK
- The Department of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Gordon S Mitchell
- Department of Physical Therapy, Center for Respiratory Research and Rehabilitation, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Esteban A Moya
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Brandon T Nokes
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Jeremy E Orr
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Marc Poulin
- Departments of Physiology & Pharmacology and Clinical Neurosciences, Cumming School of Medicine and Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jean M Rawling
- Departments of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
| | - Jyoti J Watters
- Department of Comparative Biosciences, University of Wisconsin -, Madison, WI, USA
| | - Magdy Younes
- Sleep Disorders Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA
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12
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Hoit JD, Lansing RW, Brown VP, Nitido H. Speaking dyspnea in Parkinson's disease: Preliminary findings. JOURNAL OF COMMUNICATION DISORDERS 2020; 88:106050. [PMID: 33190067 DOI: 10.1016/j.jcomdis.2020.106050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/16/2020] [Accepted: 08/29/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE To determine if people with Parkinson's disease (PD) experience dyspnea (breathing discomfort) during speaking. METHOD The participants were 11 adults with PD and 22 healthy adults (11 young, 11 old). Participants were asked to recall experiences of breathing discomfort across different speaking contexts and provide ratings of those experiences (Retrospective ratings); then they rated the breathing discomfort experienced while performing speaking tasks that were designed to differ in respiratory demands (immediate Post-Speaking ratings). RESULTS Participants with PD reported experiencing breathing discomfort during speaking significantly more frequently (approximately 60 % of the time) than did healthy participants (less than 20 % of the time). Retrospective ratings did not differ significantly from Post-Speaking ratings. Breathing discomfort was experienced by the fewest number of participants with PD for Conversation (two) and Extemporaneous Speaking (three) and by the greatest number for Extended Reading (ten) and Long Counting (nine), although the magnitude of the ratings generally reflected only "Slight" discomfort. Breathing discomfort was most frequently described as air hunger and breathing work, less frequently as mental effort, and very rarely as lung tightness. A few participants with PD reported experiencing emotions associated with their breathing discomfort and most reported using strategies to avoid breathing discomfort in their daily lives. CONCLUSIONS Individuals with PD are more apt to experience speaking dyspnea than healthy individuals, especially when speaking for extended periods or when using long breath groups. Such dyspnea may contribute to a tendency to avoid speaking situations and thereby impair quality of life.
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Affiliation(s)
- Jeannette D Hoit
- University of Arizona, Department of Speech, Language, and Hearing Sciences, United States.
| | | | - Valerie Phan Brown
- University of Arizona, Department of Speech, Language, and Hearing Sciences, United States
| | - Hallie Nitido
- University of Arizona, Department of Speech, Language, and Hearing Sciences, United States
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13
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Boswell-Ruys CL, Lewis C, McBain RA, Gandevia SC, Butler JE. The reliability of inspiratory resistive load magnitude and detection testing. Respir Physiol Neurobiol 2020; 281:103490. [PMID: 32712538 DOI: 10.1016/j.resp.2020.103490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/21/2020] [Accepted: 07/05/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To assess the test-retest reliability of inspiratory load detection and load magnitude perception tests in healthy volunteers. DESIGN Cohort of convenience. SETTING Respiratory physiology laboratory. PARTICIPANTS Twenty healthy adults. INTERVENTIONS On two separate occasions participants performed tests of inspiratory loading. Participants breathed through custom made resistive tubing and were asked to indicate when they detected a different resistance during inspiration. In a second test participants rated the magnitude of presented inspiratory loads using the modified Borg score. MAIN OUTCOME MEASURES Intra-class Correlation Coefficient (ICC2,1) values for repeated tests of inspiratory load detection threshold and load magnitude rating. RESULTS ICC2,1 values ranged from 0.657-0.786 for load detection testing and 0.739 to 0.969 for rating of load magnitude. CONCLUSIONS The tests are simple and reliable measures of inspiratory load detection and magnitude rating. They can be used in future research to determine the effectiveness of interventions to reduce the effort of breathing in health and disease.
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Affiliation(s)
- Claire L Boswell-Ruys
- Neuroscience Research Australia, Randwick, 2031, Australia; University of New South Wales, Sydney, 2052, Australia; Prince of Wales Hospital, Randwick, 2031, Australia.
| | - Chaminda Lewis
- Neuroscience Research Australia, Randwick, 2031, Australia; University of New South Wales, Sydney, 2052, Australia; Prince of Wales Hospital, Randwick, 2031, Australia
| | - Rachel A McBain
- Neuroscience Research Australia, Randwick, 2031, Australia; University of New South Wales, Sydney, 2052, Australia
| | - Simon C Gandevia
- Neuroscience Research Australia, Randwick, 2031, Australia; University of New South Wales, Sydney, 2052, Australia; Prince of Wales Hospital, Randwick, 2031, Australia
| | - Jane E Butler
- Neuroscience Research Australia, Randwick, 2031, Australia; University of New South Wales, Sydney, 2052, Australia
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14
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Basoudan N, Rodrigues A, Gallina A, Garland J, Guenette JA, Shadgan B, Road J, Reid WD. Scalene and sternocleidomastoid activation during normoxic and hypoxic incremental inspiratory loading. Physiol Rep 2020; 8:e14522. [PMID: 32726513 PMCID: PMC7389984 DOI: 10.14814/phy2.14522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/02/2022] Open
Abstract
The purpose of this study was to examine scalene (SA) and sternocleidomastoid (SM) activation during normoxic (norm-ITL; FIO2 = 21%) and hypoxic (hyp-ITL; FIO2 = 15%) incremental inspiratory threshold loading (ITL). Thirteen healthy participants (33 ± 4 years, 9 female) performed two ITL tests breathing randomly assigned gas mixtures through an inspiratory loading device where the load was increased every two minutes until task failure. SA and SM root mean square (RMS) electromyography (EMG) were calculated and expressed as a percentage of maximum (RMS%max ) to reflect muscle activation intensity. Myoelectric manifestations of fatigue were characterized as decreased SA or SM EMG median frequency during maximum inspiratory pressure maneuvers before and after ITL. Dyspnea was recorded at baseline and task failure. Ventilatory parameters and mouth pressure (Pm) were recorded throughout the ITL. SA,RMS%max and SM,RMS%max increased in association with ITL load (p ≤ .01 for both). SA,RMS%max was similar between norm-ITL and hyp-ITL (p = .17), whereas SM,RMS%max was greater during the latter (p = .001). Neither SA nor SM had a decrease in EMG median frequency after ITL (p = .75 and 0.69 respectively). Pm increased in association with ITL load (p < .001) and tended to be higher during hyp-ITL compared to norm-ITL (p = .05). Dyspnea was similar during both conditions (p > .05). There was a trend for higher tidal volumes during hyp-ITL compared to norm-ITL (p = .10). Minute ventilation was similar between both conditions (p = .23). RMS,%max of the SA and SM increased linearly with increasing ITL. The presence of hypoxia only increased SM activation. Neither SA nor SM presented myoelectric manifestations of fatigue during both conditions.
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Affiliation(s)
- Nada Basoudan
- Department of Physical TherapyUniversity of British Columbia (UBC)VancouverBCCanada
- College of Health and Rehabilitation SciencesPrincess Nourah bint Abdulrhaman UniversityRiyadhSaudi Arabia
| | | | - Alessio Gallina
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine)School of Sport, Exercise and Rehabilitation SciencesCollege of Life and Environmental SciencesUniversity of BirminghamBirminghamUK
| | - Jayne Garland
- Faculty of Health SciencesWestern UniversityLondonONCanada
| | - Jordan A. Guenette
- Department of Physical TherapyUniversity of British Columbia (UBC)VancouverBCCanada
- Centre for Heart Lung InnovationUBC and St. Paul's HospitalVancouverBCCanada
| | - Babak Shadgan
- International Collaboration on Repair DiscoveriesVancouverBCCanada
| | - Jeremy Road
- Division of Respiratory MedicineDepartment of MedicineUniversity of British Columbia (UBC)VancouverBCCanada
| | - W. Darlene Reid
- Physical TherapyUniversity of TorontoTorontoONCanada
- KITEToronto RehabTorontoONCanada
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoONCanada
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Abstract
PURPOSE OF REVIEW In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management. RECENT FINDINGS As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report. SUMMARY Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.
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16
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5-HT neurons and central CO2 chemoreception. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/b978-0-444-64125-0.00021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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17
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Maksimović Ž, Banjac N, Čović M. Significance of Dyspnoea as a symptom in the Emergency Department of the Primary Healthcare Centre. SCRIPTA MEDICA 2020. [DOI: 10.5937/scriptamed51-26726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background/Aim: Dyspnoea represents a subjective feeling of laboured breathing of different intensity. The aim of this study was to determine how often patients come with dyspnoea to a local Emergency Department of the Primary Healthcare Centre (EDPHC) and to analyse the assumed aetiology, diagnostics and therapy of the dyspnoeic patients. Methods: The records of the EDPHC of the City of Banja Luka for the period between 1 October 2019 to 31 December 2019 of all patients older than 15 years of age that have reported laboured breathing were identified and analysed. Following parameters were recorded: age, gender, diagnostics performed, administered therapy, whether the patient was examined in the field or in the ambulance, as well as whether the patient was referred to a hospital (Cardiology, Pulmonology or another department) or not. Results: Laboured breathing was reported by 665 patients. Out of this number, 108 patients were examined by their family doctor, 407 patients in EDPHC ambulance and 150 patients in the field. The average age of the patient was 61.03 ± 19.17, with an equal distribution in males and females. The aetiology of dyspnoea was cardiac and pulmonary in one-third of patients each, whereas the diagnosis in the other patients was versatile, from anxiety disorders, musculoskeletal diseases and active malignancy to unspecified chest pain that could not receive a definitive diagnosis. One half of the patients (N = 261 or 46.86 %) was completely taken care of in the ambulance or in the field, 199 (35.73 %) patients were sent to a cardiologist, 87 (15.62 %) to a pulmonologist and 10 (1.80 %) of patients to another specialist. Referral to hospital was registered more often in men (ch2 = 9.195, p = 0.027), elderly (ch2 = 53.29, p < 0.001), people with lower peripheral oxygen saturation (SpO2 ) (ch2 = 120.61, p < 0.001) and people with significant deviation of normal blood pressure values (ch2 = 120.61, p < 0.001). Conclusion: Dyspnoea can be caused by an array of different diseases and more than one diagnostic method is necessary to confirm/exclude any of the most common causes of dyspnoea. A broader diagnostical palette in ED would be preferred for purposes of ascertaining a timely diagnosis.
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18
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A Multidimensional Profile of Dyspnea in Hospitalized Patients. Chest 2019; 156:507-517. [PMID: 31128117 DOI: 10.1016/j.chest.2019.04.128] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Dyspnea is prevalent among hospitalized patients but little is known about the experience of dyspnea among inpatients. We sought to characterize the multiple sensations and associated emotions of dyspnea in patients admitted with dyspnea to a tertiary care hospital. METHODS We selected patients who reported breathing discomfort of at least 4/10 on admission (10 = unbearable). Research staff recruited 156 patients within 24 hours of admission and evaluated daily patients' current and worst dyspnea with the Multidimensional Dyspnea Profile; patients participated in the study 2.6 days on average. The Multidimensional Dyspnea Profile assesses overall breathing discomfort (A1), intensity of five sensory qualities of dyspnea, and 5 negative emotional responses to dyspnea. Patients were also asked to rate whether current levels of dyspnea were "acceptable." RESULTS At the time of the first research interview, patients reported slight to moderate dyspnea (A1 median 4); however, most patients reported experiencing severe dyspnea in the 24 hours before the interview (A1 mean 7.8). A total of 54% of patients with dyspnea ≥4 on day 1 found the symptom unacceptable. The worst dyspnea each day in the prior 24 hours usually occurred at rest. Dyspnea declined but persisted through hospitalization for most patients. "Air hunger" was the dominant sensation, especially when dyspnea was strong (>4). Anxiety and frustration were the dominant emotions associated with dyspnea. CONCLUSIONS This first multidimensional portrait of dyspnea in a general inpatient population characterizes the sensations and emotions dyspneic patients endure. The finding that air hunger is the dominant sensation of severe dyspnea has implications for design of laboratory models of these sensations and may have implications for targets of palliation of symptoms.
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Neder JA, Marillier M, Bernard AC, James MD, Milne KM, O’Donnell DE. The Integrative Physiology of Exercise Training in Patients with COPD. COPD 2019; 16:182-195. [DOI: 10.1080/15412555.2019.1606189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- J. Alberto Neder
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
| | - Mathieu Marillier
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
| | - Anne-Catherine Bernard
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
| | - Matthew D. James
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
| | - Kathryn M. Milne
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
- Clinician Investigator Program, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denis E. O’Donnell
- Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Division of Respirology, Department of Medicine, Kingston Health Science Center and Queen’s University, Kingston, Ontario, Canada
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Grogono JC, Butler C, Izadi H, Moosavi SH. Inhaled furosemide for relief of air hunger versus sense of breathing effort: a randomized controlled trial. Respir Res 2018; 19:181. [PMID: 30236110 PMCID: PMC6148783 DOI: 10.1186/s12931-018-0886-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/10/2018] [Indexed: 01/25/2023] Open
Abstract
Background Inhaled furosemide offers a potentially novel treatment for dyspnoea, which may reflect modulation of pulmonary stretch receptor feedback to the brain. Specificity of relief is unclear because different neural pathways may account for different components of clinical dyspnoea. Our objective was to evaluate if inhaled furosemide relieves the air hunger component (uncomfortable urge to breathe) but not the sense of breathing work/effort of dyspnoea. Methods A randomised, double blind, placebo-controlled crossover trial in 16 healthy volunteers studied in a university research laboratory. Each participant received 3 mist inhalations (either 40 mg furosemide or 4 ml saline) separated by 30–60 min on 2 test days. Each participant was randomised to mist order ‘furosemide-saline-furosemide’ (n- = 8) or ‘saline-furosemide-saline’ (n = 8) on both days. One day involved hypercapnic air hunger tests (mean ± SD PCO2 = 50 ± 3.7 mmHg; constrained ventilation = 9 ± 1.5 L/min), the other involved work/effort tests with targeted ventilation (17 ± 3.1 L/min) and external resistive load (20cmH2O/L/s). Primary outcome was ratings of air hunger or work/effort every 15 s on a visual analogue scale. During saline inhalations, 1.5 mg furosemide was infused intravenously to match the expected systemic absorption from the lungs when furosemide is inhaled. Corresponding infusions of saline during furosemide inhalations maintained procedural blinding. Average visual analogue scale ratings (%full scale) during the last minute of air hunger or work/effort stimuli were analysed using Linear Mixed Methods. Results Data from all 16 participants were analysed. Inhaled furosemide relative to inhaled saline significantly improved visual analogues scale ratings of air hunger (Least Squares Mean ± SE − 9.7 ± 2%; p = 0.0015) but not work/effort (+ 1.6 ± 2%; p = 0.903). There were no significant adverse events. Conclusions Inhaled furosemide was effective at relieving laboratory induced air hunger but not work/effort in healthy adults; this is consistent with the notion that modulation of pulmonary stretch receptor feedback by inhaled furosemide leads to dyspnoea relief that is specific to air hunger, the most unpleasant quality of dyspnoea. Funding Oxford Brookes University Central Research Fund. Trial registration ClinicalTrials.gov Identifier: NCT02881866. Retrospectively registered on 29th August 2018.
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Affiliation(s)
- Joanna C Grogono
- Department of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0BP, UK.
| | - Clare Butler
- Department of Nursing, Oxford Brookes University, Marston Road Site, Oxford, OX3 0FL, UK
| | - Hooshang Izadi
- School of Engineering, Computing and Mathematics, Oxford Brookes University, Wheatley Campus, Wheatley, Oxford, OX33 1HX, UK
| | - Shakeeb H Moosavi
- Department of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0BP, UK
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21
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Abstract
Dyspnea is a subjective experience of breathing discomfort that can only be known through a patient's report. Numeric rating or visual analog scales allow assessment of intensity when the patient can self-report. The Respiratory Distress Observation Scale is a valid, reliable tool for estimating distress when self-report cannot be elicited. Treating dyspnea begins with managing the underlying condition. Other dyspnea-specific evidence-based interventions include morphine and fentanyl, upright positioning, oxygen, invasive and noninvasive ventilation, and balancing rest with activity. Effectiveness has not been established for benzodiazepines, nebulized furosemide, oxygen in the face of normoxemia, other opioids, and nebulized fentanyl.
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22
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Müller CJT, Quintino-dos-Santos JW, Schimitel FG, Tufik S, Beijamini V, Canteras NS, Schenberg LC. On the verge of a respiratory-type panic attack: Selective activations of rostrolateral and caudoventrolateral periaqueductal gray matter following short-lasting escape to a low dose of potassium cyanide. Neuroscience 2017; 348:228-240. [DOI: 10.1016/j.neuroscience.2017.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 12/05/2016] [Accepted: 02/12/2017] [Indexed: 10/20/2022]
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23
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Ambrosino N, Serradori M. Determining the cause of dyspnoea: linguistic and biological descriptors. Chron Respir Dis 2016; 3:117-22. [PMID: 16916005 DOI: 10.1191/1479972306cd110ra] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Dyspnoea is the most common symptom of patients with cardio-respiratory diseases. It is a generic term related to different pathophysiological abnormalities that may result in different qualities of respiratory discomfort, defined by specific verbal descriptors for a specific diagnosis. Often it is difficult to distinguish the underlying pathology of dyspnoea, eg, either from chronic heart failure (CHF) or from other respiratory causes. The discovery of the endocrine function of the heart, as well as the development of accurate and feasible assay methods allow the use of cardiac natriuretic hormones in the assessment of cardiovascular diseases, namely acute coronary syndromes and heart failure. It is advisable to measure cardiac natriuretic hormones in order to exclude or suggest the diagnosis of CHF in patients with a suspicious diagnosis, but with ambiguous signs and symptoms or manifestations that can be confused with other pathologies (like chronic obstructive pulmonary disease). The most common symptom of patients with cardio-respiratory diseases is dyspnoea, a 'difficult, laboured, uncomfortable breathing'. Dyspnoea has been defined as 'a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioural responses'. Breathlessness is characterized by measurable intensity and qualitative dimensions, which may vary depending on the individual, the underlying disease, and other circumstances.3 The neurophysiological basis of dyspnoea relies on receptors in the airways lung parenchyma, respiratory muscles together with chemoreceptors providing sensory feedback via vagal, phrenic and intercostal nerves to the spinal cord, medulla and higher centres. Breathlessness is based on different pathophysiolagical abnormalities that may result in different qualities of respiratory discomfort, which are defined by specific verbal descriptors related to a specific diagnosis. Nevertheless different diseases may share the same descriptors. There is no clear relationship between the qualitative descriptors of dyspnoea and the quantitative intensity among the patient groups: different diseases may be distinguished by quality but not intensity of the sensation. Differences in languages, in races, cultures, gender, and in the manner in which concepts or symptoms are held can all influence the idea, quality and intensity of dyspnoea.
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O'Donnell DE, Webb KA, Harle I, Neder JA. Pharmacological management of breathlessness in COPD: recent advances and hopes for the future. Expert Rev Respir Med 2016; 10:823-34. [PMID: 27115291 DOI: 10.1080/17476348.2016.1182867] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Activity-related breathlessness is often the dominant symptom in patients with chronic obstructive pulmonary disease (COPD) and usually persists despite optimal medical therapy. Currently, our inability to meaningfully alter the pathophysiology of the underlying disease means that we must focus our attention on relieving this distressing symptom so as to improve exercise tolerance and quality of life. AREAS COVERED The current review examines the neurobiology of breathlessness and constructs a solid physiological rationale for amelioration of this distressing symptom. We will examine the efficacy of interventions which: 1) reduce the increased central drive to breathe (opioids); 2) improve the respiratory system's ability to appropriately respond to this increased demand (bronchodilators); and 3) address the important affective dimension of breathlessness (anxiolytics). Expert commentary: Advances in our understanding of the mechanisms of activity-related breathlessness in COPD, and its measurement in the clinical domain, now set the stage for the development of effective management strategies on an individual patient basis.
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Affiliation(s)
- Denis E O'Donnell
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - Katherine A Webb
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - Ingrid Harle
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - J Alberto Neder
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
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Unverdorben M, Parodi G, Pistolesi M, Storey RF. Dyspnea related to reversibly-binding P2Y12 inhibitors: A review of the pathophysiology, clinical presentation and diagnostics. Int J Cardiol 2015; 202:167-73. [PMID: 26386945 DOI: 10.1016/j.ijcard.2015.08.162] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 08/13/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
Dyspnea is a common symptom physiologically associated with strenuous exercise and pathologically reflecting well-known diseases and conditions that are predominantly pulmonary, cardiovascular, and weight-related in origin. Dyspnea improves with appropriate measures that enhance physical performance and treatment of the underlying diseases. Dyspnea is less commonly triggered by other causes such as the environment (e.g., ozone), drugs, and others, some of which do not seem to affect bronchopulmonary function as evidenced by normal results of comprehensive pulmonary function testing. In cardiovascular medicine, dyspnea has recently attracted attention because it has been reported that this symptom occurs more frequently with the administration of the new oral reversibly-binding platelet P2Y12 receptor inhibitors ticagrelor [1-6], cangrelor [7-10], and elinogrel [11]. This paper succinctly addresses the current understanding of the pathophysiology, clinical presentation, and diagnostics of dyspnea, associated either with bronchopulmonary function impairment, as triggered mainly by pulmonary and cardiovascular diseases, or without bronchopulmonary function impairment, as induced by endogenous or external compounds such as drugs in order to provide a context for understanding, recognizing and managing P2Y12 inhibitor-induced dyspnea.
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Affiliation(s)
- Martin Unverdorben
- Clinical Research Institute, Center for Cardiovascular Diseases, Academic Teaching Institution of the Goethe-University Frankfurt/Main, Rotenburg an der Fulda, Germany.
| | - Guido Parodi
- Department of Cardiology, Careggi Hospital, Florence, Italy
| | - Massimo Pistolesi
- Department of Experimental and Clinical Medicine, Respiratory Medicine, University of Florence, Italy
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
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Abstract
Dyspnea consists of various uncomfortable respiratory sensations. It is believed that hypoxia causes dyspnea, but whether hypoxia is a direct dyspnogenic factor remains uncertain. We investigated whether hypoxia has a direct dyspnogenic effect. We evaluated changes in vital signs, arterial blood gases, SaO2, CaO2, Borg scale, and Mini-Mental State Examination in seven mountain climbers by using a hypobaric hypoxic chamber in which the barometric pressure was lowered to the simulated altitude of 4500 m. PaO2 and CaO2 both decreased significantly as the simulated altitude increased. On the other hand, Borg scale score which reflects dyspnea showed no significant difference. At the simulated altitude of 4500 m, Borg scale score was 1.5 ± 1.2 (mean ± SD), despite the presence of absolute hypoxia (PaO2, 46.8 ± 8.3T; CaO2, 16.4 ± 0.6 mL/dL). These results suggest that hypoxia is not a direct dyspnogenic factor in healthy individuals capable of breathing without restriction at rest.
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Translational approach to studying panic disorder in rats: hits and misses. Neurosci Biobehav Rev 2015; 46 Pt 3:472-96. [PMID: 25316571 DOI: 10.1016/j.neubiorev.2014.10.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/26/2014] [Accepted: 10/01/2014] [Indexed: 12/30/2022]
Abstract
Panic disorder (PD) patients are specifically sensitive to 5–7% carbon dioxide. Another startling feature of clinical panic is the counterintuitive lack of increments in ‘stress hormones’. PD is also more frequent in women and highly comorbid with childhood separation anxiety (CSA). On the other hand, increasing evidence suggests that panic is mediated at dorsal periaqueductal grey matter (DPAG). In line with prior studies showing that DPAG-evoked panic-like behaviours are attenuated by clinically-effective treatments with panicolytics, we show here that (i) the DPAG harbors a hypoxia-sensitive alarm system, which is activated by hypoxia and potentiated by hypercapnia, (ii) the DPAG suffocation alarm system is inhibited by clinically-effective treatments with panicolytics, (iii) DPAG stimulations do not increase stress hormones in the absence of physical exertion, (iv) DPAG-evoked panic-like behaviours are facilitated in neonatally-isolated adult rats, a model of CSA, and (v) DPAG-evoked responses are enhanced in the late diestrus of female rats. Data are consistent with the DPAG mediation of both respiratory and non-respiratory types of panic attacks.
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Banzett RB, O'Donnell CR, Guilfoyle TE, Parshall MB, Schwartzstein RM, Meek PM, Gracely RH, Lansing RW. Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research. Eur Respir J 2015; 45:1681-91. [PMID: 25792641 PMCID: PMC4450151 DOI: 10.1183/09031936.00038914] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/19/2014] [Indexed: 12/02/2022]
Abstract
There is growing awareness that dyspnoea, like pain, is a multidimensional experience, but measurement instruments have not kept pace. The Multidimensional Dyspnea Profile (MDP) assesses overall breathing discomfort, sensory qualities, and emotional responses in laboratory and clinical settings. Here we provide the MDP, review published evidence regarding its measurement properties and discuss its use and interpretation. The MDP assesses dyspnoea during a specific time or a particular activity (focus period) and is designed to examine individual items that are theoretically aligned with separate mechanisms. In contrast, other multidimensional dyspnoea scales assess recalled recent dyspnoea over a period of days using aggregate scores. Previous psychophysical and psychometric studies using the MDP show that: 1) subjects exposed to different laboratory stimuli could discriminate between air hunger and work/effort sensation, and found air hunger more unpleasant; 2) the MDP immediate unpleasantness scale (A1) was convergent with common dyspnoea scales; 3) in emergency department patients, two domains were distinguished (immediate perception, emotional response); 4) test–retest reliability over hours was high; 5) the instrument responded to opioid treatment of experimental dyspnoea and to clinical improvement; 6) convergent validity with common instruments was good; and 7) items responded differently from one another as predicted for multiple dimensions. The Multidimensional Dyspnea Profile provides a unified, reliable instrument for both clinical and laboratory researchhttp://ow.ly/Ix8ic
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Carl R O'Donnell
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Tegan E Guilfoyle
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark B Parshall
- College of Nursing, University of New Mexico, Albuquerque, NM, USA
| | - Richard M Schwartzstein
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Paula M Meek
- College of Nursing, University of Colorado, Denver, Aurora, CO, USA
| | - Richard H Gracely
- Department of Endodontics, UNC School of Dentistry, Center for Neurosensory Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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SEINO T, MASAOKA Y, INAGAKI K, IZUMIZAKI M. Breathlessness-related Brain Activation: Electroencephalogram Dipole Modeling Analysis. ACTA ACUST UNITED AC 2015. [DOI: 10.15369/sujms.27.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Taketoshi SEINO
- Department of Physiology, Showa University School of Medicine
- Department of Orthopaedic Surgery, Showa University School of Medicine
| | - Yuri MASAOKA
- Department of Physiology, Showa University School of Medicine
| | - Katsunori INAGAKI
- Department of Orthopaedic Surgery, Showa University School of Medicine
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31
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Abstract
Sensory nerves innervating the lung and airways play an important role in regulating various cardiopulmonary functions and maintaining homeostasis under both healthy and disease conditions. Their activities conducted by both vagal and sympathetic afferents are also responsible for eliciting important defense reflexes that protect the lung and body from potential health-hazardous effects of airborne particulates and chemical irritants. This article reviews the morphology, transduction properties, reflex functions, and respiratory sensations of these receptors, focusing primarily on recent findings derived from using new technologies such as neural immunochemistry, isolated airway-nerve preparation, cultured airway neurons, patch-clamp electrophysiology, transgenic mice, and other cellular and molecular approaches. Studies of the signal transduction of mechanosensitive afferents have revealed a new concept of sensory unit and cellular mechanism of activation, and identified additional types of sensory receptors in the lung. Chemosensitive properties of these lung afferents are further characterized by the expression of specific ligand-gated ion channels on nerve terminals, ganglion origin, and responses to the action of various inflammatory cells, mediators, and cytokines during acute and chronic airway inflammation and injuries. Increasing interest and extensive investigations have been focused on uncovering the mechanisms underlying hypersensitivity of these airway afferents, and their role in the manifestation of various symptoms under pathophysiological conditions. Several important and challenging questions regarding these sensory nerves are discussed. Searching for these answers will be a critical step in developing the translational research and effective treatments of airway diseases.
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Affiliation(s)
- Lu-Yuan Lee
- Department of Physiology, University of Kentucky, Lexington, Kentucky
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Binks AP, Evans KC, Reed JD, Moosavi SH, Banzett RB. The time-course of cortico-limbic neural responses to air hunger. Respir Physiol Neurobiol 2014; 204:78-85. [PMID: 25263029 DOI: 10.1016/j.resp.2014.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/09/2014] [Accepted: 09/11/2014] [Indexed: 01/30/2023]
Abstract
Several studies have mapped brain regions associated with acute dyspnea perception. However, the time-course of brain activity during sustained dyspnea is unknown. Our objective was to determine the time-course of neural activity when dyspnea is sustained. Eight healthy subjects underwent brain blood oxygen level dependent functional magnetic imaging (BOLD-fMRI) during mechanical ventilation with constant mild hypercapnia (∼ 45 mm Hg). Subjects rated dyspnea (air hunger) via visual analog scale (VAS). Tidal volume (V(T)) was alternated every 90 s between high VT (0.96 ± 0.23 L) that provided respiratory comfort (12 ± 6% full scale) and low V(T) (0.48 ± 0.08 L) which evoked air hunger (56 ± 11% full scale). BOLD signal was extracted from a priori brain regions and combined with VAS data to determine air hunger related neural time-course. Air hunger onset was associated with BOLD signal increases that followed two distinct temporal profiles within sub-regions of the anterior insula, anterior cingulate and prefrontal cortices (cortico-limbic circuitry): (1) fast, BOLD signal peak <30s and (2) slow, BOLD signal peak >40s. BOLD signal during air hunger offset followed fast and slow temporal profiles symmetrical, but inverse (signal decreases) to the time-courses of air hunger onset. We conclude that differential cortico-limbic circuit elements have unique contributions to dyspnea sensation over time. We suggest that previously unidentified sub-regions are responsible for either the acute awareness or maintenance of dyspnea. These data enhance interpretation of previous studies and inform hypotheses for future dyspnea research.
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Affiliation(s)
- Andrew P Binks
- Department of Biomedical Sciences, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Karleyton C Evans
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Jeffrey D Reed
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Shakeeb H Moosavi
- Department of Biological and Medical Sciences, Oxford Brookes University, Oxford, UK
| | - Robert B Banzett
- Harvard Medical School, Boston, MA, USA; Division Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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HRV Analysis: A Clinical and Diagnostic Tool in Chronic Obstructive Pulmonary Disease. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:673232. [PMID: 27433490 PMCID: PMC4897192 DOI: 10.1155/2014/673232] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/20/2014] [Indexed: 12/27/2022]
Abstract
This study's aim is to analyze heart rate dynamics in subjects with chronic obstructive pulmonary disease (COPD) by measures of heart rate variability (HRV). HRV is a simple and noninvasive measure of autonomic impulses. 38 adults were divided into two equal groups based on respiratory function: COPD and normal. HRV was monitored in the supine position for 30 minutes. After tests of normality, Kruskal-Wallis was used for the statistical analysis, with the level of significance set at P < 0.05. Principal component analysis identified two components representing 99.5% of total variance. Furthermore, it is suggested that the chaos forward parameter (CFP) which applies all three “chaotic globals” is the most influential, although others are statistically more significant. The COPD subjects exhibited a decrease in the CFP. COPD can be termed a dynamical condition, decreasing the chaotic response. The perceived benefits of such analysis include quantitative assessment and suitable pharmacological intervention in the respiratory condition, especially of other related dynamical diseases such as cardiac failure.
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Dangers L, Morelot-Panzini C, Schmidt M, Demoule A. Mécanismes neurophysiologiques de la dyspnée : de la perception à la clinique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0902-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Booth S, Bausewein C, Higginson I, Moosavi SH. Pharmacological treatment of refractory breathlessness. Expert Rev Respir Med 2014; 3:21-36. [DOI: 10.1586/17476348.3.1.21] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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37
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Schmidt M, Banzett RB, Raux M, Morélot-Panzini C, Dangers L, Similowski T, Demoule A. Unrecognized suffering in the ICU: addressing dyspnea in mechanically ventilated patients. Intensive Care Med 2013; 40:1-10. [PMID: 24132382 DOI: 10.1007/s00134-013-3117-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/15/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to the detection and treatment of dyspnea (defined as "breathing discomfort"). METHODS Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed. RESULTS/CONCLUSIONS Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings. CONCLUSIONS Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols.
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Henke MO, Vogelmeier CF. [Heart and lungs : cardinal symptom dyspnea]. Herz 2013; 38:279-90. [PMID: 23615840 DOI: 10.1007/s00059-013-3800-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Dyspnea is one of the major clinical symptoms which patients report to general practitioners, internists, cardiologists and hospitals. In this review article we discuss the evidence of medical history, laboratory procedures and diagnostic investigations to approach patients with acute or chronic dyspnea and try to structure this complex symptom dyspnea to reach the etiology of the underlying disease.
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Affiliation(s)
- M O Henke
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, UKGM Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland.
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40
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Schmidt M, Raux M, Morelot-Panzini C, Similowski T, Demoule A. Dyspnée au cours de l’assistance ventilatoire mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0534-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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41
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Nishino T, Ishikawa T, Nozaki-Taguchi N, Isono S. Lung/chest expansion contributes to generation of pleasantness associated with dyspnoea relief. Respir Physiol Neurobiol 2012; 184:27-34. [PMID: 22828247 DOI: 10.1016/j.resp.2012.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/13/2012] [Accepted: 07/13/2012] [Indexed: 11/16/2022]
Abstract
Pleasantness associated with dyspnoea relief or 'respiratory pleasure' is considered as a particular sensory experience. The purpose of this study is to elucidate the mechanism of generation of this particular sensory experience. After taking deep breaths during normal breathing, 35 healthy subjects received three different magnitudes of inspiratory loads (light: 8.4; moderate: 23.4; severe: 70.5 cm H2O/L/s) to induce dyspnoeic sensation. We found that (1) deep breaths during normal breathing rarely induce 'respiratory pleasure', (2) a sudden removal of dyspnoea alone is not sufficient to produce 'respiratory pleasure', and (3) the generation of 'respiratory pleasure' can be observed when a sudden removal of dyspnoea accompanies a large increase in tidal volume (V(T)). In addition, qualitative assessment of 'respiratory pleasure' showed that this sensation is compatible with a strong, positively valenced sensation. These findings indicate that an increase in V(T) after removal of respiratory loading plays a crucial role in generation of 'respiratory pleasure' that is a specific sensory-emotional experience.
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Affiliation(s)
- Takashi Nishino
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, 1-8-1 Inohanacho, Chiba, Japan.
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42
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Hallenbeck J. Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death? J Palliat Med 2012; 15:848-53. [DOI: 10.1089/jpm.2011.0167] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- James Hallenbeck
- School of Medicine, Department of Medicine, Division of General Medical Disciplines, Stanford University, Stanford, California
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Teixeira CA, Rodrigues Júnior AL, Straccia LC, Vianna EDSO, Silva GAD, Martinez JAB. Dyspnea descriptors developed in Brazil: application in obese patients and in patients with cardiorespiratory diseases. J Bras Pneumol 2012; 37:446-54. [PMID: 21881734 DOI: 10.1590/s1806-37132011000400006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/09/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To develop a set of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) for use in Brazil and to investigate the usefulness of these descriptors in four distinct clinical conditions that can be accompanied by dyspnea. METHODS We collected 111 dyspnea descriptors from 67 patients and 10 health professionals. These descriptors were analyzed and reduced to 15 based on their frequency of use, similarity of meaning, and potential pathophysiological value. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. RESULTS The use of this set of descriptors led to a solution with seven clusters, designated sufoco (suffocating), aperto (tight), rápido (rapid), fadiga (fatigue), abafado (stuffy), trabalho/inspiração (work/inhalation), and falta de ar (shortness of breath). Overlapping of descriptors was quite common among the patients, regardless of their clinical condition. Asthma was significantly associated with the sufoco and trabalho/inspiração clusters, whereas COPD and heart failure were associated with the sufoco, trabalho/inspiração, and falta de ar clusters. Obesity was associated only with the falta de ar cluster. CONCLUSIONS In Brazil, patients who are accustomed to perceiving dyspnea employ various descriptors in order to describe the symptom, and these descriptors can be grouped into similar clusters. In our study sample, such clusters showed no usefulness in differentiating among the four clinical conditions evaluated.
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Affiliation(s)
- Christiane Aires Teixeira
- Department of Clinical Medicine, University of São Paulo at Ribeirão Preto School of Medicine – Ribeirão Preto, Brazil
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Abstract
Current definition of asthma involves four cornerstones: inflammation, hyperresponsiveness, bronchoconstriction, and symptoms. In research, the symptoms have had the slightest attention. According to international guidelines, the asthma symptoms are episodic breathlessness, wheeze, cough, tightness of the chest, and shortness of breath. As there are several symptoms, a primary question is how they are related to bronchoconstriction, the main clinical feature of asthma. Symptoms and lung function tests are regularly used for the evaluation of clinical health status and effect of treatment. However, there is no or poor correlation between these two variables, which means that they represent different mechanisms. Reduced lung function, such as a low FEV(1) , represents bronchial constriction, what do the symptoms represent? Some symptoms such as breathlessness and shortness of breath seem not to be evidence-based asthma symptoms. Focusing on bronchial obstruction is important in view of the potential risk of asthma attacks, but nonobstructive symptoms occur frequently and may also cause severe discomfort and poor quality of life. Interpreting all symptoms as signs of bronchoconstriction (asthma) may lead to misinterpretation when assessing health status and effect of treatment. Although a 'soft' variable, the strength of symptoms is that they are representing various mechanisms. The physiological preconditions for control and defense of respiration must be considered in the diagnostic process, regardless of inflammation, allergy, psychology, or other etiological factors. Based on studies on dyspnea in cardiopulmonary diseases, including asthma and asthma-like disorders, there seems to be a continuous spectrum of symptoms and mechanisms integrated in a single asthma syndrome.
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Affiliation(s)
- O. Löwhagen
- Sahlgrenska Academy; Instit Medicine; University of Göteborg; Sweden
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435-52. [PMID: 22336677 PMCID: PMC5448624 DOI: 10.1164/rccm.201111-2042st] [Citation(s) in RCA: 1098] [Impact Index Per Article: 91.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012. [PMID: 22336677 DOI: 10.1164/rccm.201111–2042st] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Banzett RB, Adams L, O'Donnell CR, Gilman SA, Lansing RW, Schwartzstein RM. Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response. Am J Respir Crit Care Med 2011; 184:920-7. [PMID: 21778294 PMCID: PMC3208656 DOI: 10.1164/rccm.201101-0005oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 07/06/2011] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Opioids are commonly used to relieve dyspnea, but clinical data are mixed and practice varies widely. OBJECTIVES Evaluate the effect of morphine on dyspnea and ventilatory drive under well-controlled laboratory conditions. METHODS Six healthy volunteers received morphine (0.07 mg/kg) and placebo intravenously on separate days (randomized, blinded). We measured two responses to a CO(2) stimulus: (1) perceptual response (breathing discomfort; described by subjects as "air hunger") induced by increasing partial pressure of end-tidal carbon dioxide (Pet(CO2)) during restricted ventilation, measured with a visual analog scale (range, "neutral" to "intolerable"); and (2) ventilatory response, measured in separate trials during unrestricted breathing. MEASUREMENTS AND MAIN RESULTS We determined the Pet(CO2) that produced a 60% breathing discomfort rating in each subject before morphine (median, 8.5 mm Hg above resting Pet(CO2)). At the same Pet(CO2) after morphine administration, median breathing discomfort was reduced by 65% of its pretreatment value; P < 0.001. Ventilation fell 28% at the same Pet(CO2); P < 0.01. The effect of morphine on breathing discomfort was not significantly correlated with the effect on ventilatory response. Placebo had no effect. CONCLUSIONS (1) A moderate morphine dose produced substantial relief of laboratory dyspnea, with a smaller reduction of ventilation. (2) In contrast to an earlier laboratory model of breathing effort, this laboratory model of air hunger established a highly significant treatment effect consistent in magnitude with clinical studies of opioids. Laboratory studies require fewer subjects and enable physiological measurements that are difficult to make in a clinical setting. Within-subject comparison of the response to carefully controlled laboratory stimuli can be an efficient means to optimize treatments before clinical trials.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
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Yashiro E, Nozaki-Taguchi N, Isono S, Nishino T. Effects of different forms of dyspnoea on pain perception induced by cold-pressor test. Respir Physiol Neurobiol 2011; 177:320-6. [DOI: 10.1016/j.resp.2011.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 05/11/2011] [Accepted: 05/12/2011] [Indexed: 10/18/2022]
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Parshall MB, Carle AC, Ice U, Taylor R, Powers J. Validation of a three-factor measurement model of dyspnea in hospitalized adults with heart failure. Heart Lung 2011; 41:44-56. [PMID: 21794918 DOI: 10.1016/j.hrtlng.2011.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 04/28/2011] [Accepted: 05/06/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to validate a 3-factor measurement model of dyspnea sensory quality (WORK-EFFORT, TIGHTNESS, SMOTHERING-AIR HUNGER) originally derived in patients with exacerbated chronic obstructive pulmonary disease. METHODS In this validation study, adult patients with heart failure were enrolled after hospital admission (median hospital day 1) and asked to rate the intensity of dyspnea sensory quality descriptors on the day of enrollment (study day 1; N = 119) and in a recall version for the day of admission (study day 0; n = 97). RESULTS Confirmatory factor analysis demonstrated good model fit for both days. Cronbach's α for each factor was greater than .87 for both study days. CONCLUSION This is the first study to validate a previously specified measurement model of dyspnea sensory quality in an independent sample. Results indicate that measurement of dyspnea sensory quality in exacerbated cardiopulmonary disease does not necessarily require disease-specific questionnaires.
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Affiliation(s)
- Mark B Parshall
- College of Nursing, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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Understanding mechanisms and documenting plausibility of palliative interventions for dyspnea. Curr Opin Support Palliat Care 2011; 5:71-6. [DOI: 10.1097/spc.0b013e328345bc84] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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