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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Cochrane Database Syst Rev 2019; 2:CD012704. [PMID: 30784058 PMCID: PMC6381295 DOI: 10.1002/14651858.cd012704.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. OBJECTIVES To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. SELECTION CRITERIA We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. DATA COLLECTION AND ANALYSIS Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. MAIN RESULTS Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. AUTHORS' CONCLUSIONS There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.
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Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Currow DC, Ekström M, Louw S, Hill J, Fazekas B, Clark K, Davidson PM, McDonald C, Sajkov D, McCaffrey N, Doogue M, Abernethy AP, Agar M. Sertraline in symptomatic chronic breathlessness: a double blind, randomised trial. Eur Respir J 2018; 53:13993003.01270-2018. [DOI: 10.1183/13993003.01270-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/03/2018] [Indexed: 11/05/2022]
Abstract
Does sertraline provide symptomatic relief for chronic breathlessness in people with advanced disease whose underlying cause(s) are optimally treated?223 participants with chronic breathlessness (modified Medical Research Council breathlessness scale ≥2) who had optimal treatment of underlying cause(s) were randomised 1:1 to sertraline 25–100 mg (titrated upwards over 9 days) or placebo for 4 weeks. The primary outcome was the proportion who had an improvement in intensity of current breathlessness >15% from baseline on a 100-mm visual analogue scale.The proportion of people responding to sertraline was similar to placebo for current breathlessness on days 26–28 (OR 1.00, 95% CI 0.71–1.40) and for other measures of breathlessness. Quality of life in the sertraline arm had a higher likelihood of improving than in the placebo arm over the 4 weeks (OR 0.21, 95% CI 0.01–0.41; p=0.044). No differences in performance status, anxiety and depression, or survival were observed. Adverse event rates were similar between arms.Sertraline does not appear to provide any benefit over placebo in the symptomatic relief of chronic breathlessness in this patient population.
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Alpert CM, Smith MA, Hummel SL, Hummel EK. Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev 2018; 22:25-39. [PMID: 27592330 DOI: 10.1007/s10741-016-9581-4] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.
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Affiliation(s)
- Craig M Alpert
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Smith
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.,Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott L Hummel
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ellen K Hummel
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Frankel Cardiovascular Center, 1500 East Medical Center Dr., SPC 5233, Ann Arbor, MI, 48109-5233, USA.
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4
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Hippokratia 2017. [DOI: 10.1002/14651858.cd012704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Jacqueline Duc
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- Faculty of Medicine; University of Brisbane Brisbane Australia
- Children's Health Queensland; Paediatric Palliative Care Service; Brisbane Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- St Vincent's Private Hospital; Department of Palliative Care; 411 Main Street Kangaroo Point Brisbane Queensland Australia 4169
| | - Sohil Khan
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Kirsty Rickett
- UQ/Mater McAuley Library; The University of Queensland Library; Raymond Terrace Brisbane Queensland Australia 4101
| | - Petra Vayne-Bossert
- University Hospitals of Geneva; Department of Readaptation and Palliative Medicine; 11 chemin de la Savonnière Collonge-Bellerive Geneva Switzerland 1245
| | - Janet R Hardy
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
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Watts GJ, Clark K, Agar M, Davidson PM, McDonald C, Lam LT, Sajkov D, McCaffrey N, Doogue M, Abernethy AP, Currow DC. Study protocol: a phase III randomised, double-blind, parallel arm, stratified, block randomised, placebo-controlled trial investigating the clinical effect and cost-effectiveness of sertraline for the palliative relief of breathlessness in people with chronic breathlessness. BMJ Open 2016; 6:e013177. [PMID: 27899400 PMCID: PMC5168508 DOI: 10.1136/bmjopen-2016-013177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Breathlessness remains a highly prevalent and distressing symptom for many patients with progressive life-limiting illnesses. Evidence-based interventions for chronic breathlessness are limited, and there is an ongoing need for high-quality research into developing management strategies for optimal palliation of this complex symptom. Previous studies have suggested that selective serotonin reuptake inhibitors such as sertraline may have a role in reducing breathlessness. This paper presents the protocol for a large, adequately powered randomised study evaluating the use of sertraline for chronic breathlessness in people with progressive life-limiting illnesses. METHODS AND ANALYSIS A total of 240 participants with modified Medical Research Council Dyspnoea Scale breathlessness of level 2 or higher will be randomised to receive either sertraline or placebo for 28 days in this multisite, double-blind study. The dose will be titrated up every 3 days to a maximum of 100 mg daily. The primary outcome will be to compare the efficacy of sertraline with placebo in relieving the intensity of worst breathlessness as assessed by a 0-100 mm Visual Analogue Scale. A number of other outcome measures and descriptors of breathlessness as well as caregiver assessments will also be recorded to ensure adequate analysis of participant breathlessness and to allow an economic analysis to be performed. Participants will also be given the option of continuing blinded treatment until either study data collection is complete or net benefit ceases. Appropriate statistical analysis of primary and secondary outcomes will be used to describe the wealth of data obtained. ETHICS AND DISSEMINATION Ethics approval was obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12610000464066.
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Affiliation(s)
- Gareth J Watts
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Meera Agar
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Clinical Trials, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Patricia M Davidson
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine McDonald
- Austin Health, Respiratory and Sleep Medicine, Austin Hospital, Heidelberg, Victoria, Australia
| | - Lawrence T Lam
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Dimitar Sajkov
- Australian Respiratory and Sleep Medicine Institute, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Nicola McCaffrey
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Matthew Doogue
- Department of Clinical Pharmacology, University of Otago, Christchurch, New Zealand
| | - Amy P Abernethy
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David C Currow
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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Chowienczyk S, Javadzadeh S, Booth S, Farquhar M. Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer. J Pain Symptom Manage 2016; 52:259-64. [PMID: 27233139 DOI: 10.1016/j.jpainsymman.2016.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 01/15/2016] [Accepted: 02/13/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Verbal descriptors are important in understanding patients' experience of breathlessness. OBJECTIVES The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness. METHODS We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis. RESULTS Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness. CONCLUSION The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.
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Affiliation(s)
- Sarah Chowienczyk
- Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Shagayegh Javadzadeh
- Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Sara Booth
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Morag Farquhar
- Department of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge, United Kingdom.
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Unverdorben M, Parodi G, Pistolesi M, Storey RF. Dyspnea related to reversibly-binding P2Y12 inhibitors: A review of the pathophysiology, clinical presentation and diagnostics. Int J Cardiol 2015; 202:167-73. [PMID: 26386945 DOI: 10.1016/j.ijcard.2015.08.162] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 08/13/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
Dyspnea is a common symptom physiologically associated with strenuous exercise and pathologically reflecting well-known diseases and conditions that are predominantly pulmonary, cardiovascular, and weight-related in origin. Dyspnea improves with appropriate measures that enhance physical performance and treatment of the underlying diseases. Dyspnea is less commonly triggered by other causes such as the environment (e.g., ozone), drugs, and others, some of which do not seem to affect bronchopulmonary function as evidenced by normal results of comprehensive pulmonary function testing. In cardiovascular medicine, dyspnea has recently attracted attention because it has been reported that this symptom occurs more frequently with the administration of the new oral reversibly-binding platelet P2Y12 receptor inhibitors ticagrelor [1-6], cangrelor [7-10], and elinogrel [11]. This paper succinctly addresses the current understanding of the pathophysiology, clinical presentation, and diagnostics of dyspnea, associated either with bronchopulmonary function impairment, as triggered mainly by pulmonary and cardiovascular diseases, or without bronchopulmonary function impairment, as induced by endogenous or external compounds such as drugs in order to provide a context for understanding, recognizing and managing P2Y12 inhibitor-induced dyspnea.
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Affiliation(s)
- Martin Unverdorben
- Clinical Research Institute, Center for Cardiovascular Diseases, Academic Teaching Institution of the Goethe-University Frankfurt/Main, Rotenburg an der Fulda, Germany.
| | - Guido Parodi
- Department of Cardiology, Careggi Hospital, Florence, Italy
| | - Massimo Pistolesi
- Department of Experimental and Clinical Medicine, Respiratory Medicine, University of Florence, Italy
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
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8
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Alyami MM, Jenkins SC, Lababidi H, Hill K. Reliability and validity of an arabic version of the dyspnea-12 questionnaire for Saudi nationals with chronic obstructive pulmonary disease. Ann Thorac Med 2015; 10:112-7. [PMID: 25829962 PMCID: PMC4375739 DOI: 10.4103/1817-1737.150730] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/25/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND: Dyspnea is a distressing symptom experienced by people with chronic obstructive pulmonary disease (COPD). The dyspnea-12 (D-12) questionnaire comprises of 12 items and assesses the quality of this symptom, its severity and the emotional response. The original (English) version of the D-12 is reliable and valid for the measurement of dyspnea in pulmonary diseases. AIM: To translate the D-12 into Arabic and determine whether this version is reliable and valid in Saudi nationals with COPD. METHODS: The D-12 was translated into Arabic version and reviewed by an expert panel before being back-translated into English. The Arabic version was administered to five patients with COPD to test whether it was easily understood after which a final Arabic version was produced. Thereafter, 40 patients with COPD (aged 63 9 years; 33 [82.5%] males; forced expiratory volume in one second (FEV
1) 47 16% predicted) completed the D-12, the COPD Assessment Test (CAT) and the Chronic Respiratory Disease Questionnaire (CRDQ). Lung function and 6-minute walk distance were also measured. The D-12 was re-administered two weeks later. RESULTS: The Arabic version of the D-12 demonstrated good reliability over the two administration (intraclass correlation coefficient = 0.94, P = 0.01). Strong associations were demonstrated between the (1) total score for the D-12 and the CAT, (2) quality sub-score of the D-12 and the CAT and (3) emotional response sub-score of the D-12 and emotional function domain of the CRDQ (r ≥ 0.6, all P < 0.01). CONCLUSION: The Arabic version of the D-12 is a reliable and valid instrument in Saudi nationals with COPD.
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Affiliation(s)
- Mohammed M Alyami
- Department of Pulmonary Rehabilitation, School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia ; Ministry of Higher Education, Riyadh, Saudi Arabia
| | - Sue C Jenkins
- Department of Pulmonary Rehabilitation, School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia ; Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Australia ; Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Australia
| | - Hani Lababidi
- Department of Pulmonary and Critical Care, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kylie Hill
- Department of Pulmonary Rehabilitation, School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia ; Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Australia
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9
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Johnson MJ, Abernethy AP, Currow DC. The evidence base for oxygen for chronic refractory breathlessness: issues, gaps, and a future work plan. J Pain Symptom Manage 2013; 45:763-75. [PMID: 23017616 DOI: 10.1016/j.jpainsymman.2012.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/03/2012] [Accepted: 03/09/2012] [Indexed: 10/27/2022]
Abstract
Breathlessness or "shortness of breath," medically termed dyspnea, is a common and distressing symptom featuring strongly in advanced lung, cardiac, and neuromuscular diseases; its prevalence and intensity increase as death approaches. However, despite the increasing understanding in the genesis of breathlessness, as well as an increasing portfolio of treatment options, breathlessness is still difficult to manage and engenders helplessness in caregivers and health care professionals and fear for patients. Although hypoxemia does not appear to be the dominant driver for breathlessness in advanced disease, the belief that oxygen is important for the relief of acute, chronic, and acute-on-chronic shortness of breath is firmly embedded in the minds of patients, caregivers, and health care professionals. This article presents current understanding of the use of oxygen for treating refractory breathlessness in advanced disease. The objective is to highlight what is still unknown, set a research agenda to resolve these questions, and highlight methodological issues for consideration in planned studies.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom.
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10
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Teixeira CA, Rodrigues Júnior AL, Straccia LC, Vianna EDSO, Silva GAD, Martinez JAB. Dyspnea descriptors translated from English to Portuguese: application in obese patients and in patients with cardiorespiratory diseases. J Bras Pneumol 2012; 37:455-63. [PMID: 21881735 DOI: 10.1590/s1806-37132011000400007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/09/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To investigate the usefulness of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) that were developed in English and translated to Brazilian Portuguese in patients with four distinct clinical conditions that can be accompanied by dyspnea. METHODS We translated, from English to Brazilian Portuguese, a list of 15 dyspnea descriptors reported in a study conducted in the USA. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. RESULTS The use of this set of descriptors led to a solution with nine clusters, designated expiração (exhalation), fome de ar (air hunger), sufoco (suffocating), superficial (shallow), rápido (rapid), aperto (tight), falta de ar (shortness of breath), trabalho (work), and inspiração (inhalation). Overlapping of the descriptors was quite common among the patients, regardless of their clinical condition. Asthma, COPD, and heart failure were significantly associated with the inspiração cluster. Heart failure was also associated with the trabalho cluster, whereas obesity was not associated with any of the clusters. CONCLUSIONS In our study sample, the application of dyspnea descriptors translated from English to Portuguese led to the identification of distinct clusters, some of which were similar to those identified in a study conducted in the USA. The translated descriptors were less useful than were those developed in Brazil regarding their ability to generate significant associations among the clinical conditions investigated here.
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Affiliation(s)
- Christiane Aires Teixeira
- Department of Clinical Medicine, University of São Paulo at Ribeirão Preto School of Medicine – Ribeirão Preto, Brazil
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11
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Teixeira CA, Rodrigues Júnior AL, Straccia LC, Vianna EDSO, Silva GAD, Martinez JAB. Dyspnea descriptors developed in Brazil: application in obese patients and in patients with cardiorespiratory diseases. J Bras Pneumol 2012; 37:446-54. [PMID: 21881734 DOI: 10.1590/s1806-37132011000400006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/09/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To develop a set of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) for use in Brazil and to investigate the usefulness of these descriptors in four distinct clinical conditions that can be accompanied by dyspnea. METHODS We collected 111 dyspnea descriptors from 67 patients and 10 health professionals. These descriptors were analyzed and reduced to 15 based on their frequency of use, similarity of meaning, and potential pathophysiological value. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. RESULTS The use of this set of descriptors led to a solution with seven clusters, designated sufoco (suffocating), aperto (tight), rápido (rapid), fadiga (fatigue), abafado (stuffy), trabalho/inspiração (work/inhalation), and falta de ar (shortness of breath). Overlapping of descriptors was quite common among the patients, regardless of their clinical condition. Asthma was significantly associated with the sufoco and trabalho/inspiração clusters, whereas COPD and heart failure were associated with the sufoco, trabalho/inspiração, and falta de ar clusters. Obesity was associated only with the falta de ar cluster. CONCLUSIONS In Brazil, patients who are accustomed to perceiving dyspnea employ various descriptors in order to describe the symptom, and these descriptors can be grouped into similar clusters. In our study sample, such clusters showed no usefulness in differentiating among the four clinical conditions evaluated.
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Affiliation(s)
- Christiane Aires Teixeira
- Department of Clinical Medicine, University of São Paulo at Ribeirão Preto School of Medicine – Ribeirão Preto, Brazil
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Parshall MB, Meek PM, Sklar D, Alcock J, Bittner P. Test-retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study. BMC Emerg Med 2012; 12:6. [PMID: 22624887 PMCID: PMC3464619 DOI: 10.1186/1471-227x-12-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 05/24/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Dyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients. METHODS Patients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration ("now" MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach's alpha. Test-retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains. RESULTS PCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach's alpha = .89 to .94; Emotional Response, 5 items; Cronbach's alpha = .81 to .85). Test-retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively). CONCLUSIONS During an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test-retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435-52. [PMID: 22336677 PMCID: PMC5448624 DOI: 10.1164/rccm.201111-2042st] [Citation(s) in RCA: 1085] [Impact Index Per Article: 90.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012. [PMID: 22336677 DOI: 10.1164/rccm.201111–2042st] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Certain bio-psychosocial–spiritual problems associated with dyspnea among advanced cancer patients in Taiwan. Support Care Cancer 2011; 20:1763-70. [DOI: 10.1007/s00520-011-1273-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 09/06/2011] [Indexed: 10/17/2022]
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Parshall MB, Carle AC, Ice U, Taylor R, Powers J. Validation of a three-factor measurement model of dyspnea in hospitalized adults with heart failure. Heart Lung 2011; 41:44-56. [PMID: 21794918 DOI: 10.1016/j.hrtlng.2011.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 04/28/2011] [Accepted: 05/06/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to validate a 3-factor measurement model of dyspnea sensory quality (WORK-EFFORT, TIGHTNESS, SMOTHERING-AIR HUNGER) originally derived in patients with exacerbated chronic obstructive pulmonary disease. METHODS In this validation study, adult patients with heart failure were enrolled after hospital admission (median hospital day 1) and asked to rate the intensity of dyspnea sensory quality descriptors on the day of enrollment (study day 1; N = 119) and in a recall version for the day of admission (study day 0; n = 97). RESULTS Confirmatory factor analysis demonstrated good model fit for both days. Cronbach's α for each factor was greater than .87 for both study days. CONCLUSION This is the first study to validate a previously specified measurement model of dyspnea sensory quality in an independent sample. Results indicate that measurement of dyspnea sensory quality in exacerbated cardiopulmonary disease does not necessarily require disease-specific questionnaires.
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Affiliation(s)
- Mark B Parshall
- College of Nursing, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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Yorke J, Russell AM, Swigris J, Shuldham C, Haigh C, Rochnia N, Hoyle J, Jones PW. Assessment of dyspnea in asthma: validation of The Dyspnea-12. J Asthma 2011; 48:602-8. [PMID: 21635136 DOI: 10.3109/02770903.2011.585412] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dyspnea is a prominent symptom in asthma. The Dyspnea-12 (D-12), an instrument that quantifies breathlessness using 12 descriptors that tap the physical and affective aspects, has shown promise for the measurement of dyspnea in cardiorespiratory disease. OBJECTIVE We report the results of a study designed to test the validity and reliability of the D-12 in a population of patients with asthma. METHODS This cross-sectional study included 102 patients with asthma. Subjects completed the D-12, Hospital Anxiety and Depression scale, St. George's Respiratory Questionnaire (SGRQ), and Medical Research Council scale. Confirmatory factor analysis confirmed the two-component structure of the D-12 (i.e., seven items that tap the physical aspects of breathlessness and five items that tap the affective aspects). RESULTS The D-12 subscales had excellent internal reliability (Cronbach's alpha for the "physical" score was 0.94 and the affective score was 0.95). The D-12 physical component was more strongly correlated with SGRQ Symptoms (r = 0.648), SGRQ Activities (r = 0.635) and Medical Research Council grade (r = 0.636), while the affective component was more strongly correlated with SGRQ Impacts (r = 0.765) and Hospital Anxiety and Depression scale scores (anxiety r = 0.641 and depression r = 0.602). CONCLUSION This study supports validity of the D-12 for use in the assessment of dyspnea of patients with asthma. It assesses one of the most pertinent symptoms of asthma from two viewpoints-physical and affective.
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Affiliation(s)
- Janelle Yorke
- School of Nursing and Midwifery, College of Health & Social Care, University of Salford, Greater Manchester, UK.
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18
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Dyspnea. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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Harver A, Schwartzstein RM, Kotses H, Humphries CT, Schmaling KB, Mullin ML. Descriptors of breathlessness in children with persistent asthma. Chest 2010; 139:832-838. [PMID: 21183610 DOI: 10.1378/chest.10-2388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In adult patients, the consistent use of language to describe dyspnea enhances patient-provider communication and contributes to diagnostic and therapeutic decisions. The objective of this research was to determine whether pediatric patients similarly display consistency in the language used to describe "uncomfortable awareness of breathing." METHODS One hundred children between the ages of 8 and 15 years with moderate to severe persistent asthma enrolled in an asthma education research program completed questionnaires regarding descriptors of asthma on each of two occasions. In addition to the breathlessness questionnaires, demographic information, self-reported asthma severity, ED visits, missed school days, anthropometrics, and spirometry were obtained for each participant. RESULTS Children were reliable in their choice of the descriptors that they applied to their breathing discomfort across two occasions, and they selected the same descriptors that were used by adults with asthma in previous studies. Children with greater self-reported asthma severity endorsed more descriptors to characterize breathing discomfort than did children with less severe asthma, but no differences were found among children based on demographic or anthropometric variables. CONCLUSIONS Children with moderate to severe persistent asthma are reliable in their choice of descriptors of breathlessness. Knowledge of their experience of symptoms may be helpful clinically in the assessment and management of asthma.
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Affiliation(s)
- Andrew Harver
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC.
| | - Richard M Schwartzstein
- Harvard Medical School and Division of Pulmonary Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Harry Kotses
- Department of Psychology, Ohio University, Athens, OH
| | - C Thomas Humphries
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC; Asthma and Allergy Specialists, P.A., Charlotte, NC
| | - Karen B Schmaling
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC
| | - Melanie Lee Mullin
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC
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Kathiresan G, Clement RF, Sankaranarayanan MT. Dyspnea in lung cancer patients: a systematic review. LUNG CANCER (AUCKLAND, N.Z.) 2010; 1:141-150. [PMID: 28210113 PMCID: PMC5312471 DOI: 10.2147/lctt.s14426] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Dyspnea is a common and distressing symptom experienced by 19%-51% of patients with advanced cancer. Higher incidences are reported in patients approaching end of life. While the prevalence of dyspnea has been reported to be as frequent as pain in people with lung cancer, less attention has been paid to the distress associated with dyspnea. This review of the literature was undertaken to investigate how dyspnea has been assessed and whether breathlessness in people with lung cancer is distressing. Using a predetermined search strategy and inclusion criteria, 31 primary studies were identified and included in this review. Different outcome measures were used to assess the experience of dyspnea, with domains including intensity, distress, quality of life, qualitative sensation, and prevalence. Overall, the studies report a high prevalence of dyspnea in lung cancer patients, with subjects experiencing a moderate level of dyspnea intensity and interference with activities of daily living. Distress associated with breathing appears to be variable, with some studies reporting dyspnea to be the most distressing sensation, and others reporting lower levels of distress. However, taking into account the prevalence, intensity, and distress of dyspnea, the general consensus appears to be that the experience of dyspnea in people with lung cancer is common, with varying degrees of intensity, but involves considerable unpleasantness. Thus, if dyspnea and pain are both distressing sensations for people with lung cancer, this has potential implications for both clinical and academic areas with regards to both management strategies and further research.
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Affiliation(s)
- Ganesan Kathiresan
- Department of Physiotherapy, School of Allied Health, Masterskill University College, Sabah, Malaysia
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Williams M, Cafarella P, Olds T, Petkov J, Frith P. Affective Descriptors of the Sensation of Breathlessness Are More Highly Associated With Severity of Impairment Than Physical Descriptors in People With COPD. Chest 2010; 138:315-22. [DOI: 10.1378/chest.09-2498] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax 2009; 65:21-6. [PMID: 19996336 PMCID: PMC2795166 DOI: 10.1136/thx.2009.118521] [Citation(s) in RCA: 217] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
RATIONALE Dyspnoea is a debilitating and distressing symptom that is reflected in different verbal descriptors. Evidence suggests that dyspnoea, like pain perception, consists of sensory quality and affective components. The objective of this study was to develop an instrument that measures overall dyspnoea severity using descriptors that reflect its different aspects. METHODS 81 dyspnoea descriptors were administered to 123 patients with chronic obstructive pulmonary disease (COPD), 129 with interstitial lung disease and 106 with chronic heart failure. These were reduced to 34 items using hierarchical methods. Rasch analysis informed decisions regarding further item removal and fit to the unidimensional model. Principal component analysis (PCA) explored the underlying structure of the final item set. Validity and reliability of the new instrument were further assessed in a separate group of 53 patients with COPD. RESULTS After removal of items with hierarchical methods (n = 47) and items that failed to fit the Rasch model (n = 22), 12 were retained. The "Dyspnoea-12" had good internal reliability (Cronbach's alpha = 0.9) and fit to the Rasch model (chi(2) p = 0.08). Items patterned into two groups called "physical"(n = 7) and "affective"(n = 5). In the separate validation study, Dyspnoea-12 correlated with the Hospital Anxiety and Depression Scale (anxiety r = 0.51; depression r = 0.44, p<0.001, respectively), 6-minute walk distance (r = -0.38, p<0.01) and MRC (Medical Research Council) grade (r = 0.48, p<0.01), and had good stability over time (intraclass correlation coefficient = 0.9, p<0.001). CONCLUSION Dyspnoea-12 fulfills modern psychometric requirements for measurement. It provides a global score of breathlessness severity that incorporates both "physical" and "affective" aspects, and can measure dyspnoea in a variety of diseases.
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Affiliation(s)
- J Yorke
- School of Nursing, Faculty of Health and Social Care, University of Salford, Greater Manchester, UK.
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Williams M, Garrard A, Cafarella P, Petkov J, Frith P. Quality of recalled dyspnoea is different from exercise-induced dyspnoea: an experimental study. ACTA ACUST UNITED AC 2009; 55:177-83. [PMID: 19681739 DOI: 10.1016/s0004-9514(09)70078-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
QUESTIONS Are volunteered and endorsed descriptors of recalled breathlessness consistent with descriptors of exercise-induced breathlessness? Are volunteered and endorsed descriptors of exercise-induced breathlessness consistent? DESIGN Within-participant, repeated measures, experimental study. PARTICIPANTS 57 people with symptomatic chronic respiratory disease aged 71 years. INTERVENTION There were three conditions. The first was recalled breathlessness. Two conditions of exercise-induced breathlessness were created by getting the participants to undertake the 6-min Walk Test twice (breathlessness 1 and 2). OUTCOME MEASURES Descriptors of breathlessness were volunteered (where participants' used their own words) or endorsed (from a pre-existing list of 15 breathlessness statements). RESULTS Emotive descriptors made up 65% of recalled descriptors compared with 11% of exercise-induced descriptors, whereas physical descriptors made up 35% of recalled descriptors compared with 89% of exercise-induced descriptors. Of the 237 potential language pairs volunteered to describe recalled and exercise-induced breathlessness 1, only 27 (11%) were identical whereas of the 171 potential language pairs endorsed as describing recalled and exercise-induced breathlessness 1, 66 (39%) were identical. Of the 175 potential language pairs of descriptors volunteered to describe exercise-induced breathlessness 1 and 2, 72 (41%) were identical whereas of the 153 potential language pairs endorsed as describing exercise-induced breathlessness 1 and 2, 71 (46%) were identical. CONCLUSION The language used to describe exercise-induced breathlessness immediately after two walking challenges was similar. However, descriptions of recalled breathlessness did not consistently match descriptions of exercise-induced breathlessness, which may reflect the different contexts under which breathlessness was recalled and induced.
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Affiliation(s)
- Marie Williams
- School of Health Sciences, University of South Australia, Adelaide 5000, South Australia, Australia.
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Oxberry SG, Lawrie I. Symptom control and palliative care: management of breathlessness. Br J Hosp Med (Lond) 2009; 70:212-6. [PMID: 19357599 DOI: 10.12968/hmed.2009.70.4.41624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Breathlessness remains a common and significant problem in palliative care. This article reviews the most commonly used interventions and discusses strategies to improve this symptom.
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Dorman S, Jolley C, Abernethy A, Currow D, Johnson M, Farquhar M, Griffiths G, Peel T, Moosavi S, Byrne A, Wilcock A, Alloway L, Bausewein C, Higginson I, Booth S. Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. Palliat Med 2009; 23:213-27. [PMID: 19251835 DOI: 10.1177/0269216309102520] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future 'between study' comparisons. Discussion of the physiology of breathlessness is included.
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Affiliation(s)
- S Dorman
- Poole Hospital NHS Foundation Trust, Longfleet Road, Poole.
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Abstract
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.
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27
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Henoch I, Bergman B, Danielson E. Dyspnea experience and management strategies in patients with lung cancer. Psychooncology 2008; 17:709-15. [PMID: 18074408 DOI: 10.1002/pon.1304] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of this paper was to describe lung cancer patients' experience of dyspnea and their strategies for managing the dyspnea. METHODS Semi-structured interviews with two main questions about dyspnea experiences and management were conducted with 20 patients with lung cancer, not amenable to curative treatment, who had completed life prolonging treatments. Data analysis was made with a descriptive, qualitative content analysis. RESULTS The two questions resulted in two domains with 7 categories and subcategories. The experience of dyspnea included four categories: 'Triggering factors' included circumstances contributing to dyspnea, which comprised physical, psychosocial and environmental triggers. Bodily manifestations were considered to be the core of the experience. 'Immediate reactions' concerned physical and psychological impact. The long-term reactions included limitations, increased dependence and existential impact concerning hope, hopelessness and thoughts of death. The experience of managing dyspnea included three categories: 'Bodily strategies', 'psychological strategies' and 'medical strategies'. CONCLUSION Dyspnea experience is a complex experience which influences the life of the patients both with immediate reactions and long-term reactions concerning physical, emotional and existential issues in life and patients address this experience with managing strategies in order to take control of their situation, although they do not seem to be able to meet the existential distress they experience.
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Affiliation(s)
- Ingela Henoch
- Institute of Health and Care Sciences, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden. ihh
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Williams M, Cafarella P, Olds T, Petkov J, Frith P. The language of breathlessness differentiates between patients with COPD and age-matched adults. Chest 2008; 134:489-496. [PMID: 18490404 DOI: 10.1378/chest.07-2916] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND If descriptors of the sensation of breathlessness are able to differentiate between medical conditions, the language of breathlessness could potentially have a role in differential diagnosis. This study investigated whether the language used to describe the sensation of breathlessness accurately categorized older individuals with and without a prior diagnosis of COPD. METHODS Using a parallel-group design, participants with and without a prior diagnosis of COPD volunteered words and phrases and endorsed up to three statements to describe their sensation of breathlessness. Cluster analysis (v-fold cross-validation) was applied, and subjects were clustered by their choice of words. Cluster membership was then compared to original group membership (COPD vs non-COPD), and predictive power was assessed. RESULTS Groups were similar for age and gender (COPD, n = 94; 48 men; mean age, 70 +/- 10 years [+/- SD]; vs non-COPD, n = 55; 21 men; mean age, 69 +/- 13 years) but differed significantly in breathlessness-related impairment, intensity, and quality of life (p < 0.0001). Cluster membership corresponded accurately with original group classifications (volunteered, 85%; and up to three statements, 68% agreement). Classification based on a single best descriptor (volunteered [62%] or endorsed [55%]) was less accurate for group membership. CONCLUSIONS Language used to describe the sensation of breathlessness differentiated people with and without a prior diagnosis of COPD when descriptors were not limited to a single best word or statement.
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Affiliation(s)
- Marie Williams
- School of Health Sciences, University of South Australia, City East Campus, Adelaide.
| | - Paul Cafarella
- Department of Respiratory Medicine, Repatriation General Hospital, Daw Park, Adelaide
| | - Timothy Olds
- School of Health Sciences, University of South Australia, City East Campus, Adelaide
| | - John Petkov
- Applied Statistics Unit, University of South Australia, Whyalla Campus, Whyalla
| | - Peter Frith
- Respiratory Services, Repatriation General Hospital and Flinders Medical Centre, Repatriation General Hospital, Daw Park, Adelaide, SA, Australia
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Oral Transmucosal Fentanyl Citrate for Dyspnea in Terminally Ill Patients: An Observational Case Series. J Palliat Med 2008; 11:643-8. [DOI: 10.1089/jpm.2007.0161] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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31
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Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. ACTA ACUST UNITED AC 2008; 5:90-100. [PMID: 18235441 DOI: 10.1038/ncponc1034] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 09/03/2007] [Indexed: 11/09/2022]
Abstract
Intractable breathlessness is a common, devastating symptom of advanced cancer causing distress and isolation for patients and families. In advanced cancer, breathlessness is complex and usually multifactorial and its severity unrelated to measurable pulmonary function or disease status. Therapeutic advances in the clinical management of dyspnea are limited and it remains difficult to treat successfully. There is growing interest in the palliation of breathlessness, and recent work has shown that a systematic, evidence-based approach by a committed multidisciplinary team can improve lives considerably. Where such care is lacking it may be owing to therapeutic nihilism in clinicians untrained in the management of chronic breathlessness and unaware that there are options other than endurance. Optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family) with the use of parenteral opioids and sedation at the end of life when appropriate. Effective care centers on the patient's needs and goals. Priorities in breathlessness research include studies on: neuroimaging, the effectiveness of new interventions, the efficacy, safety, and dosing regimens of opioids, the contribution of deconditioning, and the effect of preventing or reversing breathlessness.
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Affiliation(s)
- Sara Booth
- Cambridge University NHS Foundation Trust Hospital, UK.
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Lai YL, Chan CWH, Lopez V. Perceptions of Dyspnea and Helpful Interventions During the Advanced Stage of Lung Cancer. Cancer Nurs 2007; 30:E1-8. [PMID: 17413770 DOI: 10.1097/01.ncc.0000265011.17806.07] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dyspnea is a distressful but neglected symptom in oncology practice and research. The aim of this study was to describe the experience of dyspnea and helpful interventions in Chinese patients with advanced lung cancer admitted in the palliative care unit in 1 region in Hong Kong. A qualitative description approach using in-depth interviews was used to guide this study. Eleven participants agreed to be interviewed with age ranging from 51 to 80 years. They have been diagnosed with lung cancer from 1 to 12 months, and all required oxygen therapy from dyspnea. The results of content analysis revealed 4 main themes: (1) characteristics of dyspnea, (2) impact of dyspnea, (3) strategies used to manage dyspnea, and (4) nurses' role in managing dyspnea. Patients in this study found no Chinese words to adequately define and describe dyspnea and relied on sensations they experienced during the dyspnea episode. The impact of dyspnea was multidimensional, and patients used various strategies to manage dyspnea, including avoiding triggers and utilizing traditional Chinese medicine. Healthcare professionals were perceived to play a very inadequate role in assisting patients with dyspnea, and participants suggested that they should take a more active role in educating and supporting patients with dyspnea.
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Abstract
Dyspnea, defined as uncomfortable or labored breathing, is a common and often devastating cause of distress for patients and their caregivers with advanced cancer and other life-threatening illnesses. The mechanism by which dyspnea develops is not fully understood, but it involves integration of the central respiratory complex with the sensory (perceptual) cortex. The gold standard of diagnosis is patient self-report. Careful assessment should be undertaken to identify reversible existing causes. Systemic opioids are the first-line therapy for symptomatic management, along with other general comfort measures (positioning, cool air, calming environment). Medical or surgical management can be directed toward underlying causes. Advanced care planning should include discussions concerning the burdens and benefits of medical/surgical management of underlying causes of dyspnea to more effectively direct goals of care. This article reviews current literature on dyspnea, with a focus on items published since 2000.
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De Peuter S, Van Diest I, Lemaigre V, Verleden G, Demedts M, Van den Bergh O. Dyspnea: the role of psychological processes. Clin Psychol Rev 2005; 24:557-81. [PMID: 15325745 DOI: 10.1016/j.cpr.2004.05.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2003] [Revised: 04/05/2004] [Accepted: 05/26/2004] [Indexed: 12/12/2022]
Abstract
Breathlessness or dyspnea-the subjective experience of breathing discomfort-is a symptom in many pulmonary, cardiovascular, and neuromuscular diseases. It occurs in normals as well during intense emotional states and heavy labor or exercise. In clinical cases, it generally causes severe suffering. Dyspnea has multifactorial causes and the explanation for the symptom may differ largely among patients. Explanatory models imply the involvement of mechanisms at several levels of functioning, such as afferent signals from the respiratory muscles or blood gas levels related to hypercapnia and hypoxia. Depending on the relative involvement of specific mechanisms and their interactions, dyspnea may be experienced differently and subtypes can be distinguished. More recently, perceptual-cognitive and emotional processes related to symptom perception and interpretation have been investigated in the context of dyspnea. In this review, we focus on the psychological processes that play part in the perception of dyspnea and formulate some practical guidelines for those who are confronted with dyspnea.
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Caroci ADS, Lareau SC. Descriptors of dyspnea by patients with chronic obstructive pulmonary disease versus congestive heart failure. Heart Lung 2004; 33:102-10. [PMID: 15024375 DOI: 10.1016/j.hrtlng.2003.11.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether differences existed between reports of dyspnea in stable chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) subjects. METHODS Sixty stable COPD (n=30) and CHF (n=30) male, outpatient subjects were studied. Subjects were asked to both endorse (from a pre-designed list of descriptors) and volunteer terms that best described their breathing discomfort. Subjects also reported the frequency and the intensity of breathlessness (0-10 scale) using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS From the endorsed list of descriptors, my breath does not go out all the way, was significantly different (COPD=11, CHF=4, P<.05) between groups. The most common terms volunteered by COPD subjects were scary (n=5, P<.02), hard to breathe (n=5), shortness of breath (n=4), and cannot get enough air (n=4), whereas CHF subjects volunteered the terms, shortness of breath (n=9), gasping (n=6), and cannot get enough air (n=4). There was no difference in the frequency with which both groups experienced dyspnea or times per month they reported severe to very severe dyspnea. Subjects with COPD experienced a higher intensity of breathlessness on different occasions P<.05. CONCLUSIONS Stable COPD and CHF patients use and recognize a variety of terms that describe their breathing distress. There was, however, only 1 unique term among the endorsed and volunteered terms, and that was among the COPD subjects. COPD and CHF subjects shared many common terms and also experienced dyspnea with similar frequency. The uniqueness of terms among the COPD group was less clear. The study highlights the variability of the dyspnea experience among COPD and CHF patients and the potential difficulty identifying unique dyspnea terms in these subjects.
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Booth S, Silvester S, Todd C. Breathlessness in cancer and chronic obstructive pulmonary disease:
Using a qualitative approach to describe the experience of patients and
carers. Palliat Support Care 2003; 1:337-44. [PMID: 16594223 DOI: 10.1017/s1478951503030499] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objective: To investigate and document the effects of
breathlessness on the everyday lives of patients with cancer
and COPD and their carers. This subject has been little researched,
although dyspnoea is recognized as a disabling, distressing symptom.
The number of breathless people is increasing as patients with all
types of cardio-respiratory disease live longer.Methods: Patients with severe COPD and cancer and their
carers were interviewed at home using a semistructured format to record
their perceptions of the impact of breathlessness, the help they had
received from medical and caring services, and their ideas on how these
could be improved.Results: 10 patients with COPD (6 male) and 10 with cancer
(6 male) and their spouses were interviewed. All patients found
breathlessness frightening, disabling, and restricting. Patients
developed a stoical, philosophical approach in order to live with
dyspnoea and the difficulties it imposed: this was also an important
way of reducing the emotional impact of breathlessness. Patients'
spouses suffered significantly, experiencing severe anxiety and
helplessness as they witnessed their partners' suffering and felt
powerless to reduce it. The restrictions imposed by breathlessness
affected their lives profoundly. Support of all kinds, practical,
medical, and psychosocial was highly valued but was provided
inconsistently and sporadically. Where help was given it came most
frequently from general practitioners (GPs, family physicians) and
specialist respiratory nurses.Significance of results: This study is the first to document
the psychosocial needs of carers, which are not adequately recognized
or addressed at present. Patients and carers may feel most isolated and
need support outside the working hours of most services and future
provision needs to reflect this. Patients with cancer experience a more
rapid onset of breathlessness. More clinicians need to be educated in
the management of chronic breathlessness so known helpful strategies
are more widely employed.
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Affiliation(s)
- Sara Booth
- Oncology Centre, Addenbrooke's Hospital, Cambridge, UK.
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Affiliation(s)
- Rita Wickham
- Rush-Presbyterian-St. Luke's Medical Center and Rush College of Nursing, Chicago, IL, USA.
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