Dyspnoea and mortality in older people in the community: a 10-year follow-up

Prevalence of dyspnea in general adult populations: A systematic review and meta-analysis

INTRODUCTION

Dyspnea is a commonly described symptom in various chronic and acute conditions. Despite its frequency, relatively little is known about the prevalence and assessment of dyspnea in general populations. The aims of this review were: 1) to estimate the prevalence of dyspnea in general adult populations; 2) to identify associated factors; and 3) to identify used methods for dyspnea assessment.

METHODS

A systematic literature search was conducted using MEDLINE/PubMed, Embase, CINAHL and JAMA network. Records were screened by two independent reviewers and quality was assessed by using the Joanna Briggs Institute checklist for risk of bias in prevalence studies. Multi-level meta-analysis was performed to estimate pooled prevalence. The protocol was registered on PROSPERO (CRD42021275499).

RESULTS

Twenty original articles, all from studies in high-income countries, met the criteria for inclusion. Overall, their quality was good. Pooled prevalence of dyspnea in general adult populations based on 11 studies was 10% (95% CI 7, 15), but heterogeneity across studies was high. The most frequently reported risk factors were increasing age, female sex, higher BMI and respiratory or cardiac disease. The MRC or the modified MRC scale was the most used tool to assess dyspnea in general populations.

CONCLUSIONS

Dyspnea is a common symptom in adults in high-income countries. However, the high heterogeneity across studies and the lack of data from low- and middle-income countries limit the generalizability of our findings. Therefore, more research is needed to unveil the prevalence of dyspnea and its main risk factors in general populations around the world.

Breathlessness limiting exertion in very old adults: findings from the Newcastle 85+ study

INTRODUCTION

Long-term breathlessness is more common with age. However, in the oldest old (>85 years), little is known about the prevalence, or impact of breathlessness. We estimated breathlessness limiting exertion prevalence and explored (i) associated characteristics; and (ii) whether breathlessness limiting exertion explains clinical and social/functional outcomes.

METHODS

Health and socio-demographic characteristics were extracted from the Newcastle 85+ Study cohort. Phase 1 (baseline) and follow-up data (18 months, Phase 2; 36 months, Phase 3; 60 months, Phase 4 after baseline) were examined using descriptive statistics and cross-sectional regression models.

RESULTS

Eight hundred seventeen participants provided baseline breathlessness data (38.2% men; mean 84.5 years; SD 0.4). The proportions with any limitation of exertion, or severe limitation by breathlessness were 23% (95% confidence intervals (CIs) 20-25%) and 9% (95%CIs 7-11%) at baseline; 20% (16-25%) and 5% (3-8%) at Phase 4. Having more co-morbidities (odds ratio (OR) 1.34, 1.18-1.54; P < 0.001), or self-reported respiratory (OR 1.88, 1.25-2.82; P = 0.003) or cardiovascular disease (OR 2.38, 1.58-3.58; P < 0.001) were associated with breathlessness limiting exertion. Breathlessness severely limiting exertion was associated with poorer self-rated health (OR 0.50, 029-0.86; P = 0.012), depression (beta-coefficient 0.11, P = 0.001), increased primary care contacts (beta-co-efficient 0.13, P = 0.001) and number of nights in hospital (OR 1.81; 1.02-3.20; P = 0.042).

CONCLUSIONS

Breathlessness limiting exertion appears to become less prevalent over time due to death or withdrawal of participants with cardio-respiratory illness. Breathlessness severely limiting exertion had a wide range of service utilisation and wellbeing impacts.

Breathlessness Predicts Mortality in Adults: A Systematic Review and Meta-Analysis

Breathlessness is a commonly encountered symptom, and although its relationship with mortality is well established for many conditions, less clear is this relationship in healthy adults. This systematic review and meta-analysis examines whether breathlessness is associated with mortality in a general population. This is important in understanding the impact of this common symptom on a patient's prognosis. This review was registered with PROSPERO (CRD42023394104). Medline, EMBASE, CINAHL and EMCARE were searched for the terms 'breathlessness' and 'survival' or 'mortality' on January 24, 2023. Longitudinal studies of >1,000 healthy adults comparing mortality between breathless and non-breathless controls were eligible for inclusion. If an estimate of effect size was provided, studies were included in the meta-analysis. Eligible studies underwent critical appraisal, data extraction and risk of bias assessment. A pooled effect size was estimated for the relationship between the presence of breathlessness and mortality and levels of severity of breathlessness and mortality. Of 1,993 studies identified, 21 were eligible for inclusion in the systematic review and 19 for the meta-analysis. Studies were of good quality with a low risk of bias, and the majority controlled for important confounders. Most studies identified a significant relationship between the presence of breathlessness and increased mortality. A pooled effect size was estimated, with the presence of breathlessness increasing the risk of mortality by 43% (risk ratio (RR): 1.43, 95% confidence interval (CI): 1.28-1.61). As breathlessness severity increased from mild to severe, mortality increased by 30% (RR: 1.30, 95% CI: 1.21-1.38) and 103%, respectively (RR: 2.03, 95% CI: 1.75-2.35). The same trend was seen when breathlessness was measured using the modified Medical Research Council (mMRC) Dyspnoea Scale: mMRC grade 1 conferred a 26% increased mortality risk (RR: 1.26, 95% CI: 1.16-1.37) compared with 155% for grade 4 (RR: 2.55, 95% CI: 1.86-3.50). We conclude that mortality is associated with the presence of breathlessness and its severity. The mechanism underlying this is unclear and may reflect the ubiquity of breathlessness as a symptom of many diseases.

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

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

Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study

Study Objectives:

Pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure (HF) exacerbations can present similarly in the older adult in the Emergency Department (ED), leading to sub-optimal treatment from over- and under-diagnosis. There may be a role for antimicrobial peptides (AMPs) in improving the accurate diagnosis of pneumonia in these patients.

Methods:

This pilot was a prospective, observational cohort study of older adults (aged ≥65 years of age) who presented to the ED with dyspnea or elevated respiratory rate. To identify biomarkers of pneumonia, serum levels of white blood cell count, procalcitonin (PCT), and antimicrobial peptides (human beta defensin 1 and 2 [HBD-1, -2], human neutrophil peptides 1–3 [HNP1–3] and cathelididin [LL-37]) were compared between those with and without pneumonia. Criterion standard reviewers retrospectively determined the diagnoses present in the ED.

Results:

Three hundred ninety-one patients were screened, 140 were eligible, and 79 were enrolled. Based on criterion standard review, pneumonia was present in 10 (12.7%), COPD in 9 (11.4%) and HF in 31 (39.2%) with a co-diagnosis rate of 10.1% by criterion standard review. Comparatively, emergency medicine attending physicians diagnosed pneumonia in 16 (20.3%), COPD in 12 (15.2%), and HF in 30 (38.0%) with co-diagnosis rate of 15.2%. Emergency physicians agreed with criterion standard diagnoses in 90% of pneumonia, 75% of COPD and 65% of HF diagnoses. Differences in leukocyte count (p<0.01) and two novel AMPs (DEFA5 (p=0.08) and DEFB2 (p=0.09)) showed promise for diagnosing pneumonia.

Conclusions:

Emergency physicians continue to have poor diagnostic accuracy in dyspneic older adult patients. Serum AMP levels are one potential tool to improve diagnostic accuracy and outcomes for this important population and require further study.

Inspiratory muscle training for improving inspiratory muscle strength and functional capacity in older adults: a systematic review and meta-analysis

BACKGROUND

The ageing process can result in the decrease of respiratory muscle strength and consequently increased work of breathing and associated breathlessness during activities of daily living in older adults.

OBJECTIVE

This systematic review and meta-analysis aims to determine the effects of inspiratory muscle training (IMT) in healthy older adults.

METHODS

A systematic literature search was conducted across four databases (Medline/Pubmed, Web of Science, Cochrane Library CINAHL) using a search strategy consisting of both MeSH and text words including older adults, IMT and functional capacity. The eligibility criteria for selecting studies involved controlled trials investigating IMT via resistive or threshold loading in older adults (>60 years) without a long-term condition.

RESULTS

Seven studies provided mean change scores for inspiratory muscle pressure and three studies for functional capacity. A significant improvement was found for maximal inspiratory pressure (PImax) following training (n = 7, 3.03 [2.44, 3.61], P = <0.00001) but not for functional capacity (n = 3, 2.42 [-1.28, 6.12], P = 0.20). There was no significant correlation between baseline PImax and post-intervention change in PImax values (n = 7, r = 0.342, P = 0.453).

CONCLUSIONS

IMT can be beneficial in terms of improving inspiratory muscle strength in older adults regardless of their initial degree of inspiratory muscle weakness. Further research is required to investigate the effect of IMT on functional capacity and quality of life in older adults.

Early Predictors of Mortality in Patients with COPD, in Relation to Respiratory and Non-Respiratory Causes of Death - A National Register Study

Background

Both single factors and composite measures have been suggested to predict mortality in patients with chronic obstructive pulmonary disease (COPD) and there is a need to analyze the relative importance of each variable.

Objective

To explore the predictors of mortality for patients with COPD in relation to respiratory, cardiac, and malignant causes, as well as all causes of death.

Methods

After merging the Swedish Respiratory Tract Register (SRTR) and the Swedish Cause of Death Register, patients with respiratory, cardiac, and other causes of death were identified. Demographic and clinical variables from the deceased patients’ first registration with the SRTR were compared. Three univariable and multivariable Cox proportional hazards regression analyses were conducted for different causes of death, with time from first registration to either death or a fixed end date as dependent variable, and variables regarding demographics, respiration, and comorbidities as independent variables.

Results

In the multivariable Cox models, mortality for patients with all causes of death was predicted by older age 1.79 (CI 1.41, 2.27), lower percentage of predicted forced expiratory volume in 1 second (FEV₁ %) 0.99 (CI 0.98, 0.99), lower saturation 0.92 (CI 0.86, 0.97), worse dyspnea 1.48 (CI 1.26, 1.74) (p<0.002 to p<0.001), less exercise 0.91 (CI 0.85, 0.98), and heart disease 1.53 (CI 1.06, 2.19) (both p<0.05). Mortality for patients with respiratory causes was predicted by higher age 1.67 (CI 1.05, 2.65) (p<0.05), lower FEV_1% 0.98 (CI 0.97, 0.99), worse dyspnea 2.05 (CI 1.45, 2.90), and a higher number of exacerbations 1.27 (CI 1.11, 1.45) (p<0.001 in all comparisons). For patients with cardiac causes of death, mortality was predicted by lower FEV_1% 0.99 (CI 0.98, 0.99) (p=0.001) and lower saturation 0.82 (CI 0.76, 0.89) (p<0.001), older age 1.46 (CI 1.02, 2.09) (p<0.05), and presence of heart disease at first registration 2.06 (CI 1.13, 3.73) (p<0.05).

Conclusion

Obstruction predicted mortality in all models and dyspnea in two models and needs to be addressed. Comorbidity with heart disease could further worsen the COPD patient’s prognosis and should be treated by a multidisciplinary team of professional specialists.

Respiratory symptoms and mortality in four general population cohorts over 45 years

OBJECTIVE

This study assessed the association between respiratory symptoms and mortality in four cohorts of the general population in Norway aged 15-75 years and in selected subgroups in the pooled sample.

METHODS

The study comprised 158,702 persons, who were drawn randomly from the Norwegian population register. All subjects received a standardized, self-administered questionnaire on 11 respiratory symptoms between 1972 and 1998, with follow-up of death until December 31, 2017. Analyses were performed on 114,380 respondents.

RESULTS

The hazard of death was closely associated with sex, age, and education. The hazard ratios (HR) for death and the 95% confidence intervals (CI) by risk factors were similar in the four cohorts. After adjustment for demographic and environmental, modifiable factors, the HR for death was 1.90 (95% CI 1.80-2.00) for breathlessness score 3, 1.28 (1.21-1.37) for cough/phlegm score 5 and 1.09 (1.05-1.14) for attack of breathlessness/wheeze score 2 compared to the referent (no symptom), respectively. The cough/phlegm score was associated with death in current smokers but not in never smokers or ex-smokers. Breathlessness score was associated with death in men and women.

CONCLUSION

Among persons aged 45-75 years, respiratory symptoms were significant predictors of all cause mortality. Education and smoking habits influenced only the associations between coughing and mortality. The associations were independent of study sites.

Predicting outcome for ambulance patients with dyspnea: a prospective cohort study

OBJECTIVE

To validate the discrimination and classification accuracy of a novel acute dyspnea scale for identifying outcomes of out-of-hospital patients with acute dyspnea.

METHODS

Prospective observational population-based study in the North Denmark Region. We included patients from July 1, 2017 to September 24, 2019 assessed as having acute dyspnea by the emergency dispatcher or by emergency medical services (EMS) personnel. Patients rated dyspnea using the 11-point acute dyspnea scale. The primary outcomes were hospitalization >2 days, ICU admission within 48 hours of ambulance run, and 30-day mortality. We used 5-fold cross-validation and area under receiver operating curves (AUC) to assess predictive properties of the acute dyspnea scale score alone and combined with vital data, age, and sex.

RESULTS

We included 3144 EMS patients with reported dyspnea. Median acute dyspnea scale score was 7 (interquartile range 5 to 8). The outcomes were: 1966 (63%) hospitalized, 164 (5%) ICU stay, and 224 (9%) died within 30 days of calling the ambulance. The acute dyspnea scale score alone showed poor discrimination for hospitalization (AUC 0.56, 95% confidence intervals: 0.54-0.58), intensive care unit admission (0.58, 0.53-0.62), and mortality (0.46, 0.41-0.50). Vital signs (respiratory rate, blood oxygen saturation, blood pressure, and heart rate) showed similarly poor discrimination for all outcomes. The combination of [vital signs + acute dyspnea scale score] showed better discrimination for hospitalization, ICU admission, and mortality (AUC 0.71-0.72). Patients not able to report an acute dyspnea scale score worse outcomes on all parameters.

CONCLUSION

The dyspnea scale showed poor accuracy and discrimination when predicting hospitalization, stay at intensive care unit, and mortality on its own. However, the dyspnea scale may be beneficial as performance measure and indicator of out-of-hospital care.

Prognostic value of first-recorded breathlessness for future chronic respiratory and heart disease: a cohort study using a UK national primary care database

BACKGROUND

Breathlessness is a common presentation in primary care.

AIM

To assess the long-term risk of diagnosed chronic obstructive pulmonary disease (COPD), asthma, ischaemic heart disease (IHD), and early mortality in patients with undiagnosed breathlessness.

DESIGN AND SETTING

Matched cohort study using data from the UK Clinical Practice Research Datalink.

METHOD

Adults with first-recorded breathlessness between 1997 and 2010 and no prior diagnostic or prescription record for IHD or a respiratory disease ('exposed' cohort) were matched to individuals with no record of breathlessness ('unexposed' cohort). Analyses were adjusted for sociodemographic and comorbidity characteristics.

RESULTS

In total, 75 698 patients (the exposed cohort) were followed for a median of 6.1 years, and more than one-third subsequently received a diagnosis of COPD, asthma, or IHD. In those who remained undiagnosed after 6 months, there were increased long-term risks of all three diagnoses compared with those in the unexposed cohort. Adjusted hazard ratios for COPD ranged from 8.6 (95% confidence interval [CI] = 6.8 to 11.0) for >6-12 months after the index date to 2.8 (95% CI = 2.6 to 3.0) for >36 months after the index date; asthma, 11.7 (CI = 9.4 to 14.6) to 4.3 (CI = 3.9 to 4.6); and IHD, 3.0 (CI = 2.7 to 3.4) to 1.6 (CI = 1.5 to 1.7). Risk of a longer time to diagnosis remained higher in members of the exposed cohort who had no relevant prescription in the first 6 months; approximately half of all future diagnoses were made for such patients. Risk of early mortality (all cause and disease specific) was higher in members of the exposed cohort.

CONCLUSION

Breathlessness can be an indicator of developing COPD, asthma, and IHD, and is associated with early mortality. With careful assessment, appropriate intervention, and proactive follow-up and monitoring, there is the potential to improve identification at first presentation in primary care in those at high risk of future disease who present with this symptom.

Incidence and predictors of dyspnea on exertion in a prospective cohort of patients with rheumatoid arthritis

OBJECTIVE

To investigate the incidence and predictors of dyspnea on exertion among subjects with rheumatoid arthritis (RA).

METHODS

We investigated dyspnea on exertion using a prospective cohort, the Brigham RA Sequential Study (BRASS). Clinically significant dyspnea on exertion was defined as a score of ≥3 (unable to ambulate without breathlessness or worse) on the validated Medical Research Council (MRC) scale (range 0-5). We analyzed subjects with MRC score <3 at BRASS baseline and ≥1 year of follow-up. The MRC scale was administered annually. We determined the incidence rate (IR) of dyspnea on exertion. We used Cox regression to estimate the HR for dyspnea on exertion occurring one year after potential predictors were assessed.

RESULTS

We analyzed 829 subjects with RA and no clinically significant dyspnea on exertion during mean follow-up of 3.0 years (SD 1.9). At baseline, mean age was 55.7 years (SD 13.6), 82.4% were female, and median RA duration was 8 years. During follow-up, 112 subjects (13.5%) developed incident dyspnea on exertion during 2,476 person-years of follow-up (IR 45.2 per 1000 person-years). Independent predictors of incident dyspnea on exertion were: older age (HR 1.03 per year, 95%CI 1.01-1.04), female sex (HR 2.22, 95%CI 1.14-4.29), mild dyspnea (HR 2.62, 95%CI 1.60-4.28), and worsened MDHAQ (HR 2.36 per unit, 95%CI 1.54-3.60). Methotrexate use, RA disease activity, and seropositivity were not associated with incident dyspnea on exertion.

CONCLUSION

Dyspnea on exertion occurred commonly in patients with RA. Older women with impaired physical function were especially vulnerable to developing dyspnea on exertion.

Breathlessness and inflammation: potential relationships and implications

PURPOSE OF REVIEW

Breathlessness and chronic inflammation both span a wide range of disease contexts and hold prognostic significance. The possibility of a causal relationship between the two has been hypothesized. The aims of this article are to review the intersections between breathlessness and inflammation in the literature, describe potential mechanisms connecting the two phenomena, and discuss the potential clinical implications of a causal relationship.

RECENT FINDINGS

There is a very limited literature exploring the relationship between systemic inflammation and breathlessness in chronic obstructive pulmonary disease, heart failure, and cancer. One large study in cancer patients is suggestive of a weak association between self-reported breathlessness and inflammation. Studies exploring the relationship between inflammation and Medical Research Council Dyspnoea grade in chronic obstructive pulmonary disease patients have produced inconsistent findings. Although a causal relationship has not yet been proven, there is evidence to support the existence of potential mechanisms mediating a relationship. This evidence points to a role for the skeletal muscle and stress hormone systems.

SUMMARY

There is much progress to be made in this area. Interventional studies, evaluating the impact of anti-inflammatory interventions on breathlessness, are needed to help determine whether a causal relationship exists. If proven, this relationship might have important implications for both the treatment and impact of breathlessness.

Correlates of dyspnoea and its association with adverse outcomes in a cohort of adults aged 80 and over

Background

adults aged 80 and over, a fast growing age-group, with increased co-morbidity and frailty have not been the focus of previous research on dyspnoea. We investigate the correlates of dyspnoea and its association with adverse outcomes in a cohort of adults aged 80 and over.

Methods

about 565 community-dwelling adults aged 80 and over of the BELFRAIL prospective cohort had assessment of Medical Research Council dyspnoea scale (MRC), forced expiratory volume in 1 s (FEV1), N-terminal pro-brain natriuretic peptide (NT-proBNP), physical performance tests, grip strength, 15 items geriatric depression scale, activities of daily living (ADL), body mass index (BMI) and demographics data. Kaplan-Meier survival curves, Cox and logistic multivariable regression, classification and regression tree (CART) analysis assessed association of dyspnoea (MRC 3-5) with time-to-cardiovascular and all-cause death (5 years), time to first hospitalisation (3 years), new/worsened ADL disability (2 years), and its correlates.

Results

participants with dyspnoea MRC 3-5 (29.9%) had increased hazard ratios for cardiovascular mortality 2.85 (95% confidence interval 1.93-4.20), all-cause mortality 2.04 (1.58-2.64), first hospitalisation 1.72 (1.35-2.19); and increased odds ratio for new/worsened disability 2.49 (1.54-4.04), independent of age, sex and smoking status. Only FEV1, physical performance, BMI and NT-proBNP (in order of importance) were selected in the tree-based classification model for dyspnoea.

Conclusions

in a cohort of adults aged 80 and over, dyspnoea was common and an independent predictor of adverse outcomes, with cardio-respiratory and physical performance impairments as key independent correlates. Its routine and comprehensive evaluation in primary care could be very valuable in caring for this age-group.

A cross-sectional survey of current treatment and symptom burden of patients with COPD consulting for routine care according to GOLD 2014 classifications

Background

As part of the Respiratory Disease Specific Program (DSP) conducted to provide observations of clinical practice from a physician and matched patient viewpoint, this study aimed to establish how patients with COPD are treated according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system and to quantify the symptom burden.

Methods

Data were obtained from the Respiratory DSP, a cross-sectional survey of patients with a diagnosis of COPD consulting for routine care in France, Germany, Italy, Spain, the UK, and the USA during the third quarter of 2013. Patients’ exacerbation risk and symptom data were used for classification into GOLD groups A−D based on GOLD 2014 criteria. Prescribing practices were stratified by physician type and time since patient diagnosis.

Results

A total of 903 physicians participated in the Respiratory DSP, with data from 1,641 patients included in this analysis. Most patients were classified into GOLD groups B (n=742; 45.2%) and D (n=704; 42.9%). Patients in groups A and D were most likely to be treated in line with GOLD recommendations (61.5% and 77.5%, respectively), compared with 40.1% for group B. Patients with a diagnosis within the past 12 months were more likely to be treated according to recommendations. Inhaled corticosteroids (ICSs) in combination with one or more long-acting bronchodilator were prescribed across all GOLD groups. Patterns of treatment were, in general, similar for patients treated by a primary care physician or a pulmonologist. COPD assessment test scores ≥10 indicating a high symptom burden were reported for >80% of patients.

Conclusion

This analysis confirmed a high symptom burden among patients with COPD and indicates some misalignment of prescribing with GOLD recommendations, particularly regarding the role of ICS/long-acting β₂-agonist (LABA) and ICS/LABA + long-acting muscarinic antagonist combinations across the different GOLD groups.

Salivary diurnal cortisol profiles in patients suffering from chronic breathlessness receiving supportive and palliative care services: A cross-sectional study

Chronic breathlessness is a common source of psychological and physical stress in patients with advanced or progressive disease, suggesting that hypothalamic-pituitary-adrenal (HPA) axis dysregulation may be prevalent. The aim of this study was to measure the salivary diurnal cortisol profile in patients receiving supportive and palliative care for a range of malignant and non-malignant conditions and to compare the profile of those experiencing moderate-to-severe disability due to breathlessness against that of patients with mild/no breathlessness and that of healthy controls. Saliva samples were collected over two consecutive weekdays at 3, 6, and 12h after awakening in 49 patients with moderate-to-severe breathlessness [Medical Research Council (MRC) dyspnoea grade ≥3], 11 patients with mild/no breathlessness (MRC dyspnoea grade ≤2), and 50 healthy controls. Measures of breathlessness, stress, anxiety, depression, wellbeing and sleep were examined concomitantly. The diurnal cortisol slope (DCS) was calculated for each participant by regressing log-transformed cortisol values against collection time. Mean DCS was compared across groups using ANCOVA. Individual slopes were categorised into one of four categories: consistent declining, consistent flat, consistent ascending and inconsistent. Controlling for age, gender and socioeconomic status, the mean DCS was significantly flatter in patients with moderate-to-severe breathlessness compared to patients with mild/no breathlessness and healthy controls [F (2, 103)=45.64, p<0.001]. Furthermore, there was a higher prevalence of flat and ascending cortisol profiles in patients with moderate-to-severe breathlessness (23.4%) compared to healthy controls (0%). The only variable which correlated significantly with DCS was MRC dyspnoea grade (rs=0.29, p<0.05). These findings suggest that patients with moderate-to-severe breathlessness have evidence of HPA axis dysregulation and that this dysregulation may be related to the functional disability imposed by breathlessness.

The association between health-related quality of life and disease progression in idiopathic pulmonary fibrosis: a prospective cohort study

Background and objective: Generally, a disease-specific health-related quality of life (HRQOL) measurement is more useful than generic measures in assessing perceived physical and mental health characteristic of a particular disease. The idiopathic pulmonary fibrosis (IPF)-specific version of St. George’s Respiratory Questionnaire (SGRQ-I) has been recently developed for patients with IPF. We proposed to evaluate associations between the SGRQ-I and other clinical indices, as well as its prognostic value in patients with IPF. Methods: Fifty-two patients with IPF were recruited in this prospective cohort study. HRQOL was assessed using the SGRQ-I and the Medical Outcomes Study 36-item Short Form, dyspnea using the modified Medical Research Council (mMRC) dyspnea scale, and psychological status using the Hospital Anxiety and Depression Scale (HADS). We then evaluated the relationship between the SGRQ-I and other clinical measures, as well as one-year clinical deterioration defined as a hospital admission due to respiratory exacerbation or all-cause death. Results: Stepwise multiple-regression analyses revealed that the mMRC dyspnea scale, the HADS anxiety or depression, and minimum oxygen saturation during a six-minute walk test significantly contributed to the Total and three components of the SGRQ-I. In multivariate Cox proportional-hazards analyses, the Total score of SGRQ-I predicted clinical deterioration independent of forced vital capacity, the six-minute walk distance, or partial pressure of arterial oxygen on room air. Conclusions: The SGRQ-I is a multidisciplinary instrument representing physical, functional and psychological impairments in patients with IPF. The SGRQ-I is a significant predictor of short-term disease progression independent of physiological measurements. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 226-235)

Breathlessness in Elderly Adults During the Last Year of Life Sufficient to Restrict Activity: Prevalence, Pattern, and Associated Factors

OBJECTIVES

To investigate relationships between age, clinical characteristics, and breathlessness sufficient to have people spend at least half a day a month in bed or to cut down on their usual activities (restricting breathlessness) during the last year of life.

DESIGN

Secondary data analysis.

SETTING

General community.

PARTICIPANTS

Nondisabled persons aged 70 and older (N=754).

MEASUREMENTS

Monthly telephone interviews were conducted to determine the occurrence of restricting breathlessness. The primary outcome was percentage of months with restricting breathlessness reported during the last year of life.

RESULTS

Data regarding breathlessness were available for 548 of 589 (93.0%) participants who died (mean age 86.7, range 71-106; 38.8% male) between enrollment (March 1998 to October 1999) and June 2013; 311 of these (56.8%) reported restricting breathlessness at some point during the last year of life, but none reported it every month. Frequency increased in the months closer to death, irrespective of cause. Restricting breathlessness was associated with anxiety (0.25 percentage points greater in months with breathlessness per percentage point months reported anxiety, 95% confidence interval (CI)=0.16-0.34, P<.001), depression (0.14, 95% CI=0.05-0.24, P=.003), and mobility problems (0.07, 0.03-0.1, P<.001). Percentage months of restricting breathlessness was greater if chronic lung disease was noted at the most-recent comprehensive assessment (6.62 percentage points, 95% CI=4.31-8.94, P<.001), heart failure (3.34 percentage points, 95% CI=0.71-5.97, P=.01), and ex-smoker status (3.01 percentage points, 95% CI=0.94-5.07, P=.004) but decreased with older age (-0.19 percentage points, 95% CI=-0.37 to -0.02, P=.03).

CONCLUSION

Restricting breathlessness increased in this elderly population in the months preceding death from any cause. Breathlessness should be assessed and managed in the context of poor prognosis.

Dyspnea as an independent predictor of mortality

BACKGROUND AND AIM

Dyspnea is a common and easily elicited presenting complaint in patients seen by physicians who evaluate and take care of chronic respiratory disorders. Although dyspnea is subjective and tends to increase with age or reduced lung function, it appears to be reproducible as a symptom and often signifies serious underlying disease.

METHODS

Systematic review of longitudinal studies with dyspnea as the exposure and mortality as the outcome; age, smoking and lung function had to be controlled for to be included in the review. In addition, a minimum sample size at baseline of 500 subjects was required for each study.

RESULTS

From over 3000 potential references, 10 longitudinal studies met all criteria and were included. All 10 studies suggested that dyspnea was an independent predictor of mortality with point estimates by odds ratio, rate ratio or hazard ratios ranging from 1.3 up to 2.9-fold greater than baseline. All 10 studies had actual or implied 95% confidence interval bands greater than the null value of one.

CONCLUSION

Dyspnea, a symptom, predicts mortality and is a proxy for underlying diseases, most often of heart and lung. Therefore, chronic dyspnea needs to be evaluated as to etiology to allow for treatment to minimize morbidity and mortality when possible.

Pulmonary ventilation defects in older never-smokers

Hyperpolarized (3)He MRI previously revealed spatially persistent ventilation defects in healthy, older compared with healthy, younger never-smokers. To understand better the physiological consequences and potential relevance of (3)He MRI ventilation defects, we evaluated (3)He-MRI ventilation-defect percent (VDP) and the effect of deep inspiration (DI) and salbutamol on VDP in older never-smokers. To identify the potential determinants of ventilation defects in these subjects, we evaluated dyspnea, pulmonary function, and cardiopulmonary exercise test (CPET) measurements, as well as occupational and second-hand smoke exposure. Fifty-two never-smokers (71 ± 6 yr) with no history of chronic respiratory disease were evaluated. During a single visit, pulmonary function tests, CPET, and (3)He MRI were performed and the Burden of Obstructive Lung Disease questionnaire administered. For eight of 52 subjects, there was spirometry evidence of airflow limitation (Global Initiative for Chronic Obstructive Lung Disease-Unclassified, I, and II), and occupational exposure was reported in 13 of 52 subjects. In 13 of 52 (25%) subjects, there were no ventilation defects and in 39 of 52 (75%) subjects, ventilation defects were observed. For those subjects with ventilation defects, six of 39 showed a VDP response to DI/salbutamol. Ventilation heterogeneity and VDP were significantly greater, and forced expiratory volume in 1 s (FEV1)/forced vital capacity was significantly lower (P < 0.05) for subjects with ventilation defects with a response to DI/salbutamol than subjects with ventilation defects without a response to DI/salbutamol and subjects without ventilation defects. In a step-wise, forward multivariate model, FEV1, inspiratory capacity, and airway resistance significantly predicted VDP (R(2) = 0.45, P < 0.001). In conclusion, most never-smokers had normal spirometry and peripheral ventilation defects not reversed by DI/salbutamol; such ventilation defects were likely related to irreversible airway narrowing/collapse but not to dyspnea and decreased exercise capacity.