Verbal numerical scales are as reliable and sensitive as visual analog scales for rating dyspnea in young and older subjects

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Rating Dyspnea and Pain: "No" is Not Always "Zero"

Nurses routinely assess pain in hospitalized patients; similar assessment of dyspnea is increasing. Most nurses start with a yes-no question when assessing pain or dyspnea; many record "no" as a zero rating, skipping the rating scale. We tested the hypothesis that recording "no" answers as "zero" fails to detect the symptoms that would have been detected with a rating scale. Nurses asked 60 patients yes-no questions about the presence of dyspnea and pain, then asked patients to rate the symptoms using a 0-10 scale. All "yes" answers were followed by a concordant rating (i.e., greater than zero). More than 25% of "no" answers were followed by a discordant rating (> zero). Documenting "no" as "zero" missed information potentially useful in care planning; patients who rate dyspnea above zero are at greater risk of adverse outcomes. This information can also provide opportunity to start a discussion with patients who may benefit from symptom management.

Examining the repeatability of a novel test to measure exertional dyspnoea in chronic obstructive pulmonary disease

BACKGROUND

Exertional dyspnoea(ED) is a hallmark of chronic obstructive pulmonary disease(COPD). We examined the repeatability and face validity of the end-exercise ED(ED_end) response during the Dyspnoea Challenge and compared those to the six-minute walk test (6MWT) in COPD.

METHODS

Twenty-six individuals with COPD(13 Females, age:69 ± 5.5yrs, FEV₁:63.4 ± 11.9 %) completed 2 × 6MWTs and 4 x Dyspnoea Challenges on three occasions. The challenge consisted of a two-minute treadmill walk at 80 % of 6MWT speed(3.9 ± 0.5 km·hr^-1) at either a low(LI_DC:5.3 ± 2%) or high angle of incline(HI_DC:9.5 ± 3%). Dyspnoea(0-10 scale), heart rate(HR) and oxygen saturation(S_pO₂) were monitored continuously.

RESULTS

Mean 6MWT distance was 488 ± 58 m. End-exercise ED and HR were higher in the HI_DC(ED_end 6.2 ± 2.0; HR: 123 ± 17beats·min^-1) compared to the LI_DC(ED_end 4.2 ± 2.0; HR: 119 ± 15beats·min^-1) and the 6MWT(ED_end 4.3 ± 2.0; HR: 115 ± 16beats·min^-1)(P < 0.01). SpO₂ was not different between 6MWT, LI_DC or HI_DC(P = 0.34). The intraclass correlation coefficient(ICC) for each intensity was excellent (HI_DC, ICC = 0.88, LI_DC, ICC = 0.93, P < 0.001) with neither reporting bias(HI_DC, P = 0.63; LI_DC, P = 0.94).

CONCLUSIONS

The Dyspnoea Challenge is a simple measure of ED that appears to have both repeatability and face validity. With further optimisation, this test may enhance the field-based clinical assessment of ED.

Cas d’une patiente de grand âge en hospitalisation aiguë pour une atteinte sévère de COVID-19 : aspects moteurs

Le virus SRAS-CoV-2, à l’origine de la pandémie actuelle de COVID-19, engendre des troubles respiratoires aigus qui peuvent conduire à une hospitalisation, essentiellement chez les personnes âgées. Le cas présenté est celui d’une patiente de grand âge présentant une atteinte pulmonaire sévère. Les évaluations motrices quotidiennes sur une semaine comprenaient le test Timed up and go, le test Five sit-to-stand, le test de force de serrage maximal et le recueil des constantes cardio-respiratoires (fréquence cardiaque, respiratoire et saturation en oxygène). Une évaluation cognitive et de la qualité de vie ont aussi été réalisés. Entre l’éva-luation initiale et finale, la durée de réalisation du Timed Up and Go a diminué de 4,9 s, la performance au Five sit-to-stand est restée relativement stable, dans un contexte de sevrage de l’oxygène, de maintien de la saturation et d’une augmentation de la fréquence respiratoire. Malgré un pronostic péjoratif, l’amélioration respiratoire de la patiente s’est accompagnée d’améliorations motrices fonctionnelles. Les relations de régulations motrices et cardio-respiratoires sont discutées.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study

Background

Acute dyspnoea is common among ambulance patients, but little is known of the patients’ experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.

Methods

We performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.

Results

We included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6–10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6–9) to 4 (2–5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.

Conclusions

We found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients’ experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.

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.

A Multidimensional Profile of Dyspnea in Hospitalized Patients

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.

Reliability, validity and minimal detectable change of computerized respiratory sounds in patients with chronic obstructive pulmonary disease

INTRODUCTION

Computerized respiratory sounds (CRS) are closely related to the movement of air within the tracheobronchial tree and are promising outcome measures in patients with chronic obstructive pulmonary disease (COPD). However, CRS measurement properties have been poorly tested.

OBJECTIVE

The aim of this study was to assess the reliability, validity and the minimal detectable changes (MDC) of CRS in patients with stable COPD.

METHODS

Fifty patients (36♂, 67.26 ± 9.31y, FEV₁ 49.52 ± 19.67%predicted) were enrolled. CRS were recorded simultaneously at seven anatomic locations (trachea; right and left anterior, lateral and posterior chest). The number of crackles, wheeze occupation rate, median frequency (F50) and maximum intensity (Imax) were processed using validated algorithms. Within-day and between-days reliability, criterion and construct validity, validity to predict exacerbations and MDC were established.

RESULTS

CRS presented moderate-to-excellent within-day reliability (ICC_1,3  ≥ 0.51; P < .05) and moderate-to-good between-days reliability (ICC_1,2  ≥ 0.47; P < .05) for most locations. Negligible-to-moderate correlations with FEV₁ %predicted were found (-0.53 < r_s  < -0.28; P < .05), and the inspiratory number of crackles were the best discriminator between mild-to-moderate and severe-to-very severe airflow limitations (area under the curve >0.78). CRS correlated poorly with patient-reported outcomes (r_s  < 0.48; P < .05) and did not predict exacerbations. Inspiratory number of crackles at posterior right chest, inspiratory F50 at trachea and anterior left chest and expiratory Imax at anterior right chest were simultaneously reliable and valid, and their MDC were 2.41, 55.27, 29.55 and 3.98, respectively.

CONCLUSION

CRS are reliable and valid. Their use, integrated with other clinical and patient-reported measures, may fill the gap of assessing small airways and contribute toward a patient's comprehensive evaluation.

Are within-person Numerical Rating Scale (NRS) ratings of breathlessness 'on average' valid in advanced disease for patients and for patients' informal carers?

INTRODUCTION

The Numerical Rating Scale (NRS) is frequently used to assess patient-reported breathlessness in both a research and clinical context. A subgroup of patients report average breathlessness as worse than their worst breathlessness in the last 24 hours (paradoxical average). The Peak/End rule describes how the most extreme and current breathlessness influence reported average. This study seeks to highlight the existence of a subpopulation who give 'paradoxical averages using the NRS, to characterise this group and to investigate the explanatory relevance of the 'Peak/End' rule.

METHODS

Data were collected within mixed method face-to-face interviews for three studies: the Living with Breathlessness Study and the two subprotocols of the Breathlessness Intervention Service phase III randomised controlled trial. Key variables from the three datasets were pooled (n=561), and cases where participants reported a paradoxical average (n=45) were identified. These were compared with non-cases and interview transcripts interrogated. NRS ratings of average breathlessness were assessed for fit to Peak/End rule.

RESULTS

Patients in the paradoxical average group had higher Chronic Respiratory Questionnaire physical domain scores on average p=0.042). Peak/End rule analysis showed high positive correlation (Spearman's rho=0.756, p<0.001).

CONCLUSIONS

The NRS requires further standardisation with reporting of question order and construction of scale used to enable informed interpretation. The application of the Peak/End rule demonstrates fallibility of NRS-Average as a construct as it is affected by current breathlessness. Measurement of breathlessness is important for both clinical management and research, but standardisation and transparency are required for meaningful results.

Palliative Care for Patients with Nonmalignant Respiratory Disease

Nonmalignant respiratory diseases are chronic and life-limiting conditions that need holistic palliative care. Such patients not only have a variety of physical symptoms such as dyspnea, pain, cough, depression, and anxiety, but also have a number of psychosocial and spiritual issues, which are not addressed to by us. This leads to a poor quality of life. Hence, these patients require supportive palliative care to relieve their sufferings, but unfortunately such care is not available to them in our country. In this article, we have tried to discuss the barriers to the provision of palliative care to such patients and suggested some measures to overcome them.

Exertional dyspnea associated with chest wall strapping is reduced when external dead space substitutes for part of the exercise stimulus to ventilation

Chest wall strapping has been used to assess mechanisms of dyspnea with restrictive lung disease. This study examined the hypothesis that dyspnea with restriction depends principally on the degree of reflex ventilatory stimulation. We compared dyspnea at the same (iso)ventilation when added dead space provided a component of the ventilatory stimulus during exercise. Eleven healthy men undertook a randomized controlled crossover trial that compared four constant work exercise conditions: 1) control (CTRL): unrestricted breathing at 90% gas exchange threshold (GET); 2) CTRL+dead space (DS): unrestricted breathing with 0.6-l dead space, at isoventilation to CTRL due to reduced exercise intensity; 3) CWS: chest wall strapping at 90% GET; and 4) CWS+DS: chest strapping with 0.6-l dead space, at isoventilation to CWS with reduced exercise intensity. Chest strapping reduced forced vital capacity by 30.4 ± 2.2% (mean ± SE). Dyspnea at isoventilation was unchanged with CTRL+DS compared with CTRL (1.93 ± 0.49 and 2.17 ± 0.43, 0–10 numeric rating scale, respectively; P = 0.244). Dyspnea was lower with CWS+DS compared with CWS (3.40 ± 0.52 and 4.51 ± 0.53, respectively; P = 0.003). Perceived leg fatigue was reduced with CTRL+DS compared with CTRL (2.36 ± 0.48 and 2.86 ± 0.59, respectively; P = 0.049) and lower with CWS+DS compared with CWS (1.86 ± 0.30 and 4.00 ± 0.79, respectively; P = 0.006). With unrestricted breathing, dead space did not change dyspnea at isoventilation, suggesting that dyspnea does not depend on the mode of reflex ventilatory stimulation in healthy individuals. With chest strapping, dead space presented a less potent stimulus to dyspnea, raising the possibility that leg muscle work contributes to dyspnea perception independent of the ventilatory stimulus.

NEW & NOTEWORTHY Chest wall strapping was applied to healthy humans to simulate restrictive lung disease. With chest wall strapping, dyspnea was reduced when dead space substituted for part of a constant exercise stimulus to ventilation. Dyspnea associated with chest wall strapping depended on the contribution of leg muscle work to ventilatory stimulation. Chest wall strapping might not be a clinically relevant model to determine whether an alternative reflex ventilatory stimulus mimics the intensity of exertional dyspnea.

Effectiveness of pulmonary rehabilitation for patients with asthma: study protocol of a randomized controlled trial (EPRA)

BACKGROUND

Asthma patients are enrolled in multimodal pulmonary rehabilitation (PR) programs. However, available data for the effectiveness of PR in asthma are sparse. Therefore, the primary aim of this randomized control trial (RCT) is to evaluate short-term (end of rehabilitation) and intermediate-term effectiveness (3 months after rehabilitation) of PR for patients with asthma regarding asthma control (primary outcome) and other outcomes. Secondly, moderator effects of gender, age, baseline asthma control, quality of life, and anxiety will be examined. Thirdly, a longitudinal follow-up study will explore the course of the outcomes over one year and the annual costs.

METHODS

The EPRA study is a single-center randomized controlled waiting-list trial in the Bad Reichenhall Clinic. Inclusion criteria include a referral diagnosis for uncontrolled asthma, no cognitive impairment and no very severe co-morbidities that indicate significantly greater illness morbidity than asthma alone. In the intervention group (IG), participants will start PR within 4 weeks after randomization; participants of the control group (CG) will start PR 20 weeks after randomization. Data will be assessed at randomization (T0), after 4 weeks (T1; IG: begin of PR), 7 weeks (T2; IG: end of PR), and 20 weeks (T3, CG: begin of PR). The primary outcome is asthma control at T2/T3. Secondary outcomes are health-related quality of life, functional exercise capacity, dyspnea, anxiety, depression, subjective self-management skills, illness perceptions, sick leave and subjective work ability. Outcomes will be analyzed with analysis of covariance, including baseline values of the respective outcomes as covariates. Healthcare costs will be analyzed with a gamma model with a log-link. A longitudinal follow-up study will generate additional data at 3/6/9/12 months after PR for both IG and CG. Latent change models will be used to analyze the course of the primary and secondary outcomes. Annual cost differences before and after rehabilitation will be compared by paired t-test.

DISCUSSION

This RCT will determine the effectiveness of a complex inpatient PR for asthma patients concerning asthma control. Furthermore, important medical and economic information regarding the effectiveness of PR as part of the long-term management of patients with uncontrolled asthma will be generated.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00007740 , May 15, 2015). Protocol version: 1.0 (December, 23, 2016).

How well do patients and providers agree on the severity of dyspnea?

BACKGROUND

Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions.

OBJECTIVE

To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment.

DESIGN, SETTINGS AND PARTICIPANTS

Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital.

INTERVENTION AND MEASUREMENTS

A numerical rating scale (0-10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient.

RESULTS

Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance.

CONCLUSIONS

Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701-707. © 2016 Society of Hospital Medicine.

The Effect of Using an Electric Fan on Dyspnea in Chinese Patients With Terminal Cancer

Background:

Fan therapy is often suggested for relieving the symptom of dyspnea in patients with advanced cancer, but relevant literature among Asians is limited.

Objective:

Phase 2 clinical trial to assess the clinical feasibility and outcome of using an electric fan to alleviate the symptom of dyspnea in Chinese patients with advanced cancer.

Methods:

Thirty patients with advanced cancer having unresolved breathlessness were recruited from Hospice and Palliative Care Centre of Kiang Wu Hospital in Macau. Participants were randomly and equally allocated to the experimental group and the control group, respectively. Outcome Measures: Verbal numerical rating scale (NRS) of breathlessness, respiratory rate (RR), and saturation of peripheral oxygen (SpO2) was collected before and after the intervention.

Results:

T test was used to analyze the data collected. There was a significant difference in the NRS scores of the experimental group ( P < .01), indicating a significant reduction in the patients’ sensation of breathlessness after fan therapy, whereas no significant difference was found in the objective statistic results of RR and SpO2. No significant difference ( P > .05) was found in the control group for all the 3 variables before and after routine treatment.

Conclusion:

The results of the study suggested that fan therapy could be effective in alleviating dyspnea in Chinese patients with advanced cancer. It should be considered as one of the nonpharmacological treatment option. Future large-scale phase 3 clinical trials are warranted.

A methodology using in-chair movements as an objective measure of discomfort for the purpose of statistically distinguishing between similar seat surfaces

This study presents a method for objectively measuring in-chair movement (ICM) that shows correlation with subjective ratings of comfort and discomfort. Employing a cross-over controlled, single blind design, healthy young subjects (n = 21) sat for 18 min on each of the following surfaces: contoured foam, straight foam and wood. Force sensitive resistors attached to the sitting interface measured the relative movements of the subjects during sitting. The purpose of this study was to determine whether ICM could statistically distinguish between each seat material, including two with subtle design differences. In addition, this study investigated methodological considerations, in particular appropriate threshold selection and sitting duration, when analysing objective movement data. ICM appears to be able to statistically distinguish between similar foam surfaces, as long as appropriate ICM thresholds and sufficient sitting durations are present. A relationship between greater ICM and increased discomfort, and lesser ICM and increased comfort was also found.

Effect of experimental modulation of mood on perception of exertional dyspnea in healthy subjects

In many diseases across a range of pathologies (e.g., cardiopulmonary, neuromuscular, and cancer), chronic dyspnea, particularly on exertion, is a major debilitating symptom often associated with clinical anxiety/depression. This study aims to explore the interaction between mood state and exertional dyspnea in a healthy population. Following familiarization, 20 healthy subjects (27-54 years old) performed six 5-min treadmill tests on three separate days. On each day subjects viewed randomly assigned images designed to induce positive, negative, or neutral mood states (International Affective Picture System). For each condition, at minute intervals, subjects rated dyspnea (sensory and affective domains) in the first test and mood (valence and arousal domains) in the second test. Oxygen uptake (V̇O2 , liters/min), carbon dioxide production (V̇CO2, liters/min), ventilation (V̇E, liters/min), respiratory frequency (f(R), beats/min), and heart rate (HR, bpm), were measured throughout the exercise. V̇O2, V̇CO2, V̇E, HR, and f(R) were not statistically significantly different among the three mood states (P > 0.05). Mood valence was significantly higher with parallel viewing of positive (last 2-min mean ± SE = 6.9 ± 0.2) compared with negative pictures (2.4 ± 0.2; P < 0.001). Both sensory and affective domains of dyspnea were significantly higher during negative (sensory: 5.6 ± 0.3; affective: 3.3 ± 0.5) compared with positive mood (sensory: 4.4 ± 0.4, P < 0.001; affective: 2.1 ± 0.4, P = 0.002). These findings suggest that positive mood alleviates both the sensory and affective domains of exertional dyspnea in healthy subjects. Thus the treatment of anxiety/depression in dyspenic populations could be a worthwhile therapeutic strategy in increasing symptom-limited exercise tolerance, thereby contributing to improved quality of life.

Hospitalist attitudes toward the assessment and management of dyspnea in patients with acute cardiopulmonary diseases

BACKGROUND

Dyspnea is a common symptom in patients hospitalized with acute cardiopulmonary diseases. Routine assessment of dyspnea severity is recommended by clinical guidelines based on the evidence that patients are not treated consistently for dyspnea relief.

OBJECTIVE

To evaluate attitudes and beliefs of hospitalists regarding the assessment and management of dyspnea.

DESIGN

Cross-sectional survey.

SETTINGS

Nine hospitals in the United States.

MEASUREMENTS

Survey questions assessed the following domains regarding dyspnea: importance in clinical care, potential benefits and challenges of implementing a standardized assessment, current approaches to assessment, and how awareness of severity affects management. A 5-point Likert scale was used to assess the respondent's level of agreement; strongly agree and agree were combined into a single category.

RESULTS

Of the 255 hospitalists invited to participate, 69.8% completed the survey; 77.0% agreed that dyspnea relief is an important goal when treating patients with cardiopulmonary conditions. Approximately 90% of respondents stated that awareness of dyspnea severity influences their decision to intensify treatment, to pursue additional diagnostic testing, and the timing of discharge. Of the respondents, 61.0% agreed that standardized assessment of dyspnea should be part of the vital signs, and 64.6% agreed that awareness of dyspnea severity influences their decision to prescribe opioids. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized scale.

CONCLUSIONS

Most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and patient care. Measurement and documentation of dyspnea severity may represent an opportunity to improve dyspnea management.

Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research

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

Effect of induced leg muscle fatigue on exertional dyspnea in healthy subjects

The genesis of dyspnea is complex. It appears to be related to central respiratory drive although prevailing leg fatigue could independently potentiate dyspnea. We hypothesized that experimentally induced leg fatigue generates more intense exertional dyspnea for a given level of ventilatory drive. Following familiarization, 19 healthy subjects (32.2 ± 7.6 yr; 11 men) performed a 5-min treadmill test (speed: ∼4 km/h; grade: ∼25%) on two separate days randomized between control (C) and experimentally induced leg fatigue (E) achieved by repeated knee extension against 40% body weight until task failure. Oxygen uptake (V̇o2, l/min), carbon dioxide output (V̇co2, l/min), ventilation (V̇e, l/min), and respiratory rate (fR) were measured breath by breath. Heart rate (HR) and perceived dyspnea intensity (0–10 numerical scale) were recorded continuously. Data were averaged over 30-s intervals. Exertional dyspnea during E was statistically significantly higher (E vs. C: 4.2 ± 0.2 vs. 3.4 ± 0.2, P < 0.001) and accompanied by a significant increase in V̇e (E vs. C: 61.7 ± 3.7 vs. 55.3 ± 2.8, P = 0.005) and fR (E vs. C: 26.7 ± 1.0 vs. 24.2 ± 1.3, P = 0.036). Dyspnea following E remained significantly higher after allowing for the V̇e confound (ANCOVA, P = 0.003). V̇o2, V̇co2, and HR were not significantly different between two conditions. However, the slopes for dyspnea vs. V̇o2 and dyspnea vs. V̇e were similar between E and C, which suggested that gain in dyspnea per unit change in V̇o2 or V̇e was not altered by leg fatigue. These findings support the hypothesis that the intensity of exertional dyspnea is exacerbated by peripheral afferent information from fatigued leg muscles.

The affective dimension of dyspnea improves in a dyspnea self-management program with exercise training

CONTEXT

The perception of dyspnea includes both sensory and affective dimensions that are shaped by emotions and psychological, social, and environmental experiences. Previous investigators have studied either measurement or strategies to decrease the affective dimension with laboratory-induced dyspnea. Few have reported the effect of a therapeutic clinical intervention on the affective dimension of dyspnea.

OBJECTIVES

(1) To evaluate the effects of three different versions of a dyspnea self-management program (DM) on the affective dimension of dyspnea, measured by dyspnea-related anxiety (DA) and dyspnea-related distress (DD); and (2) to determine the stability of DA and DD over two baseline incremental treadmill tests (ITTs).

METHODS

Participants with chronic obstructive pulmonary disease were randomly assigned to three 12 month DMs with varying doses of supervised exercise (DM, DM-Exposure, and DM-Training). The measurements of the affective dimension, DA and DD, were rated during ITTs on two baseline days and at two, six, and 12 months. Changes over time in DA and DD were analyzed using linear mixed-effects models.

RESULTS

Participants in the DM-Training group who received 24 nurse-coached exercise sessions had significantly greater reductions in DA and DD compared with those who had four exercise sessions (DM-Exposure) or only received a home-walking program (DM). Reductions in DA and DD in the DM-Training group were only maintained through six months. There were no significant differences in ratings of DA and DD at end between the two baseline ITTs.

CONCLUSION

These findings provide initial support for the positive impact of a self-management program with nurse-coached exercise on the affective dimension of dyspnea. Further investigation of interventions that target the affective dimension in addition to the sensory dimension of dyspnea should be encouraged.

Routine dyspnea assessment on unit admission

Dyspnea assessment is valuable in diagnosis, prognosis, symptom management, and targeted intervention, and in the allotment and management of patient care resources. The assessment of dyspnea, like that of pain, depends on patient self-report. Expert consensus panels have called for dyspnea to be measured quantitatively and documented on a routine basis, as is the practice with pain. But little information is available on how to measure and record dyspnea ratings systematically. Consequently, the prevalence of dyspnea in hospital settings may be greater than is generally recognized, and dyspnea may be insufficiently managed. This article describes a pilot study that sought to test the feasibility of measuring dyspnea as part of the initial patient assessment performed by nurses within several inpatient units of a large urban hospital.

Qualitative assessment of attributes and ease of use of the ELLIPTA™ dry powder inhaler for delivery of maintenance therapy for asthma and COPD

Background

Medications for respiratory disorders including asthma and chronic obstructive pulmonary disease (COPD) are typically delivered to the lung by means of a handheld inhaler. Patient preference for and ability to use the inhaler may influence their adherence to maintenance therapy, and adherence may affect treatment outcomes. In this study, patient experience of using a dry powder inhaler (DPI), the ELLIPTA™ DPI, in clinical trials of a new maintenance therapy for asthma and COPD was investigated. The ELLIPTA DPI has been designed to contain two separate blister strips from which inhalation powder can be delivered, and to be simple to use with a large, easy-to-read dose counter.

Methods

Semi-structured, in-depth, qualitative interviews were carried out 2–4 weeks after patients had completed one of six phase IIIa clinical trials using the ELLIPTA DPI. Interview participants were asked about their satisfaction with various attributes of the inhaler and their preference for the ELLIPTA DPI relative to currently-prescribed inhalers, and responses were explored using an inductive content analysis approach. Participants also rated the performance of the inhaler on several criteria, using a subjective 1–10 scale.

Results

Participants with asthma (n = 33) and COPD (n = 42) reported high levels of satisfaction with the ELLIPTA DPI. It was frequently described as straightforward to operate and easy to use by interview participants. Ergonomic design, mouthpiece fit, and dose counter visibility and ease of interpretation emerged as frequently cited drivers of preference for the ELLIPTA DPI compared with their current prescribed inhaler. Of participants with asthma, 71% preferred the ELLIPTA DPI to DISKUS™ and 60% to metered dose inhalers. Of participants with COPD, 86% preferred the ELLIPTA DPI to DISKUS, 95% to HandiHaler™, and 85% to metered dose inhalers. Overall average performance scores were >9 (out of 10) in participants with asthma and COPD.

Conclusion

The ELLIPTA DPI was associated with high patient satisfaction and was preferred to other inhalers by interview participants with asthma and COPD. The development of an inhaler that is regarded as easy and intuitive to use may have positive implications for adherence to therapy in asthma and COPD.

Trial registration

Asthma: NCT01165138, NCT01431950. COPD: NCT01053988, NCT01054885, NCT01009463, NCT01017952.

Research priorities in geriatric palliative care: nonpain symptoms

Research addressing the burden, assessment, and management of nonpain symptoms associated with advanced illness in older adults is limited. While nonpain symptoms such as fatigue, sleep, dyspnea, anxiety, depression, cognitive impairment, nausea, and anorexia-cachexia are commonly noted by patients and clinicians, research quantifying their effects on quality of life, function, and other outcomes are lacking and there is scant evidence regarding management. Most available studies have focused on relatively narrow conditions (e.g., chemotherapy-induced nausea) and there are almost no data relevant to patients with multiple morbidities or multiple concurrent symptoms. Assessment and treatment of nonpain symptoms in older adults with serious illness and multiple comorbidities is compromised by the lack of data relevant to their care. Recommended research priorities address the documented high prevalence of distressing symptoms in older adults with serious illness, the unique needs of this population due to coexistence of multiple chronic conditions along with physiologic changes related to aging, the lack of evidence for effective pharmacologic and nonpharmacologic interventions, and the need for validated measures that are relevant across multiple care settings.

Validation of a verbal dyspnoea rating scale in the emergency department

OBJECTIVE

Use of a verbal dyspnoea rating scale in the emergency department (ED) has many potential benefits, providing information to clinicians otherwise not afforded by objective parameters. In the present study, we aimed to investigate the validity of a verbal dyspnoea rating scale, previously validated in the setting of cardiac stress tests, among patients presenting to the ED with acute shortness of breath (SOB).

METHODS

This was a prospective observational study conducted at an inner-urban adult tertiary hospital. A convenience sample of patients presenting with SOB to the ED had objective data collected at triage and 30 min later, including respiratory rate (RR), oxygen saturation (S(a)O(2)), heart rate (HR) and systolic blood pressure (SPB). These were correlated with the participants' subjective response to the question: 'On a scale from 0 to 10, how bad is your SOB, with zero being no SOB and 10 the worst SOB you could ever imagine?' Spearman correlations were then calculated between objective and subjective breathlessness measures.

RESULTS

For 253 breathless ED patients (mean age 60.6 years, 126 male), verbal dyspnoea scores at triage correlated with RR (r = 0.77, P < 0.001), S(a)O(2) (r =-0.43, P < 0.001), HR (r = 0.35, P < 0.001) and SPB (r = 0.19, P < 0.05). Thirty minutes later, correlations remained significant for RR (r = 0.74, P < 0.001), S(a)O(2) (r =-0.39, P < 0.001) and HR (r = 0.40, P < 0.001).

CONCLUSION

A verbal numerical SOB rating scale is a valid measure of breathlessness in the ED, and might therefore provide useful insight into a symptom that is otherwise unmeasurable.

Dyspnea in the thoracic trauma patient: a human response to illness

Dyspnea is one of the most common presenting symptoms in thoracic trauma patients; therefore, trauma nurses require extensive knowledge of this symptom. The Human Response to Illness model provides an organizing framework to establish a comprehensive understanding of the human response of dyspnea following thoracic trauma. The model is used to describe the physiological, pathophysiological, behavioral, and experiential perspectives of dyspnea in thoracic trauma, while considering personal and environmental factors. This comprehensive overview will provide the trauma nurse with appropriate evidence-based rationale for interventions in the management of acute dyspnea in the thoracic trauma population.

Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial

CONTEXT

Dyspnea is a disabling distressing symptom that is common in advanced disease affecting millions of people worldwide. Current palliative strategies are partially effective in managing this symptom; facial cooling has been shown to reduce the sensation of breathlessness when induced in volunteers but has not been formally investigated in dyspnea associated with disease.

OBJECTIVE

The objective of this study was to investigate whether a handheld fan reduces the sensation of breathlessness in such patients, enhancing palliative approaches.

METHODS

The effectiveness of a handheld fan (blowing air across the nose and mouth) in reducing the sensation of breathlessness was assessed in patients with advanced disease. Fifty participants were randomized to use a handheld fan for five minutes directed to their face or leg first and then crossed over to the other treatment. The primary outcome measure was a decrease of greater than 1cm in breathlessness recorded on a 10 cm visual analog scale (VAS).

RESULTS

There was a significant difference in the VAS scores between the two treatments, with a reduction in breathlessness when the fan was directed to the face (P=0.003).

CONCLUSION

This study supports the hypothesis that a handheld fan directed to the face reduces the sensation of breathlessness. The fan was acceptable to participants: it is inexpensive, portable, enhances self-efficacy, and available internationally. It should be recommended as part of a palliative management strategy for reducing breathlessness associated with advanced disease.

Measurement of dyspnoea in the clinical rather than the research setting

PURPOSE OF REVIEW

Refractory dyspnoea is a common and difficult to treat symptom in advanced disease. Accurate assessment helps to guide treatment and prognosis.

RECENT FINDINGS

The absence of commonly agreed assessment tools has been a significant barrier to improving care through inhibition of clinical research and limitation of clinicians' ability to assess the effectiveness of their interventions. Two recently published systematic reviews on measurement tools for breathlessness identified a variety of tools but none could be recommended as gold standard. Validation of these tools in palliative care seems more appropriate than development of new tools. For clinical purposes, the combination of a unidimensional tool to assess dyspnoea severity and a multidimensional tool to evaluate the impact on a person's quality of life seem most appropriate. This review discusses the present evidence and puts forward a strategy for assessment and measurement of the symptom in clinical practice.

SUMMARY

Despite a variety of measurement tools none can be recommended as gold standard for the assessment of dyspnoea. A combination of unidimensional and multidimensional tools seems to be the best for clinical assessment. Measurement of dyspnoea has to be seen in context with the person's history, physical examination and diagnostic tests.