Control and Context Are Central for People With Advanced Illness Experiencing Breathlessness: A Systematic Review and Thematic Synthesis

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

The effect of unpredictability on the perception of breathlessness: a narrative review

Breathlessness is an aversive bodily sensation impacting millions of people worldwide. It is often highly detrimental for patients and can lead to profound distress and suffering. Notably, unpredictable breathlessness episodes are often reported as being more severe and unpleasant than predictable episodes, but the underlying reasons have not yet been firmly established in experimental studies. This review aimed to summarize the available empirical evidence about the perception of unpredictable breathlessness in the adult population. Specifically, we examined: (1) effects of unpredictable relative to predictable episodes of breathlessness on their perceived intensity and unpleasantness, (2) potentially associated neural and psychophysiological correlates, (3) potentially related factors such as state and trait negative affectivity. Nine studies were identified and integrated in this review, all of them conducted in healthy adult participants. The main finding across studies suggested that unpredictable compared to predictable, breathlessness elicits more frequently states of high fear and distress, which may contribute to amplify the perception of unpredictable breathlessness, especially its unpleasantness. Trait negative affectivity did not seem to directly affect the perception of unpredictable breathlessness. However, it seemed to reinforce state fear and anxiety, hence possible indirect modulatory pathways through these affective states. Studies investigating neural correlates of breathlessness perception and psychophysiological measures did not show clear associations with unpredictability. We discuss the implication of these results for future research and clinical applications, which necessitate further investigations, especially in clinical samples suffering from breathlessness.

Non-medical devices for chronic breathlessness: use, barriers and facilitators for patients, carers and clinicians - a scoping review

BACKGROUND

Non-medical devices such as the handheld fan (fan), mobility aids (wheeled walkers with seats) and inspiratory muscle training (IMT) devices offer benefits for patient management of chronic breathlessness. We examined the published evidence regarding patient, carer and clinician use of the fan, mobility aids and IMT devices for chronic breathlessness management, and the potential barriers and facilitators to day-to-day use in a range of settings.

METHODS

MEDLINE, Embase, Scopus, EBSCO and the Cochrane Database of Systematic Reviews were searched. Papers were imported into EndNote and Rayyan for review against a priori eligibility criteria. Outcome data relevant to use were extracted and categorised as potential barriers and facilitators, and a narrative synthesis exploring reasons for similarities and differences conducted.

RESULTS

Seven studies met the inclusion criteria (n=5 fan, n=2 mobility aids and n=0 IMT devices). All of the studies presented patient use of non-medical devices only. Patients found the fan easy to use at home. Mobility aids were used mainly for outdoor activities. Outdoor use for both devices were associated with embarrassment. Key barriers included: appearance; credibility; self-stigma; technical specifications. Common facilitators were ease of use, clinical benefit and feeling safe with the device.

CONCLUSION

The efforts of patients, carers and clinicians to adopt and use non-medical devices for the management of chronic breathlessness is impeded by lack of implementation research. Future research should improve knowledge of the barriers and facilitators to use. This would enhance understanding of how decision-making in patient-carer-clinician triads impacts on non-medical devices use for breathlessness management.

Nursing support for breathlessness in patients with cancer: a scoping review

OBJECTIVE

To identify nursing support provided for the relief of breathlessness in patients with cancer.

DESIGN

A scoping review following a standard framework proposed by Arksey and O'Malley.

STUDY SELECTION

Electronic databases (PubMed, CINAHL, CENTRAL and Ichushi-Web of the Japan Medical Abstract Society Databases) were searched from inception to 31 January 2022. Studies reporting on patients with cancer (aged ≥18 years), intervention for relief from breathlessness, nursing support and quantitatively assessed breathlessness using a scale were included.

RESULTS

Overall, 2629 articles were screened, and 27 were finally included. Results of the qualitative thematic analysis were categorised into 12 nursing support components: fan therapy, nurse-led intervention, multidisciplinary intervention, psychoeducational programme, breathing technique, walking therapy, inspiratory muscle training, respiratory rehabilitation, yoga, acupuncture, guided imagery and abdominal massage.

CONCLUSIONS

We identified 12 components of nursing support for breathlessness in patients with cancer. The study results may be useful to understand the actual state of nursing support provided for breathlessness in patients with terminal cancer and to consider possible support that can be implemented.

Exploring the Experience of Breathlessness with the Common-Sense Model of Self-Regulation (CSM)

Chronic breathlessness is a multidimensional, unpleasant symptom common to many health conditions. The Common-Sense Model of Self-Regulation (CSM) was developed to help understand how individuals make sense of their illness. This model has been underused in the study of breathlessness, especially in considering how information sources are integrated within an individual's cognitive and emotional representations of breathlessness. This descriptive qualitative study explored breathlessness beliefs, expectations, and language preferences of people experiencing chronic breathlessness using the CSM. Twenty-one community-dwelling individuals living with varying levels of breathlessness-related impairment were purposively recruited. Semi-structured interviews were conducted with questions reflecting components of the CSM. Interview transcripts were synthesized using deductive and inductive content analysis. Nineteen analytical categories emerged describing a range of cognitive and emotional breathlessness representations. Representations were developed through participants' personal experience and information from external sources including health professionals and the internet. Specific words and phrases about breathlessness with helpful or nonhelpful connotations were identified as contributors to breathlessness representations. The CSM aligns with current multidimensional models of breathlessness and provides health professionals with a robust theoretical framework for exploring breathlessness beliefs and expectations.

Existential suffering in the day to day lives of those living with palliative care needs arising from chronic obstructive pulmonary disease (COPD): A systematic integrative literature review

BACKGROUND

The impact of living with palliative care needs arising from COPD disrupts an individual's existential situation. However, no comprehensive synthesis of existing research has been published to determine the presentation and impact of existential suffering.

AIM

To provide a synthesis of existing evidence on existential suffering for those living with palliative care needs arising from COPD.

DESIGN

This is an integrative review paper, undertaken using the methodological approach developed by Soares and reported in accordance with PRISMA guidelines. Data analysis was undertaking using an integrated convergent synthesis approach.

DATA SOURCES

Nine electronic databases were searched from April 2019 to December 2019. A second search was undertaken in January 2021 to identify recently published papers meeting the inclusion and exclusion criteria. No date restrictions were imposed. Only papers published in the English Language were considered for inclusion. Empirical research papers employing qualitative and/or quantitative methodologies and systematic literature reviews were included. Articles were accepted for inclusion if they discussed any component of existential suffering when living with COPD and palliative care needs.

RESULTS

Thirty-five papers were included within this review comprising of seven systematic reviews, 10 quantitative studies and 18 qualitative studies. The following themes relating to existential suffering were found: Liminality, Lamented Life, Loss of Personal Liberty, Life meaning and Existential isolation. The absence of life meaning, and purpose was of most importance to participants.

CONCLUSIONS

This review suggests existential suffering is present and of significant impact within the daily lives of those living with palliative care needs arising from COPD. The absence of life meaning has the most significant impact. Further research is required to understand the essential components of an intervention to address existential suffering for this patient group, to ensure holistic palliative care delivery.

Relieving from Breathlessness in the Wind: A Meta-Analysis and Subjective Report of Effectiveness of Fan Blowing in Patients with Cardiorespiratory Diseases or Cancer

OBJECTIVES

Breathlessness is common among terminally ill patients with cardiorespiratory disease or cancer. The experience may induce secondary physiological and behavioral responses that limit patient well-being and independence and cause emotional distress.

METHODS

We conducted a meta-analysis on randomized controlled trials (RCTs) that examined the effectiveness of fan blowing on breathlessness among patients with cardiorespiratory diseases or cancer. The PubMed, Cochrane Library, Embase, SCOPUS, and CINAHL databases were searched to retrieve potential articles. The primary outcome was breathlessness severity. The secondary outcomes were SpO₂, anxiety, depression, and quality of life. Also, we presented the changes of vital signs and subjective feeling of a male patient who used fan blowing for relieving his breathlessness.

RESULTS

Eight RCTs were available for analysis. The pooled results demonstrated no significant difference in breathlessness severity between fan-to-face blowing and control methods (standard mean difference: -0.21, 95% confidence interval: -.59 to .17); however, a significant reduction in breathlessness severity was observed in the short-time intervention compared with long-time intervention. A trend occurred toward significance in the reduction of respiratory rate in fan-to-face blowing compared with control methods (MD: -.64, 95% CI: -1.37 to .09). No differences were observed between groups in oxygen saturation, anxiety, depression, or QoL. The male patient who used fan blowing showed an improved vital signs and a satisfied subjective feeling.

CONCLUSIONS

Consistent short-time fan-to-face blowing is effective for relieving breathlessness among conscious terminally ill patients with cardiorespiratory diseases or cancer. The use of this convenient method for relieving breathlessness symptoms in terminally ill patients is recommended.

A Systematic Review with Thematic Synthesis of the Experience of Hospitalization in People with Advanced Chronic Obstructive Pulmonary Disease

Hospital admissions are common for people with advanced chronic obstructive pulmonary disease (COPD). To provide effective, responsive care, it is important to understand how people experience hospitalization. The aim of this review was to explore the experience of hospitalization in people with advanced COPD, drawing from qualitative research data. Guided by a thematic synthesis approach, a systematic search of databases (n = 13) including PubMed, CINAHL, PsycINFO and ProQuest was undertaken from database inception to May 2020. Inclusion criteria included papers reporting qualitative research focused on any aspect of hospitalization for people with advanced COPD and reported in English language from peer reviewed journals. Following quality appraisal, relevant data were extracted, and a three-stage thematic synthesis method used to develop inductive themes. From 1935 papers, the 11 included studies focused on specific aspects of hospitalization (e.g., care and treatment), rather than the totality of the experience. Four analytical themes were identified: unpredictable hospitalization, benefits and burdens of treatment, overwhelming distress and the communicative attitude of staff. Hospitalization was unpredictable because of the frequent, sudden admissions required for acute breathlessness. Hospital could be perceived both as a safe place, due to immediate symptom relief, but also as a place for experiencing overwhelming distress. Breathlessness was the most difficult symptom experienced, causing physical and psychological distress. Both communication and attitudes of the staff could influence the experience. A holistic approach to the care of hospitalized individuals with advanced COPD is required to improve care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1971186 .

Management of Dyspnea in Advanced Cancer: ASCO Guideline

PURPOSE

To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer.

METHODS

ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020.

RESULTS

The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea.

RECOMMENDATIONS

A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .

Bearing witness to the challenges of breathlessness

The community respiratory nurse specialist (CRNS) supports patients at different stages of lung disease, witnessing the challenge of living with chronic obstructive pulmonary disease (COPD), a progressive illness for which there is no cure. Breathlessness is the most prominent and debilitating symptom experienced; it is frightening, distressing and very difficult to manage. Little is known about the experience of CRNSs in witnessing the distress of patients, specifically those experiencing breathlessness. The nurse may have cared for such patients over many months or years. In witnessing this distress, CRNSs engage in emotional labour, which is associated with burnout and poor-quality care. This paper seeks to identify bearing witness to suffering and vulnerability as components of emotional labour in the context of the CRNS role. It highlights the need for research to explore the experience of CRNSs and insights into supporting people with long-term breathlessness. It is more likely that well-supported staff can provide sustained, supportive care to patients living with breathlessness.

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

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

IoT Based Health—Related Topic Recognition from Emerging Online Health Community (Med Help) Using Machine Learning Technique

The unprompted patient’s and inimitable physician’s experience shared on online health communities (OHCs) contain a wealth of unexploited knowledge. Med Help and eHealth are some of the online health communities offering new insights and solutions to all health issues. Diabetes mellitus (DM), thyroid disorders and tuberculosis (TB) are chronic diseases increasing rapidly every year. As part of the project described in this article comments related to the diseases from Med Help were collected. The comments contain the patient and doctor discussions in an unstructured format. The sematic vision of the internet of things (IoT) plays a vital role in organizing the collected data. We pre-processed the data using standard natural language processing techniques and extracted the essential features of the words using the chi-squared test. After preprocessing the documents, we clustered them using the K-means++ algorithm, which is a popular centroid-based unsupervised iterative machine learning algorithm. A generative probabilistic model (LDA) was used to identify the essential topic in each cluster. This type of framework will empower the patients and doctors to identify the similarity and dissimilarity about the various diseases and important keywords among the diseases in the form of symptoms, medical tests and habits.

"So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians

CONTEXT

People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services.

OBJECTIVE

To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations.

METHODS

Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited.

RESULTS

Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable.

CONCLUSIONS

The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.

Terminological Usage Related to Dyspnea by Nursing Staff: A Cross-Sectional Questionnaire Survey

In recent years, additional expressions such as 'sensation of breathing discomfort' and 'discomfort of dyspnea' are being used in daily nursing care in Japan. To better understand the current status of the use of these terms by nurses, and to ascertain what the term 'dyspnea' may not express, we designed an original questionnaire and conducted a study with all nurses at our hospital. The questionnaire included questions to determine if nurses used these terms, and in what context. Of the 279 nurses in our hospital, 225 (80.6%) responded. Three-quarters of nurses indicated that they use these terms in clinical nursing practice. There was no difference in the usage of these terms between nurses who had or had not worked in a respiratory outpatients/ward. However, the percentage of nurses using these terms was higher amongst those with 10 years or less nursing experience compared with those with more than 10 years' experience. Open-ended questions revealed that these terms were used to communicate information between nurses and between nurses and patients' families. Our observations need to be verified in large-scale studies to determine if these terms are meaningful for nursing practice in that they describe something not expressed with 'dyspnea'. There is the possibility of confusion due to the use of inappropriate terms and a lack of education on the subject. Many nurses used these terms, and there may be things that the term 'dyspnea' could not express. The results of this study can be used to identify something that is lacking in communication about dyspnea between nurses, nurses and patients, and nurses and patients' families.

Oral morphine drops for prompt relief of breathlessness in patients with advanced cancer-a randomized, double blinded, crossover trial of morphine sulfate oral drops vs. morphine hydrochloride drops with ethanol (red morphine drops)

PURPOSE

Episodic breathlessness is frequent in palliative cancer patients. Opioids are the only pharmacological agents with sufficient evidence in treatment. In Denmark, the main recommendation is red morphine drops (RMD), an off-label solution of morphine, ethanol, and red color (cochenille) described since 1893 (Pharmacopoea Danica). In 2015, the Danish Medicines Agency increased focus on off-label medicines and recommended registered morphine drops without ethanol instead. However, our palliative patients told us that RMD was better. For that reason, we conducted a clinical trial to clarify any perceived difference between the two types of drops.

METHODS

We conducted a randomized, double blinded, crossover trial. Patients were asked to perform standardized activity (2-min walk) aiming to provoke breathlessness. Primary endpoint (breathlessness NRS) and secondary endpoints (saturation, pulse, respiratory frequency) were measured before (t = 0) and after test medicine at t = 1, t = 3, t = 5, t = 10, and t = 20 min. After 2-4 days (washout period), the patients repeated the test, receiving the alternative drops in a blinded setup (crossover).

RESULTS

In the first 3 min, the relative drop in breathlessness for morphine drops with ethanol (RMD) was significant more than for morphine drops without ethanol. We found no significant difference in secondary endpoints.

CONCLUSIONS

A conclusion could be that ethanol might facilitate morphine absorption in the mouth. Our results needs further research of opioid absorption in the mouth as well as trials, testing morphine vs. more lipophilic opioids. The RMD drops are cheap, easy to use, and noninvasive and keep the patient independent of health care professionals.

"I had the feeling that I was trapped": a bedside qualitative study of cognitive and affective attitudes toward noninvasive ventilation in patients with acute respiratory failure

Background

Noninvasive ventilation (NIV) is the application of mechanical ventilation through a mask. It is used to treat certain forms of acute respiratory failure in intensive care units (ICU). NIV has clinical benefits but can be anxiogenic for the patients. This study aimed at describing cognitive and affective attitudes toward NIV among patients experiencing NIV for the first time in the context of an ICU stay.

Methods

Semi-structured interviews were conducted in 10 patients during their ICU stay and soon after their first NIV experience. None of the patients had ever received NIV previously. Evaluative assertion analysis and thematic analysis were used to investigate cognitive and affective attitudes toward NIV before, during, and after the first NIV experience, as well as patient attitudes toward caregivers and relatives.

Results

Before their first NIV session, the cognitive attitudes of the patients were generally positive. They became less so and more ambiguous during and after NIV, as the patients discovered the actual barriers associated with NIV. Affective attitudes during NIV were more negative than affective attitudes before and after NIV, with reports of dyspnea, anxiety, fear, claustrophobic feelings, and reactivation of past traumatic experiences. The patients had more positive attitudes toward the presence of a caregiver during NIV, compared to the presence of a family member.

Conclusion

This study corroborates the possibly negative—or even traumatic—nature of the NIV experience, with emphasis on the role of affective attitudes. This is a rationale for evaluating the impact of NIV-targeted psychological interventions in ICU patients with acute respiratory failure.

To What Extent Do the NRS and CRQ Capture Change in Patients' Experience of Breathlessness in Advanced Disease? Findings From a Mixed-Methods Double-Blind Randomized Feasibility Trial

CONTEXT

Chronic or refractory breathlessness is common and distressing. To evaluate new treatments, outcome measures that capture change in patients' experience are needed.

OBJECTIVES

To explore the extent to which the numerical rating scale (NRS) worst and average, and the Chronic Respiratory Questionnaire capture change in patients' experience during a trial of mirtazapine for refractory breathlessness.

METHODS

Convergent mixed-methods design embedded within a randomized trial comprising 1) semi-structured qualitative interviews (considered to be the gold standard) and 2) outcome measure data collected pre- and post-intervention. Data were integrated, exploring examples where findings agreed and disagreed. Adults with advanced cancer, chronic obstructive pulmonary disease, interstitial lung disease, or chronic heart failure, with a modified Medical Research Council dyspnea scale grade 3 or 4 were recruited from three U.K. sites.

RESULTS

Data were collected for 22 participants. Eleven had a diagnosis of chronic obstructive pulmonary disease, eight interstitial lung disease, two chronic heart failure, and one cancer. Median age was 71 (56-84) years. Sixteen participants were men. Changes in the qualitative data were commonly captured in the NRS (worst and average) and the Chronic Respiratory Questionnaire. The NRS worst captured change most frequently. Improvement in the emotional domain was associated with physical changes, improved confidence, and control.

CONCLUSION

This study found that the NRS using the question "How bad has your breathlessness felt at its worst over the past 24 hours?" captured change across multiple domains, and therefore may be an appropriate primary outcome measure in trials in this population. Future work should confirm the construct validity of this question.

Strategies to relieve dyspnoea in patients with advanced chronic respiratory diseases. A narrative review

BACKGROUND AND OBJECTIVE

The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients.

METHODS

We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed.

RESULTS

Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers.

CONCLUSION

Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this.

The Impact of Unpredictability on Dyspnea Perception, Anxiety and Interoceptive Error Processing

Dyspnea is a prevalent interoceptive sensation and the aversive cardinal symptom in many cardiorespiratory diseases as well as in mental disorders. Especially the unpredictability of the occurrence of dyspnea episodes has been suggested to be highly anxiety provoking for affected patients. Moreover, previous studies demonstrated that unpredictable exteroceptive stimuli increased self-reports and electrophysiological responses of anxiety such as the startle probe N100 as well as amplified the processing of errors as reflected by greater error-related negativity (ERN). However, studies directly examining the role of unpredictability on dyspnea perception, anxiety, and error processing are widely absent. Using high-density electroencephalography, the present study investigated whether unpredictable compared to predictable dyspnea would increase the perception of dyspnea, anxiety and interoceptive error processing. Thirty-two healthy participants performed a respiratory forced choice reaction time task to elicit an interoceptive ERN during two conditions: an unpredictable and a predictable resistive load-induced dyspnea condition. Predictability was manipulated by pairing (predictable condition) or not pairing (unpredictable condition) dyspnea with a startle tone probe. Self-reports of dyspnea and affective state as well as the startle probe N100 and interoceptive ERN were measured. The results demonstrated greater dyspnea unpleasantness in the unpredictable compared to the predictable condition. Post hoc analyses revealed that this was paralleled by greater anxiety, and greater amplitudes for the startle probe N100 and the interoceptive ERN during the unpredictable relative to the predictable condition, but only when the unpredictable condition was experienced in the first experimental block. Furthermore, higher trait-like anxiety sensitivity was associated with higher ratings for dyspnea unpleasantness and experimental state anxiety ratings. The present findings suggest that unpredictability increases the perception of dyspnea unpleasantness. This effect seems related to increased state and trait anxiety and interoceptive error processing, especially when upcoming dyspnea is particularly unpredictable, such as in early experimental phases. Future studies are required to further substantiate these findings in patients suffering from dyspnea.