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

Validation of a Novel Clinical Dyspnea Scale - A Retrospective Pilot Study

Objective: to examine the validity of a novel dyspnea scale, Edmonton Dyspnea Inventory in idiopathic pulmonary fibrosis (IPF). Methods: Edmonton Dyspnea Inventory (EDI), is a clinical instrument to measure dyspnea severity with activities of daily living, exercise and rest using a numeric rating scale (0 -10). Consecutive IPF patients (2012-2018) with baseline MRC and EDI were included. To validate EDI, psychometric analysis was conducted. Correlations between EDI, MRC and lung function were examined. Group-based trajectory modeling was used to group patients based on dyspnea severity. Net Reclassification Improvement (NRI) was calculated to assess the improvement in 1-year mortality prediction by adding trajectory groups to MRC grade. Results: 100 consecutive IPF patients were identified; mean age 73 years (SD = 9) and 65% males; 73% were in MRC grades ≥3. Item analysis showed all 8 EDI components have excellent discrimination power with ability to differentiate patients with varying dyspnea severity. EDI has good internal consistency (Cronbach α = .92). Exploratory factor analysis showed a one-factor solution with loadings from .66 to .89 suggesting 8 EDI components measured essentially one dimension of dyspnea. All EDI components were correlated with MRC and some with lung function. Modeling data identified three EDI dyspnea severity groups with differing mortality (P = .009). The addition of EDI dyspnea severity groups to the MRC score improved 1-year mortality prediction (NRI = .66; 95% CI, .18-1.14). Conclusions: EDI is a valid dyspnea instrument, correlated with MRC and lung function. It can categorize IPF patients into 3 dyspnea severity groups associated with increased mortality. Key Message: We describe the development of a novel scale, Edmonton Dyspnea Inventory, that facilitates measurement of dyspnea severity in the context of daily activities in patients with IPF. The results indicate that the new instrument is valid and correlated to MRC. It identifies 3 categories of severity not recognized by MRC with impact on mortality. Knowledge of dyspnea severity can help triage patients and assign appropriate therapies.

Timely Assessment of Breathing-Related Distress in Community Palliative Care: A Multidisciplinary Collaborative Quality Improvement Project

Background: Breathlessness is a common symptom for palliative patients that can cause distress and decrease function and quality of life. Palliative care services in Australia aim to routinely assess patients for breathing-related distress, but timely reassessment is not always achieved. Objective: To improve the timeliness of breathlessness reassessment in a home-based community palliative care service in New South Wales for people with moderate-to-severe breathing-related distress. Breathing-related distress was defined as a Symptom Assessment Score for "breathing problems" of four or more. Methods: This collaborative quality improvement (QI) project between SPHERE Palliative Care CAG, Stanford University mentors, and a Sydney metropolitan specialist palliative care service included a: (1) retrospective chart audit; (2) cause and effect analyses using a fishbone diagram; (3) development and implementation of key drivers and interventions; and (4) a pre-and-post evaluation of the timeliness of reassessment of breathing-related distress and changes in Symptom Assessment Scale scores for "breathing problems." Results: Key interventions included multidisciplinary education sessions to facilitate buy-in, with nurses as case managers responsible for breathlessness reassessment and documentation of scores, access and training in electronic palliative care data entry software, fortnightly monitoring and reporting of breathing-related distress scores, and development of an educational flowchart. The proportion of patients reassessed within seven days of an initial nursing assessment of moderate-to-severe breathing-related distress increased from 34% at baseline to 92% at six months. Conclusion: A local QI project increased the proportion of patients with a timely reassessment of their breathing-related distress in a community palliative care service.

The modified Medical Research Council scale misclassifies exertional breathlessness among people referred for exercise testing

Background

Exertional breathlessness is a major symptom in cardiorespiratory disease and is often assessed using the modified Medical Research Council (mMRC) questionnaire. The mMRC might underestimate exertional breathlessness in people with impaired exercise capacity who have reduced their physical activity to avoid the symptom. We aimed to evaluate the ability of mMRC to detect abnormally high exertional breathlessness or abnormally low exercise capacity during incremental cycle exercise testing (IET).

Methods

A secondary analysis of data from a randomised controlled trial of outpatients aged 18 years or older referred for IET was carried out. Participants completed the mMRC before IET. Abnormally high exertional breathlessness was defined as a breathlessness (Borg 0-10) intensity response more than the upper limit of normal. Abnormally low exercise capacity was defined using published reference equations. The sensitivity, specificity, accuracy and discriminative ability of each mMRC rating to detect each outcomewas calculated.

Results

92 participants were included; the mean age was 59 years, 61% were male, and 64% and 15% had mMRC 1 and ≥2, respectively. An mMRC ≥2 had the highest accuracy (71%) to detect abnormally high exertional breathlessness, with a specificity of 93% but a sensitivity of only 28%, failing to identify 72% of people with abnormally high exertional breathlessness. The accuracy, specificity and sensitivity for abnormally low exercise capacity was 64%, 88% and 19%, respectively.

Conclusion

Among people referred for clinical exercise testing, the mMRC dyspnoea scale misclassified exertional breathlessness and exercise capacity assessed using cycle IET, with substantial underdetection. A mMRC dyspnoea rating of 0-1 does not preclude the presence of abnormally high exertional breathlessness or abnormally low exercise capacity.

Breathlessness in older adults: What we know and what we still need to know

Breathlessness is common among older adults, but it is often hidden as "normal aging "or considered narrowly as a symptom of cardio-respiratory diseases. Studies on breathlessness in older adults are mostly focused on specific diseases, whereas older adults are characterized by multimorbidity and multi-system age-related impairments. This article aims to provide an overview of what is known so far on breathlessness in the general population of older adults and identify areas for further research. Research shows that breathlessness in older adults is a multifactorial geriatric condition, crossing the borders of system-based impairments and diseases, and a valuable independent prognostic indicator for adverse outcomes. Further research needs to investigate (1) the multi-factorial mechanisms of breathlessness in community-dwelling older adults including the role of respiratory sarcopenia; (2) the influence of affective and cognitive changes of older age on the perception and report of breathlessness; (3) the best way to assess and use breathlessness for risk prediction of adverse outcomes in general geriatric assessments; and (4) the most appropriate multi-modal rehabilitation interventions and their outcomes. Clinicians need to shift their approach to dyspnea from a disease symptom to a multifactorial geriatric condition that should be proactively searched for, as it identifies higher risk for adverse outcomes, and can be addressed with evidence-based interventions that can improve the quality of life and may reduce the risk of adverse outcomes in older adults.

Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure

BACKGROUND

Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains.

OBJECTIVE

To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure.

DESIGN

We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G).

PARTICIPANTS

We used data from a multi-site randomized clinical trial among outpatients with heart failure.

MAIN MEASURES

We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods.

KEY RESULTS

Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change.

CONCLUSIONS

The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.

Dyspnoea-12 and Multidimensional Dyspnea Profile: Systematic Review of Use and Properties

CONTEXT

The Dyspnoea-12 (D-12) and Multidimensional Dyspnea Profile (MDP) were specifically developed for assessment of multiple sensations of breathlessness.

OBJECTIVES

This systematic review aimed to identify the use and measurement properties of the D-12 and MDP across populations, settings and languages.

METHODS

Electronic databases were searched for primary studies (2008-2020) reporting use of the D-12 or MDP in adults. Two independent reviewers completed screening and data extraction. Study and participant characteristics, instrument use, reported scores and minimal clinical important differences (MCID) were evaluated. Data on internal consistency (Cronbach's α) and test-retest reliability (intraclass correlation coefficient, ICC) were pooled using random effects models between settings and languages.

RESULTS

A total 75 publications reported use of D-12 (n = 35), MDP (n = 37) or both (n = 3), reflecting 16 chronic conditions. Synthesis confirmed two factor structure, internal consistency (Cronbach's α mean, 95% CI: D-12 Total = 0.93, 0.91-0.94; MDP Immediate Perception [IP] = 0.88, 0.85-0.90; MDP Emotional Response [ER] = 0.86, 0.82-0.89) and 14 day test-rest reliability (ICC: D-12 Total = 0.91, 0.88-0.94; MDP IP = 0.85, 0.70-0.93; MDP ER = 0.84, 0.73-0.90) across settings and languages. MCID estimates for clinical interventions ranged between -3 and -6 points (D-12 Total) with small variability in scores over 2 weeks (D-12 Total 2.8 (95% CI: 2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1) and six months (D-12 Total 2.9 (2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1)).

CONCLUSION

D-12 and MDP are widely used, reliable, valid and responsive across various chronic conditions, settings and languages, and could be considered standard instruments for measuring dimensions of breathlessness in international trials.

Health service utilisation associated with chronic breathlessness: random population sample

BACKGROUND

Most health service utilisation studies are of people with specific diagnoses or demographic characteristics, and rarely of specific chronic symptoms. The aim of this study was to establish whether population-level health service utilisation increases in people with chronic breathlessness.

METHODS

A cross-sectional analysis was carried out of the South Australian Health Omnibus Survey 2017, a multi-stage, clustered area, systematic sampling survey of adults where questions are administered face-to-face in respondents' homes. Self-report of health service utilisation in the previous 3 months (medical consultations, emergency department, hospital admission), chronic breathlessness (severity, duration, modified Medical Research Council (mMRC) breathlessness scale) and demographic data were used to predict self-reported health service utilisation.

RESULTS

A total of 2898 people were included (49.0% male; median age 48.0 years (IQR 32.0-63.0); 64.1% educated beyond school; 55.4% in work; 73.5% had outpatient contact; 6.3% had a hospital admission in the previous 3 months). Chronic breathlessness (mMRC ≥1) was reported by 8.8% of respondents. In bivariable analyses, people with greater contact with health services were older, and a higher proportion were overweight/obese and had more severe chronic breathlessness. In multivariable analyses, chronic breathlessness and older age were positively associated with outpatient care and inpatient care, and people with chronic breathlessness were hospitalised for longer (incidence rate ratio 2.5; 95% CI 1.4-4.5).

CONCLUSION

There is a significant association between worse chronic breathlessness and increased health service utilisation. There is a need for greater understanding of factors that initiate contact with health services.

Cutting through complexity: the Breathing, Thinking, Functioning clinical model is an educational tool that facilitates chronic breathlessness management

Chronic breathlessness is a distressing symptom that is challenging to manage. The Breathing, Thinking, Functioning clinical model is an educational tool developed to support breathlessness management. Health professionals report that the model increases clinician and patient understanding of this complex symptom, and provides a simple and structured approach to personalised self-management.

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 .

How Physicians in South India Recognize, Assess, and Manage People with Chronic Breathlessness Syndrome: A Thematic Analysis

OBJECTIVES

Chronic breathlessness syndrome has been defined to help clinicians actively seek, and patients legitimately present with, persistent breathlessness, and to drive services and research. However, views from low- to middle-income countries were not included. We aimed to explore the views of hospital physicians regarding chronic breathlessness syndrome, its recognition and management.

METHODS

This was a secondary analysis of qualitative data collected during a service development project. Three focus groups of physicians caring for patients with chronic breathlessness in a single tertiary hospital in South India were conducted in English, audio-recorded, transcribed, and subjected to thematic analysis.

RESULTS

Fifteen physicians from oncology, palliative care, cardiology, and respiratory specialties participated. Three major themes (impact, invisibility, and purpose) were generated. Findings mirrored those in high-income countries. Chronic breathlessness, as defined, was seen as prevalent, with a major impact on patients, families, and physicians. Nonpalliative care physicians described therapeutic helplessness with poor awareness and/or ability to manage breathlessness accompanied by active avoidance. This helplessness, a perceived lack of assessment tools and lack of access to palliative care contributed to the "invisibility" of chronic breathlessness. Most participants agreed with the name of chronic breathlessness syndrome. All agreed that systematic identification would foster education regarding assessment and management and support service development and research.

CONCLUSIONS

Chronic breathlessness syndrome is recognized in South India but, as in higher-income countries, risks being invisible due to the lack of awareness of therapeutic interventions. A named and defined syndrome was seen as a way to improve identification and management.