A multidimensional computer adaptive test approach to dyspnea assessment

Breathing on the mind: Treating dyspnea and anxiety symptoms with biofeedback in chronic lung disease - A qualitative analysis

RATIONALE

Chronic obstructive pulmonary disease (COPD) is characterized by dysfunctional breathing patterns that contribute to impaired lung function and symptoms of dyspnea, anxiety, and abnormal carbon dioxide (CO2) levels.

OBJECTIVE

The study objective was to measure the acceptability of a new mind-body intervention we developed called Capnography-Assisted, Learned Monitored (CALM) Breathing, implemented before pulmonary rehabilitation.

METHODS

CALM Breathing is a 4-week (8-session) intervention designed to treat dyspnea and anxiety in adults with COPD by targeting dysfunctional breathing behaviors (guided by end-tidal CO2 levels). CALM Breathing consists of ten core breathing exercises, CO2 biofeedback, and motivational interviewing. Using qualitative methods and semi-structured interviews immediately post-intervention, we evaluated the acceptability and participation process of CALM Breathing. Themes were identified using constant comparative analysis.

RESULTS

Sixteen participants were interviewed after receiving CALM Breathing. Three main themes of CALM Breathing were identified: (1) Process of learning self-regulated breathing, (2) Mechanisms of a mind-body intervention, (3) Clinical and implementation outcomes.

CONCLUSIONS

Positive themes supported the acceptability of CALM Breathing and described participants' process of learning more self-regulated breathing to manage their dyspnea and anxiety. Positive signals from qualitative participant feedback provided support for CALM Breathing as an intervention for COPD, but larger scale efficacy trials are needed.

Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation

BACKGROUND

Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes.

METHODS

We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group.

RESULTS

Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement.

CONCLUSION

By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.

Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned

Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).

Study Protocol for the Breathe Easier Trial: A Pilot RCT of a Dyad-Based, Multiple-Behavior Intervention for Improving Physical and Emotional Health in Survivors Facing Lung Cancer

BACKGROUND

Research targeting survivors of lung cancer has yet to adequately address the management of physical deconditioning and unresolved symptoms (dyspnea, fatigue). The objective of the Breathe Easier trial is to test the feasibility and preliminary effects of a theory-based, multiple-behavior intervention (physical activity, smoking reduction for current smokers, stress management) targeting survivors of localized non-small-cell lung cancer (NSCLC, stages I-III) and their supportive partners.

METHODS

This pilot RCT will enroll 30 dyads (60 participants). Each dyad will consist of one survivor and one partner (defined as a family member or friend) Dyads will be randomized to the Intervention Group (IG) or the Attention Control Group (AC). IG members will receive the 12-week, home-based intervention based on the individual and family self-management theory, which targets improvements in self-efficacy, social support, and self-regulation. Improvement in lifestyle behaviors is a proximal outcome. Improvements in physical and emotional health are distal outcomes. Breathe Easier (IG) includes educational content written in plain language as well as breathing exercises and meditations; SMART goal setting; daily text messaging; and weekly telephone calls with trained staff. The AC program includes relevant National Institutes of Health publications plus weekly telephone chats. Members who currently smoke will also receive an evidence-based smoking cessation resource.

DISCUSSION

Breathe Easier focuses on changes in multiple behaviors in dyads coping with a diagnosis of NSCLC (stages I-III) with the overall purpose of improving physical and emotional health. Findings will provide additional evidence of the feasibility and preliminary effects of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05956782; This trial was registered retrospectively.

Multi-Dimensional Dyspnea-Related Scales Validated in Individuals With Cardio-Respiratory and Cancer Diseases. A Systematic Review of Psychometric Properties

CONTEXT

In order to examine the multi-dimensional nature of dyspnea and its impact on the activities of daily living (ADLs) in patients with cardio-respiratory and cancer diseases, validated measures are needed.

OBJECTIVES

Our aim was to identify all the multi-dimensional clinical scales assessing dyspnea and its impact on ADLs in patients with cardio-respiratory and cancer diseases, and to critically appraise their psychometric properties.

METHODS

Five databases were systematically searched up to July 2020. Eligible criteria were: the examination of at least one psychometric property, and the recruitment of adults with a cardio-respiratory or cancer disease in non-emergency settings. The characteristics and psychometric properties of the studies included were presented through a narrative synthesis. The methodological quality of the studies and evidence synthesis were rated using the "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" criteria.

RESULTS

Forty-three studies, for which eight assessment scales had been identified, were included in the review. At the time of the review, three multi-dimensional assessment scales were available for assessing dyspnea symptoms, and five multi-dimensional scales were available to examine the impact of dyspnea on ADLs. Although the use of these scales has rapidly grown, evidence of psychometric properties has been reported as limited in most of the scales.

CONCLUSION

Despite the potential of the identified scales, further studies are needed to strength evidence on the validity and reliability of the multi-dimensional dyspnea scales. Furthermore, more studies appraising the content validity and responsiveness of the scales are specifically recommended.

Psychometric Properties of Patient-Reported Outcome Measures Assessing Self-Efficacy in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review

This systematic review aimed to synthesize the evidence of the psychometric properties of self-efficacy patient-reported outcome measures (PROMs) in patients with chronic obstructive pulmonary disease (COPD). We conducted a systematic search of MEDLINE and other common databases from inception until September 2020. Studies that reported psychometric properties of self-efficacy outcome measures in COPD patients were included. We used the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 2018 guidelines for data extraction and evidence synthesis. Eighteen studies that assessed nine self-efficacy PROMs were eligible for inclusion. The assessment of structural validity indicated sufficient results rating for the Exercise Self-Regulatory Efficacy Scale and the Self-Care-Self-Efficacy Scale, and insufficient rating for the COPD Self-Efficacy Scale and the Pulmonary Rehabilitation Adaptation Index for Self-Efficacy (PRAISE). Construct validity measures displayed sufficient results rating with correlations ranging from -0.48 to - 0.71 between self-efficacy PROMs and other PROMs such as St. George's Respiratory Questionnaire, Hospital Anxiety and Depression Scale and Chronic Respiratory Questionnaire. Internal consistency measures indicated sufficient rating for all self-efficacy PROMs with a Cronbach's alpha range of 0.71 - 0.98. Responsiveness was assessed for the PRAISE with an overall sufficient rating (effect sizes of 0.21 - 0.37). The evidence regarding the psychometric properties of self-efficacy PROMs in COPD is variable. The PRAISE is responsive to changes in self-efficacy in COPD patients attending a pulmonary rehabilitation program. When using self-efficacy PROMs in clinical practice or research, clinicians and researchers should consider the psychometric properties and choose the appropriate outcome measure based on the purpose.

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

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

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

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

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

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

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

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

Construct Validation of a Multidimensional Computerized Adaptive Test for Fatigue in Rheumatoid Arthritis

OBJECTIVE

Multidimensional computerized adaptive testing enables precise measurements of patient-reported outcomes at an individual level across different dimensions. This study examined the construct validity of a multidimensional computerized adaptive test (CAT) for fatigue in rheumatoid arthritis (RA).

METHODS

The 'CAT Fatigue RA' was constructed based on a previously calibrated item bank. It contains 196 items and three dimensions: 'severity', 'impact' and 'variability' of fatigue. The CAT was administered to 166 patients with RA. They also completed a traditional, multidimensional fatigue questionnaire (BRAF-MDQ) and the SF-36 in order to examine the CAT's construct validity. A priori criterion for construct validity was that 75% of the correlations between the CAT dimensions and the subscales of the other questionnaires were as expected. Furthermore, comprehensive use of the item bank, measurement precision and score distribution were investigated.

RESULTS

The a priori criterion for construct validity was supported for two of the three CAT dimensions (severity and impact but not for variability). For severity and impact, 87% of the correlations with the subscales of the well-established questionnaires were as expected but for variability, 53% of the hypothesised relations were found. Eighty-nine percent of the items were selected between one and 137 times for CAT administrations. Measurement precision was excellent for the severity and impact dimensions, with more than 90% of the CAT administrations reaching a standard error below 0.32. The variability dimension showed good measurement precision with 90% of the CAT administrations reaching a standard error below 0.44. No floor- or ceiling-effects were found for the three dimensions.

CONCLUSION

The CAT Fatigue RA showed good construct validity and excellent measurement precision on the dimensions severity and impact. The dimension variability had less ideal measurement characteristics, pointing to the need to recalibrate the CAT item bank with a two-dimensional model, solely consisting of severity and impact.

Item exposure control for multidimensional computer adaptive testing under maximum likelihood and expected a posteriori estimation

Item bank stratification has been shown to be an effective method for combating item overexposure in both uni- and multidimensional computer adaptive testing. However, item bank stratification cannot guarantee that items will not be overexposed-that is, exposed at a rate exceeding some prespecified threshold. In this article, we propose enhancing stratification for multidimensional computer adaptive tests by combining it with the item eligibility method, a technique for controlling the maximum exposure rate in computerized tests. The performance of the method was examined via a simulation study and compared to existing methods of item selection and exposure control. Also, for the first time, maximum likelihood (MLE) and expected a posteriori (EAP) estimation of examinee ability were compared side by side in a multidimensional computer adaptive test. The simulation suggested that the proposed method is effective in suppressing the maximum item exposure rate with very little loss of measurement accuracy and precision. As compared to MLE, EAP generates smaller mean squared errors of the ability estimates in all simulation conditions.

A review of the most common patient-reported outcomes in COPD--revisiting current knowledge and estimating future challenges

Patient-reported outcome (PRO) measures that quantify disease impact have become important measures of outcome in COPD research and treatment. The objective of this literature review was to comprehensively evaluate psychometric properties of available PRO instruments and the ability of each of them to characterize pharmaceutical treatment effects from published clinical trial evidence. Identified in this study were several PRO measures, both those that have been used extensively in COPD clinical trials (St George’s Respiratory Questionnaire and Chronic Respiratory Questionnaire) and new instruments whose full value is still to be determined. This suggests a great need for more information about the patient experience of treatment benefit, but this also may pose challenges to researchers, clinicians, and other important stakeholders (eg, regulatory agencies, pharmaceutical companies) who develop new treatment entities and payers (including but not limited to health technology assessment agencies such as the National Institute for Health and Care Excellence and the Canadian Agency for Drugs and Technologies in Health). The purpose of this review is to enable researchers and clinicians to gain a broad overview of PRO measures in COPD by summarizing the value and purpose of these measures and by providing sufficient detail for interested audiences to determine which instrument may be the most suitable for evaluating a particular research purpose.

Working mechanism of a multidimensional computerized adaptive test for fatigue in rheumatoid arthritis

BACKGROUND

This paper demonstrates the mechanism of a multidimensional computerized adaptive test (CAT) to measure fatigue in patients with rheumatoid arthritis (RA). A CAT can be used to precisely measure patient-reported outcomes at an individual level as items are consequentially selected based on the patient's previous answers. The item bank of the CAT Fatigue RA has been developed from the patients' perspective and consists of 196 items pertaining to three fatigue dimensions: severity, impact and variability of fatigue.

METHODS

The CAT Fatigue RA was completed by fifteen patients. To test the CAT's working mechanism, we applied the flowchart-check-method. The adaptive item selection procedure for each patient was checked by the researchers. The estimated fatigue levels and the measurement precision per dimension were illustrated with the selected items, answers and flowcharts.

RESULTS

The CAT Fatigue RA selected all items in a logical sequence and those items were selected which provided the most information about the patient's individual fatigue. Flowcharts further illustrated that the CAT reached a satisfactory measurement precision, with less than 20 items, on the dimensions severity and impact and to somewhat lesser extent also for the dimension variability. Patients' fatigue scores varied across the three dimensions; sometimes severity scored highest, other times impact or variability. The CAT's ability to display different fatigue experiences can improve communication in daily clinical practice, guide interventions, and facilitate research into possible predictors of fatigue.

CONCLUSIONS

The results indicate that the CAT Fatigue RA measures precise and comprehensive. Once it is examined in more detail in a consecutive, elaborate validation study, the CAT will be available for implementation in daily clinical practice and for research purposes.

Evidence for cognitive-behavioral strategies improving dyspnea and related distress in COPD

BACKGROUND

Dyspnea is a complex, prevalent, and distressing symptom of chronic obstructive pulmonary disease (COPD) associated with decreased quality of life, significant disability, and increased mortality. It is a major reason for referral to pulmonary rehabilitation.

METHODS

We reviewed 23 COPD studies to examine the evidence for the effectiveness of cognitive-behavioral strategies for relieving dyspnea in COPD.

RESULTS

Preliminary evidence from randomized controlled trials exists to support cognitive- behavioral strategies, used with or without exercise, for relieving sensory and affective components of dyspnea in COPD. Small to moderate treatment effects for relieving dyspnea were noted for psychotherapy (effect size [ES] = 0.08-0.25 for intensity; 0.26-0.65 for mastery) and distractive auditory stimuli (ES = 0.08-0.33 for intensity; 0.09 to -0.61 for functional burden). Small to large dyspnea improvements resulted from yoga (ES = 0.2-1.21 for intensity; 0.67 for distress; 0.07 for mastery; and -8.37 for functional burden); dyspnea self-management education with exercise (ES = -0.14 to -1.15 for intensity; -0.62 to -0.69 for distress; 1.04 for mastery; 0.14-0.35 for self-efficacy); and slow-breathing exercises (ES = -0.34 to -0.83 for intensity; -0.61 to -0.80 for distress; and 0.62 for self-efficacy). Cognitive-behavioral interventions may relieve dyspnea in COPD by (1) decreasing sympathetic nerve activity, dynamic hyperinflation, and comorbid anxiety, and (2) promoting arterial oxygen saturation, myelinated vagus nerve activity, a greater exercise training effect, and neuroplasticity.

CONCLUSION

While evidence is increasing, additional randomized controlled trials are needed to evaluate the effectiveness of psychosocial and self-management interventions in relieving dyspnea, in order to make them more available to patients and to endorse them in official COPD, dyspnea, and pulmonary rehabilitation practice guidelines. By relieving dyspnea and related anxiety, such interventions may promote adherence to exercise programs and adaptive lifestyle change.

Items and dimensions for the construction of a multidimensional computerized adaptive test to measure fatigue in patients with rheumatoid arthritis

OBJECTIVES

Development of an item pool to construct a future computerized adaptive test (CAT) for fatigue in rheumatoid arthritis (RA). The item pool was based on the patients' perspective and examined for face and content validity previously. This study assessed the fit of the items with seven predefined dimensions and examined the item pool's dimensionality structure in statistical terms.

STUDY DESIGN AND SETTING

A total of 551 patients with RA participated in this study. Several steps were conducted to come from an explorative item pool to a psychometrically sound item bank. The item response theory (IRT) analysis using the generalized partial credit model was conducted for each of the seven predefined dimensions. Poorly fitting items were removed. Finally, the best possible multidimensional IRT (MIRT) model for the data was identified.

RESULTS

In IRT analysis, 49 items showed insufficient item characteristics. Items with a discriminative ability below 0.60 and/or model misfit effect sizes greater than 0.10 were removed. Factor analysis on the 196 remaining items revealed three dimensions, namely severity, impact, and variability of fatigue. The dimensions were further confirmed in MIRT model analysis.

CONCLUSION

This study provided an initially calibrated item bank and showed which dimensions and items can be used for the development of a multidimensional CAT for fatigue in RA.

Outcome measures for palliative care research

PURPOSE OF REVIEW

The aim of this review is to summarize the current state of the science in physical symptoms and other end-of-life care domains and/or illness-specific outcomes in palliative care. The review includes progress in outcome measure development and interpretation, with specific reference to the clinical trial context.

RECENT FINDINGS

There are validated measures in a wide range of domains, which can measure outcomes specific to palliative care interventions; which are sufficiently validated to ensure the results of the trial are robust and measuring differences which are both clinically meaningful. In several areas, consensus is emerging which will allow consolidation of outcome measurement and the ability to extend measurement from the clinical trial setting into routine clinical practice. Potential exists for composite measures covering areas prioritized by patients to improve comparability and efficiency. Adverse events need to be measured with the same degree of rigor as efficacy outcomes.

SUMMARY

Clinical trials of palliative care interventions need to consider a range of outcomes, however, the choice and timing of measurement of the primary outcome need to be guided by the domain most likely to be influenced by the intervention.

Beyond FEV₁ in COPD: a review of patient-reported outcomes and their measurement

Patients with chronic obstructive pulmonary disease (COPD) present with a variety of symptoms and pathological consequences. Although primarily viewed as a respiratory disease, COPD has both pulmonary and extrapulmonary effects, which have an impact on many aspects of physical, emotional, and mental well-being. Traditional assessment of COPD relies heavily on measuring lung function, specifically forced expiratory volume in 1 second (FEV(1)). However, the evidence suggests that FEV(1) is a relatively poor correlate of symptoms such as breathlessness and the impact of COPD on daily life. Furthermore, many consequences of the disease, including anxiety and depression and the ability to perform daily activities, can only be described and reported reliably by the patient. Thus, in order to provide a comprehensive view of the effects of interventions in clinical trials, it is essential that spirometry is accompanied by assessments using patient-reported outcome (PRO) instruments. We provide an overview of patient-reported outcome concepts in COPD, such as breathlessness, physical functioning, and health status, and evaluate the tools used for measuring these concepts. Particular attention is given to the newly developed instruments emerging in response to recent regulatory guidelines for the development and use of PROs in clinical trials. We conclude that although data from the development and validation of these new PRO instruments are emerging, to build the body of evidence that supports the use of a new instrument takes many years. Furthermore, new instruments do not necessarily have better discriminative or evaluative properties than older instruments. The development of new PRO tools, however, is crucial, not only to ensure that key COPD concepts are being reliably measured but also that the relevant treatment effects are being captured in clinical trials. In turn, this will help us to understand better the patient's experience of the disease.