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Müller A, Wouters EF, Koul P, Welte T, Harrabi I, Rashid A, Loh LC, Al Ghobain M, Elsony A, Ahmed R, Potts J, Mortimer K, Rodrigues F, Paraguas SN, Juvekar S, Agarwal D, Obaseki D, Gislason T, Seemungal T, Nafees AA, Jenkins C, Dias HB, Franssen FME, Studnicka M, Janson C, Cherkaski HH, El Biaze M, Mahesh PA, Cardoso J, Burney P, Hartl S, Janssen DJA, Amaral AFS. Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study. Pulmonology 2024:S2531-0437(24)00044-8. [PMID: 38614859 DOI: 10.1016/j.pulmoe.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/14/2024] [Accepted: 03/31/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function. METHODS Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis. RESULTS The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC CONCLUSION The prevalence of dyspnoea varies substantially across the world and is strongly associated with lung function impairment. Using the mMRC scale in epidemiological research should be discussed.
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Affiliation(s)
- A Müller
- Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - E F Wouters
- Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Sigmund Freud University, Faculty of Medicine, Vienna, Austria; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - P Koul
- Department of Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Srinagar, India
| | - T Welte
- Department of Respiratory Medicine/Infectious Disease, Member of the German Centre for Lung Research, Hannover School of Medicine, Hannover, Germany
| | - I Harrabi
- Faculté de Médecine, Sousse, Tunisia
| | - A Rashid
- RCSI and UCD Malaysia Campus, Penang, Malaysia
| | | | - M Al Ghobain
- King Abdullah International Medical Research Center, King Saud ben Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - A Elsony
- The Epidemiological Laboratory, Khartoum, Sudan
| | - R Ahmed
- The Epidemiological Laboratory, Khartoum, Sudan
| | - J Potts
- National Heart and Lung Institute, Imperial College London, London, UK
| | - K Mortimer
- University of Cambridge, Cambridge, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - F Rodrigues
- Pulmonology Department, Lisbon North Hospital Centre, Lisbon, Portugal; Institute of Environmental Health, Associate Laboratory TERRA, Lisbon Medical School, Lisbon University, Lisbon, Portugal
| | - S N Paraguas
- Philippine College of Chest Physicians, Manila, Philippines
| | - S Juvekar
- KEM Hospital Research Centre, Pune, India
| | - D Agarwal
- KEM Hospital Research Centre, Pune, India
| | - D Obaseki
- Department of Medicine, Obafemi Awolowo University, Nigeria; Faculty of Medicine, University of British Columbia, Canada
| | - T Gislason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Department of Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - T Seemungal
- Faculty of Medical Sciences, University of West Indies, St Augustine, Trinidad and Tobago
| | | | - C Jenkins
- Woolcock Institute of Medical Research, Sydney, Australia
| | - H B Dias
- Escola Superior de Tecnologia da Saúde de Lisboa, Politecnico de Lisboa, Lisbon, Portugal
| | - F M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Research and Development, Ciro, Horn, the Netherlands
| | - M Studnicka
- Department of Pulmonary Medicine, Paracelsus Medical University, Salzburg, Austria
| | - C Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - H H Cherkaski
- Faculty of Medicine, University Badji Mokhtar, Annaba, Algeria
| | - M El Biaze
- Department of Respiratory Medicine, Faculty of Medicine, Mohammed Ben Abdellah University, Fes, Morocco
| | - P A Mahesh
- Department of Respiratory Medicine, JSS Medical College and Hospital, Mysore, Karnataka, India
| | - J Cardoso
- Pulmonology Department, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; NOVA Medical School, Nova University Lisbon, Lisboa, Portugal
| | - P Burney
- National Heart and Lung Institute, Imperial College London, London, UK
| | - S Hartl
- Ludwig Boltzmann Institute for Lung Health, Vienna, Austria; Sigmund Freud University, Faculty of Medicine, Vienna, Austria
| | - D J A Janssen
- Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Ciro, Horn, the Netherlands
| | - A F S Amaral
- National Heart and Lung Institute, Imperial College London, London, UK; NIHR Imperial Biomedical Research Centre, London, UK
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Cristea L, Olsson M, Sandberg J, Kochovska S, Currow D, Ekström M. Which breathlessness dimensions associate most strongly with fatigue?-The population-based VASCOL study of elderly men. PLoS One 2023; 18:e0296016. [PMID: 38117831 PMCID: PMC10732411 DOI: 10.1371/journal.pone.0296016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/04/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Breathlessness and fatigue are common symptoms in older people. We aimed to evaluate how different breathlessness dimensions (overall intensity, unpleasantness, sensory descriptors, emotional responses) were associated with fatigue in elderly men. METHODS This was a cross-sectional analysis of the population-based VAScular disease and Chronic Obstructive Lung Disease (VASCOL) study of 73-year old men. Breathlessness dimensions were assessed using the Dyspnoea-12 (D-12), Multidimensional Dyspnoea Profile (MDP), and the modified Medical Research Council (mMRC) scale. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Clinically relevant fatigue was defined as FACIT-F≤ 30 units. Scores were compared standardized as z-scores and analysed using linear regression, adjusted for body mass index, smoking, depression, cancer, sleep apnoea, prior cardiac surgery, respiratory and cardiovascular disease. RESULTS Of 677 participants, 11.7% had clinically relevant fatigue. Higher breathlessness scores were associated with having worse fatigue; for D-12 total, -0.35 ([95% CI] -0.41 to -0.30) and for MDP A1, -0.24 (-0.30 to -0.18). Associations were similar across all the evaluated breathlessness dimensions even when adjusting for the potential confounders. CONCLUSION Breathlessness assessed using D-12 and MDP was associated with worse fatigue in elderly men, similarly across different breathlessness dimensions.
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Affiliation(s)
- Lucas Cristea
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Kallinge Health Center, Kallinge, Sweden
| | - Max Olsson
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Jacob Sandberg
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Magnus Ekström
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Müller A, Mraz T, Wouters EF, van Kuijk SM, Amaral AF, Breyer-Kohansal R, Breyer MK, Hartl S, Janssen DJ. Prevalence of dyspnea in general adult populations: A systematic review and meta-analysis. Respir Med 2023; 218:107379. [PMID: 37595674 DOI: 10.1016/j.rmed.2023.107379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/20/2023]
Abstract
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.
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Affiliation(s)
- Alexander Müller
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria; Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - Tobias Mraz
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria; Department of Respiratory and Critical Care Medicine, Clinic Penzing, Vienna Healthcare Group, Sanatoriumstrasse 2, 1140, Vienna, Austria
| | - Emiel Fm Wouters
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria
| | - Sander Mj van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Peter Debyeplein 1, 6229 HA, Maastricht, the Netherlands
| | - André Fs Amaral
- National Heart and Lung Institute, Imperial College London, 1B Manresa Road, London, SW3 6LR, UK; NIHR Imperial Biomedical Research Centre, The Bays, Entrance 2, South Wharf Road, St. Mary's Hospital, London, W2 1NY, UK
| | - Robab Breyer-Kohansal
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria; Department of Respiratory and Pulmonary Diseases, Clinic Hietzing, Vienna Healthcare Group, Wolkersbergenstrasse 1, 1130, Vienna, Austria
| | - Marie-Kathrin Breyer
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria; Department of Respiratory and Critical Care Medicine, Clinic Penzing, Vienna Healthcare Group, Sanatoriumstrasse 2, 1140, Vienna, Austria
| | - Sylvia Hartl
- Ludwig Boltzmann Institute for Lung Health, Sanatoriumstrasse 2, 1140, Vienna, Austria
| | - Daisy Ja Janssen
- Department of Health Services Research and Department of Family Medicine, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands; Department of Research & Development, Ciro, Hornerheide 1, 6085 NM, Horn, the Netherlands
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Johnson MJ, Pitel L, Currow DC, Forbes C, Soyiri I, Robinson L. Breathlessness limiting exertion in very old adults: findings from the Newcastle 85+ study. Age Ageing 2023; 52:afad155. [PMID: 37658750 PMCID: PMC10474592 DOI: 10.1093/ageing/afad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Indexed: 09/05/2023] Open
Abstract
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.
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Affiliation(s)
- Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lukas Pitel
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - David C Currow
- Department of Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Cynthia Forbes
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | | | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Hegendörfer E, Degryse JM. Breathlessness in older adults: What we know and what we still need to know. J Am Geriatr Soc 2023. [PMID: 36929105 DOI: 10.1111/jgs.18326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/18/2023]
Abstract
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.
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Affiliation(s)
- Eralda Hegendörfer
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven (KU Leuven), Leuven, Belgium
| | - Jean-Marie Degryse
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven (KU Leuven), Leuven, Belgium.,Institute of Health and Society, Université Catholique de Louvain (UC Louvain), Leuven, Belgium
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Ankuda CK, Covinsky K, Freedman VA, Langa K, Aldridge MD, Yee C, Kelley AS. The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies. J Am Geriatr Soc 2023; 71:858-868. [PMID: 36511646 PMCID: PMC10023348 DOI: 10.1111/jgs.18158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/30/2022] [Accepted: 11/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS). METHODS We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing. RESULTS NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability. CONCLUSIONS In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.
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Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth Covinsky
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
| | - Vicki A Freedman
- Michigan Center on the Demography of Aging, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth Langa
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Cynthia Yee
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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Kochovska S, Ekström M, Hansen-Flaschen J, Ferreira D, Similowski T, Johnson MJ, Currow DC. Hiding in plain sight: the evolving definition of chronic breathlessness and new ICD-11 wording. Eur Respir J 2023; 61:61/3/2300252. [PMID: 36997231 DOI: 10.1183/13993003.00252-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
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Zhou Y, Ampon MR, Abramson MJ, James AL, Maguire GP, Wood-Baker R, Johns DP, Marks GB, Reddel HK, Toelle BG. Risk factors and clinical characteristics of breathlessness in Australian adults: Data from the BOLD Australia study. Chron Respir Dis 2023; 20:14799731231221820. [PMID: 38126966 DOI: 10.1177/14799731231221820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Breathlessness is a common symptom related to a significant health burden. However, the association of breathlessness with clinical characteristics, especially objective pulmonary test results is scarce. We aimed to identify the characteristics independently associated with breathlessness in Australian adults. METHOD The analysis used data from BOLD Australia, a cross-sectional study that included randomly selected adults aged ≥40 years from six sites in Australia. Clinical characteristics and spirometry results were compared for breathlessness (modified Medical Research Council [mMRC] grade ≥2). RESULTS Among all respondents (n = 3321), 252 participants (7.6%) reported breathlessness. The main univariate associations were obesity, chronic respiratory diseases, heart diseases and being Indigenous Australians (odds ratios [ORs] = 2.78, 5.20, 3.77 and 4.38, respectively). Participants with breathlessness had lower pre-and post-bronchodilator lung function than those without. Impaired spirometry results including FVC or FEV1 below 80% predicted, or FEV1/FVC < LLN were independently associated with breathlessness (adjusted ORs = 2.66, 2.94 and 2.34, respectively). CONCLUSIONS Breathlessness is common among Australian adults and is independently associated with obesity, chronic respiratory diseases, heart diseases, being Indigenous Australians, and impaired spirometry. Multi-disciplinary assessment and comprehensive investigation is needed in clinical practice to address the many factors associated with breathlessness in the population.
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Affiliation(s)
- Yijun Zhou
- The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Maria R Ampon
- Australian Centre for Airways Disease Monitoring, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | - Richard Wood-Baker
- Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - David P Johns
- Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - Guy B Marks
- The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
- South Western Sydney Clinical School, Sydney, NSW, Australia
| | - Helen K Reddel
- Australian Centre for Airways Disease Monitoring, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Science, Macquarie University, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, Australia
| | - Brett G Toelle
- The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Science, Macquarie University, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, Australia
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Ha DM, Deng LR, Lange AV, Swigris JJ, Bekelman DB. Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure. J Gen Intern Med 2022; 37:2541-2547. [PMID: 34981344 PMCID: PMC9360273 DOI: 10.1007/s11606-021-07307-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains. OBJECTIVE To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure. DESIGN We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G). PARTICIPANTS We used data from a multi-site randomized clinical trial among outpatients with heart failure. MAIN MEASURES We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods. KEY RESULTS Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change. CONCLUSIONS The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.
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Affiliation(s)
- Duc M Ha
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA. .,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Lubin R Deng
- Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
| | - David B Bekelman
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.,Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Bartz-Overman C, Albanese AM, Fan V, Locke ER, Parikh T, Thielke S. Potential Explanatory Factors for the Concurrent Experience of Dyspnea and Pain in Patients with COPD. COPD 2022; 19:282-289. [PMID: 35666540 DOI: 10.1080/15412555.2022.2081540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Previous research has identified unexpectedly strong associations between dyspnea and pain, but the reasons remain unclear. Ascertaining the underlying biological and psychological mechanisms might enhance the understanding of the experience of both conditions, and suggest novel treatments. We sought to elucidate whether demographic factors, disease severity, psychological symptoms and biomarkers might account for the association between pain and dyspnea in individuals with COPD. We analyzed data from 301 patients with COPD who were followed in a prospective longitudinal observational study over 2 years. Measures included self-reported dyspnea and pain, pulmonary function tests, serum levels of inflammatory cytokines, measures of physical deconditioning, and scales for depression and anxiety. Analyses involved cross-sectional and longitudinal linear regression models. Pain and dyspnea were strongly correlated cross-sectionally (r = 0.77, 95% CI 0.72-0.82) and simultaneously across time (r = 0.42, 95% CI 0.28-0.56). Accounting for any of the other health factors only slightly mitigated the associations. Symptoms of pain and dyspnea thus may be fundamentally linked in COPD, rather than being mediated by common biological, psychological, or functional factors. From the patient's perspective, pain and dyspnea may be part of the same essential experience. It is possible that treatments for one condition would improve the other.
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Affiliation(s)
| | - Anita M Albanese
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Vincent Fan
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Emily R Locke
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Toral Parikh
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, USA.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen Thielke
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Psychiatry, University of Washington, Seattle, Washington, USA
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11
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Olsson M, Ekström M. Validation of the Dyspnoea-12 and Multidimensional Dyspnea profile among older Swedish men in the population. BMC Geriatr 2022; 22:477. [PMID: 35655151 PMCID: PMC9164708 DOI: 10.1186/s12877-022-03166-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Dyspnoea-12 (D12) and Multidimensional dyspnea profile (MDP) are commonly used instruments for assessing multiple dimensions of breathlessness but have not been validated in older people in the population. The aim of this study was to validate the D12 and MDP in 73-years old men in terms of the instruments’ underlying factor structures, internal consistency, and validity. Methods A postal survey was sent out to a population sample of 73-years old men (n = 1,193) in southern Sweden. The two-factor structures were evaluated with confirmatory factor analysis, internal consistency with Cronbach's alpha, and validity using Pearson´s correlations with validated scales of breathlessness, anxiety, depression, fatigue, physical/mental quality of life, body mass index (BMI), and cardiorespiratory disease. Results A total 684 men were included. Respiratory and cardiovascular disease were reported by 17% and 38%, respectively. For D12 and MDP, the proposed two-factor structure was not fully confirmed in this population. Internal consistency was excellent for all D12 and MDP domain scores (Cronbach's alpha scores > 0.92), and the instruments’ domains showed concurrent validity with other breathlessness scales, and discriminant validity with anxiety, depression, physical/mental quality of life, BMI, and cardiorespiratory disease. Conclusions In a population sample of 73-years old men, the D12 and MDP had good psychometrical properties in terms of reliability and validity, which supports that the instruments are valid for use in population studies of older men. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03166-5.
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12
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Buarque GLA, Borim FSA, Neri AL, Yassuda MS, de Melo RC. Relationships between self-reported dyspnea, health conditions and frailty among Brazilian community-dwelling older adults: a cross-sectional study. SAO PAULO MED J 2022; 140:356-365. [PMID: 35508002 PMCID: PMC9671253 DOI: 10.1590/1516-3180.2021.0237.r2.27072021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/27/2021] [Indexed: 11/21/2022] Open
Abstract
CONTEXT Dyspnea is a symptom present in several chronic diseases commonly seen among older adults. Since individuals with dyspnea tend to stay at rest, with consequently reduced levels of physical activity, they are likely to be at greater risk of developing frailty, especially at older ages. DESIGN AND SETTING Cross-sectional study at community level, Brazil. OBJECTIVE To analyze the relationships between self-reported dyspnea, health conditions and frailty status in a sample of community-dwelling older adults. METHOD Secondary data from the follow-up of the Frailty in Brazilian Elderly (FIBRA) study, involving 415 community-dwelling older adults (mean age: 80.3 ± 4.68 years), were used. The variables analyzed were sociodemographic characteristics, reported dyspnea, clinical data and frailty phenotype. Associations between dyspnea and other variables (age, sex, education and body mass index) were verified through the crude (c) and adjusted (a) odds ratios. RESULTS The prevalence of dyspnea in the entire sample was 21.0%. Dyspnea was more present in individuals with pulmonary diseases, heart disease, cancer and depression. Older adults with multimorbidities (adjusted odds ratio, ORa = 2.91; 95% confidence interval, CI = 1.41-5.99) and polypharmacy (ORa = 2.02; 95% CI = 1.15-3.54) were more likely to have dyspnea. Those who reported dyspnea were 2.54 times more likely to be frail (ORa = 2.54; 95% CI = 1.08-5.97), and fatigue was their most prevalent phenotype component. CONCLUSION Dyspnea was associated with different diseases, multimorbidities, polypharmacy and frailty. Recognizing the factors associated with dyspnea may contribute to its early identification and prevention of its negative outcomes among older adults.
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Affiliation(s)
- Giselle Layse Andrade Buarque
- PT, MSc. Physiotherapist and Doctoral Student, Postgraduate Program on Gerontology, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Flávia Silva Arbex Borim
- PT, PhD. Physiotherapist, Assistant Professor, Department of Collective Health, School of Health Sciences, Universidade de Brasília (UnB), Brasília (DF), Brazil; and Advisor, Postgraduate Program on Gerontology, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Anita Liberalesso Neri
- PhD. Psychologist and Collaborating Professor, Department of Medical Psychology and Psychiatry and Advisor, Postgraduate Program on Gerontology, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Mônica Sanches Yassuda
- PhD. Psychologist, Full Professor, School of Arts, Sciences and Humanities, and Advisor, Postgraduate Program on Gerontology, School of Arts, Sciences and Humanities, Universidade de São Paulo (USP), São Paulo (SP), Brazil; and Advisor, Postgraduate Program on Gerontology, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Ruth Caldeira de Melo
- PT, PhD. Physiotherapist and Assistant Professor, School of Arts, Sciences and Humanities, and Advisor, Postgraduate Program on Gerontology, School of Arts, Sciences and Humanities, Universidade de São Paulo (USP), São Paulo (SP), Brazil.
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Luckett T, Roberts M, Smith T, Garcia M, Dunn S, Swan F, Ferguson C, Kochovska S, Phillips JL, Pearson M, Currow DC, Johnson MJ. Implementing the battery-operated hand-held fan as an evidence-based, non-pharmacological intervention for chronic breathlessness in patients with chronic obstructive pulmonary disease (COPD): a qualitative study of the views of specialist respiratory clinicians. BMC Pulm Med 2022; 22:129. [PMID: 35387636 PMCID: PMC8985391 DOI: 10.1186/s12890-022-01925-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/25/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction The battery-operated hand-held fan (‘fan’) is an inexpensive and portable non-pharmacological intervention for chronic breathlessness. Evidence from randomised controlled trials suggests the fan reduces breathlessness intensity and improves physical activity in patients with a range of advanced chronic conditions. Qualitative data from these trials suggests the fan may also reduce anxiety and improve daily functioning for many patients. This study aimed to explore barriers and facilitators to the fan’s implementation in specialist respiratory care as a non-pharmacological intervention for chronic breathlessness in patients with chronic obstructive pulmonary disease (COPD). Methods A qualitative approach was taken, using focus groups. Participants were clinicians from any discipline working in specialist respiratory care at two hospitals. Questions asked about current fan-related practice and perceptions regarding benefits, harms and mechanisms, and factors influencing its implementation. Analysis used a mixed inductive/deductive approach. Results Forty-nine participants from nursing (n = 30), medical (n = 13) and allied health (n = 6) disciplines participated across 9 focus groups. The most influential facilitator was a belief that the fan’s benefits outweighed disadvantages. Clinicians’ beliefs about the fan’s mechanisms determined which patient sub-groups they targeted, for example anxious or palliative/end-stage patients. Barriers to implementation included a lack of clarity about whose role it was to implement the fan, what advice to provide patients, and limited access to fans in hospitals. Few clinicians implemented the fan for acute-on-chronic breathlessness or in combination with other interventions. Conclusion Implementation of the fan in specialist respiratory care may require service- and clinician-level interventions to ensure it is routinely recommended as a first-line intervention for chronic breathlessness in patients for whom this symptom is of concern, regardless of COPD stage.
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Affiliation(s)
- Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.
| | - Mary Roberts
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia.,Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Sydney, NSW, Australia.,The University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Tracy Smith
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia.,The University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Maja Garcia
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia
| | - Sarah Dunn
- Respiratory Medicine Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Flavia Swan
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - Caleb Ferguson
- Western Sydney Nursing & Midwifery Research Centre, Blacktown Clinical & Research School, Western Sydney Local Health District, Western Sydney University, Blacktown Hospital, Sydney, NSW, Australia
| | - Slavica Kochovska
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.,School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - David C Currow
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
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Assessment and diagnosis of chronic dyspnoea: a literature review. NPJ Prim Care Respir Med 2022; 32:10. [PMID: 35260575 PMCID: PMC8904603 DOI: 10.1038/s41533-022-00271-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022] Open
Abstract
Dyspnoea or breathlessness is a common presenting symptom among patients attending primary care services. This review aimed to determine whether there are clinical tools that can be incorporated into a clinical decision support system for primary care for efficient and accurate diagnosis of causes of chronic dyspnoea. We searched MEDLINE, EMBASE and Google Scholar for all literature published between 1946 and 2020. Studies that evaluated a clinical algorithm for assessment of chronic dyspnoea in patients of any age group presenting to physicians with chronic dyspnoea were included. We identified 326 abstracts, 55 papers were reviewed, and eight included. A total 2026 patients aged between 20–80 years were included, 60% were women. The duration of dyspnoea was three weeks to 25 years. All studies undertook a stepwise or algorithmic approach to the assessment of dyspnoea. The results indicate that following history taking and physical examination, the first stage should include simply performed tests such as pulse oximetry, spirometry, and electrocardiography. If the patient remains undiagnosed, the second stage includes investigations such as chest x-ray, thyroid function tests, full blood count and NT-proBNP. In the third stage patients are referred for more advanced tests such as echocardiogram and thoracic CT. If dyspnoea remains unexplained, the fourth stage of assessment will require secondary care referral for more advanced diagnostic testing such as exercise tests. Utilising this proposed stepwise approach is expected to ascertain a cause for dyspnoea for 35% of the patients in stage 1, 83% by stage 3 and >90% of patients by stage 4.
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Olsson M, Currow DC, Johnson MJ, Sandberg J, Engström G, Ekström M. Prevalence and severity of differing dimensions of breathlessness among elderly males in the population. ERJ Open Res 2021; 8:00553-2021. [PMID: 35141316 PMCID: PMC8819243 DOI: 10.1183/23120541.00553-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/31/2021] [Indexed: 12/02/2022] Open
Abstract
Breathlessness is common in the general population. Existing data were obtained primarily with the uni-dimensional modified Medical Research Council breathlessness scale (mMRC) that does not assess intensities of unpleasantness nor physical, emotional and affective dimensions. The aim of this research was to determine the prevalence and intensity of these dimensions of breathlessness in elderly males and any associations with their duration, change over time and mMRC grade. We conducted a population-based, cross-sectional study of 73-year-old males in a county in southern Sweden. Breathlessness was self-reported at one time point using a postal survey including the Dyspnea-12 (D-12), the Multidimensional Dyspnea Profile (MDP) and the mMRC. Presence of an increased dimension score was defined as a score ≥minimal clinically important difference for each dimension scale. Association with the mMRC, recalled change since age 65, and duration of breathlessness were analysed with linear regression. Among 907 men, an increased dimension score was present in 17% (D-12 total score), 33% (MDP A1 unpleasantness), 19% (D-12 physical), 17% (MDP immediate perception), 10% (D-12 affective) and 17% (MDP emotional response). The unpleasantness and affective dimensions were strongly associated with mMRC≥3. Higher MDP and D-12 scores were associated with worsening of breathlessness since age 65, and higher MDP A1 unpleasantness was associated with breathlessness of less than 1 year duration. Increased scores of several dimensions of breathlessness are prevalent in 73-year-old males and are positively correlated with mMRC scores, worsening of breathlessness after age 65, and duration of less than 1 year. This first epidemiological study of multidimensional breathlessness shows that unpleasant, physical, affective and emotional experiences of breathlessness are common among elderly males, and are strongly associated with mMRC ≥3https://bit.ly/3EThp5a
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Doe G, Clanchy J, Wathall S, Chantrell S, Edwards S, Baxter N, Jackson D, Armstrong N, Steiner M, Evans RA. Feasibility study of a multicentre cluster randomised control trial to investigate the clinical and cost-effectiveness of a structured diagnostic pathway in primary care for chronic breathlessness: protocol paper. BMJ Open 2021; 11:e057362. [PMID: 34815293 PMCID: PMC8611440 DOI: 10.1136/bmjopen-2021-057362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Chronic breathlessness is a common and debilitating symptom, associated with high healthcare use and reduced quality of life. Challenges and delays in diagnosis for people with chronic breathlessness frequently occur, leading to delayed access to therapies. The overarching hypothesis is a symptom-based approach to diagnosis in primary care would lead to earlier diagnosis, and therefore earlier treatment and improved longer-term outcomes including health-related quality of life. This study aims to establish the feasibility of a multicentre cluster randomised controlled trial to assess the clinical and cost-effectiveness of a structured diagnostic pathway for breathlessness in primary care. METHODS AND ANALYSIS Ten general practitioner (GP) practices across Leicester and Leicestershire will be cluster randomised to either a structured diagnostic pathway (intervention) or usual care. The structured diagnostic pathway includes a panel of investigations within 1 month. Usual care will proceed with patient care as per normal practice. Eligibility criteria include patients presenting with chronic breathlessness for the first time, who are over 40 years old and without a pre-existing diagnosis for their symptoms. An electronic template triggered at the point of consultation with the GP will aid opportunistic recruitment in primary care. The primary outcome for this feasibility study is recruitment rate. Secondary outcome measures, including time to diagnosis, will be collected to help inform outcomes for the future trial and to assess the impact of an earlier diagnosis. These will include symptoms, health-related quality of life, exercise capacity, measures of frailty, physical activity and healthcare utilisation. The study will include nested qualitative interviews with patients and healthcare staff to understand the feasibility outcomes, explore what is 'usual care' and the study experience. ETHICS AND DISSEMINATION The Research Ethics Committee Nottingham 1 has provided ethical approval for this research study (REC Reference: 19/EM/0201). Results from the study will be disseminated by presentations at relevant meetings and conferences including British Thoracic Society and Primary Care Respiratory Society, as well as by peer-reviewed publications and through patient presentations and newsletters to patients, where available. TRIAL REGISTRATION NUMBER ISRCTN14483247.
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Affiliation(s)
- Gillian Doe
- Respiratory Sciences, University of Leicester, Leicester, UK
| | - Jill Clanchy
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Simon Wathall
- Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Stacey Chantrell
- NIHR Leicester Biomedical Research Centre - Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sarah Edwards
- NIHR Leicester Biomedical Research Centre - Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Noel Baxter
- International Primary Care Respiratory Group, London, UK
| | | | | | - Michael Steiner
- Respiratory Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre - Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rachael A Evans
- Respiratory Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre - Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
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Nishimura K, Nakayasu K, Mori M, Sanda R, Shibayama A, Kusunose M. Are Fatigue and Pain Overlooked in Subjects with Stable Chronic Obstructive Pulmonary Disease? Diagnostics (Basel) 2021; 11:diagnostics11112029. [PMID: 34829376 PMCID: PMC8620334 DOI: 10.3390/diagnostics11112029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
Although there have been many published reports on fatigue and pain in patients with chronic obstructive pulmonary disease (COPD), it is considered that these symptoms are seldom, if ever, asked about during consultations in Japanese clinical practice. To bridge this gap between the literature and daily clinical experience, the authors attempted to gain a better understanding of fatigue and pain in Japanese subjects with COPD. The Brief Fatigue Inventory (BFI) to analyse and quantify the degree of fatigue, the revised Short–Form McGill Pain Questionnaire 2 (SF-MPQ-2) for measuring pain and the Kihon Checklist to judge whether a participant is frail and elderly were administered to 89 subjects with stable COPD. The median BFI and SF-MPQ-2 Total scores were 1.00 [IQR: 0.11–2.78] and 0.00 [IQR: 0.00–0.27], respectively. They were all skewed toward the milder end of the respective scales. A floor effect was noted in around a quarter on the BFI and over half on the SF-MPQ-2. The BFI scores were significantly different between groups regarding frailty determined by the Kihon Checklist but not between groups classified by the severity of airflow limitation. Compared to the literature, neither fatigue nor pain are considered to be frequent, important problems in a real-world Japanese clinical setting, especially among subjects with mild to moderate COPD. In addition, our results might suggest that fatigue is more closely related to frailty than COPD.
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Affiliation(s)
- Koichi Nishimura
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
- Correspondence: ; Tel.: +81-562-46-2311
| | - Kazuhito Nakayasu
- Data Research Section, Kondo Photo Process Co., Ltd., Osaka 543-0011, Japan;
| | - Mio Mori
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
| | - Ryo Sanda
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
| | - Ayumi Shibayama
- Department of Nursing, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan;
| | - Masaaki Kusunose
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
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Serresse L, Simon-Tillaux N, Decavèle M, Gay F, Nion N, Lavault S, Guerder A, Châtelet A, Dabi F, Demoule A, Morélot-Panzini C, Moricot C, Similowski T. Lifting dyspnoea invisibility: COVID-19 face masks, the experience of breathing discomfort, and improved lung health perception - a French nationwide survey. Eur Respir J 2021; 59:13993003.01459-2021. [PMID: 34475232 DOI: 10.1183/13993003.01459-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/03/2021] [Indexed: 11/05/2022]
Abstract
QUESTION ADDRESSED In contrast with pain, dyspnoea is not visible to the general public who lack the corresponding experiential baggage. We tested the hypotheses that the generalised use of face masks to fight SARS-CoV2 dissemination could change this and sensitise people to respiratory health. METHODS General population polling (1012-person panel demographically representative of the adult French population -quota sampling method-; 517 women, 51%). 860 (85%) answered "no" to "treated for a chronic respiratory disease" ("respiratory healthy", RH) and 152 "yes" ("respiratory disease", RD). 14% of RH respondents reported having a close family member treated for a chronic respiratory disease (RH-family+ and RH-family-). Respondents described mask-related attitudes, beliefs, inconveniencies, dyspnoea, and changes in their respiratory health vision . RESULTS: Compliance with masks was high (94.7%). Dyspnoea ranked first among mask inconveniencies (RD 79.3%, RH 67.3%, p=0.013). "Air hunger" was the main sensory dyspnoea descriptor. Mask-related dyspnoea was independently associated with belonging to RH-family+ (Odds Ratio [OR] [95% confidence interval (CI)]: 1.85 [1.16-2.98]) and removing masks to improve breathing (OR 5.21 [3.73-7.28]). It was negatively associated with considering masks effective to protect others (OR]: 0.42 [0.25-0.75]). Half the respondents were more concerned with their respiratory health since wearing masks; 41% reported better understanding patients' experiences. ANSWER TO THE QUESTION Wearing protective face masks leads to the mass discovery of breathing discomfort. It raises the public's awareness of what respiratory diseases involve and sensitises to the importance of breathing. These data should be used as the fulcrum of respiratory-health-oriented communication actions.
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Affiliation(s)
- Laure Serresse
- Unité Mobile de Soins Palliatifs, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,co-first authors
| | - Noémie Simon-Tillaux
- Département de Santé Publique, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Sorbonne Université, INSERM, UMRS 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France.,co-first authors
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Paris, France
| | - Frederick Gay
- Laboratoire de parasitologie-mycologie, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Nathalie Nion
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Sophie Lavault
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | - Antoine Guerder
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Soins de Suite et de Réadaptation Respiratoire, Paris, France
| | | | - Frédéric Dabi
- Institut Français d'Opinion Publique (IFOP), Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | - Caroline Moricot
- Département de Sociologie & EA 2483 Centre d'étude des techniques, des connaissances et des pratiques -CETCOPRA-, Université Paris I Panthéon Sorbonne, Paris, France.,co-last authors
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France .,Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,co-last authors
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Currow DC, Chang S, Ferreira D, Eckert DJ, Gonzalez-Chica D, Stocks N, Ekström MP. Chronic breathlessness and sleep problems: a population-based survey. BMJ Open 2021; 11:e046425. [PMID: 34385238 PMCID: PMC8362739 DOI: 10.1136/bmjopen-2020-046425] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This study aimed to explore the relationship (presence and severity) between chronic breathlessness and sleep problems, independently of diagnoses and health service contact by surveying a large, representative sample of the general population. SETTING Analysis of the 2017 South Australian Health Omnibus Survey, an annual, cross-sectional, face-to-face, multistage, clustered area systematic sampling survey carried out in Spring 2017.Chronic breathlessness was self-reported using the ordinal modified Medical Research Council (mMRC; scores 0 (none) to 4 (housebound)) where breathlessness has been present for more than 3 of the previous 6 months. 'Sleep problems-ever' and 'sleep problem-current' were assessed dichotomously. Regression models were adjusted for age; sex and body mass index (BMI). RESULTS 2900 responses were available (mean age 48.2 years (SD=18.6); 51% were female; mean BMI 27. 1 (SD=5.9)). Prevalence was: 2.7% (n=78) sleep problems-past; 6.8% (n=198) sleep problems-current and breathlessness (mMRC 1-4) was 8.8% (n=254). Respondents with sleep problemspast were more likely to be breathless, older with a higher BMI and sleep problems-present also included a higher likelihood of being female.After adjusting for age, sex and BMI, respondents with chronic breathlessness had 1.9 (95% CI=1.0 to 3.5) times the odds of sleep problems-past and sleep problems-current (adjusted OR=2.3; 95% CI=1.6 to 3.3). CONCLUSIONS There is a strong association between the two prevalent conditions. Future work will seek to understand if there is a causal relationship using validated sleep assessment tools and whether better managing one condition improves the other.
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Affiliation(s)
- David C Currow
- MPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Sungwon Chang
- MPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Diana Ferreira
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | | | - Nigel Stocks
- University of Adelaide, Adelaide, South Australia, Australia
| | - Magnus Per Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
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20
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Olsson M, Engström G, Currow DC, Johnson M, Sandberg J, Ekström MP. VAScular and Chronic Obstructive Lung disease (VASCOL): a longitudinal study on morbidity, symptoms and quality of life among older men in Blekinge county, Sweden. BMJ Open 2021; 11:e046473. [PMID: 34312196 PMCID: PMC8314706 DOI: 10.1136/bmjopen-2020-046473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Despite data showing breathlessness to be more prevalent in older adults, we have little detail about the severity or multidimensional characteristics of breathlessness and other self-reported measures (such as quality of life and other cardiorespiratory-related symptoms) in this group at the population level. We also know little about the relationship between multidimensional breathlessness, other symptoms, comorbidities and future clinical outcomes such as quality of life, hospitalisation and mortality. This paper reports the design and descriptive findings from the first two waves of a longitudinal prospective cohort study in older adults. PARTICIPANTS Between 2010 and 2011, 1900 men in a region in southern Sweden aged 65 years were invited to attend for VAScular and Chronic Obstructive Lung disease (VASCOL) baseline (Wave 1) assessments which included physiological measurements, blood sampling and a self-report survey of lifestyle and previous medical conditions. In 2019, follow-up postal survey data (Wave 2) were collected with additional self-report measures for breathlessness, other symptoms and quality of life. At each wave, data are cross-linked with nationwide Swedish registry data of diseases, treatment, hospitalisation and cause of death. FINDINGS TO DATE 1302/1900 (68%) of invited men participated in Wave 1, which include 56% of all 65-year-old men in the region. 5% reported asthma, 2% chronic obstructive pulmonary disease, 56% hypertension, 10% diabetes and 19% had airflow limitation. The VASCOL cohort had comparable characteristics to those of similarly aged men in Sweden. By 2019, 109/1302 (8.4%) had died. 907/1193 (76%) of the remainder participated in Wave 2. Internal data completeness of 95% or more was achieved for most Wave 2 measures. FUTURE PLANS A third wave will be conducted within 4 years, and the cohort will be followed through repeated follow-ups planned every fourth year, as well as national registry data of diagnosis, treatments and cause of death.
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Affiliation(s)
- Max Olsson
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Gunnar Engström
- Faculty of Medicine, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - David C Currow
- Faculty of Health, University of Technology Sydney, IMPACCT, Ultimo, New South Wales, Australia
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Jacob Sandberg
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Magnus Per Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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21
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Sandberg J, Ekström M, Börjesson M, Bergström G, Rosengren A, Angerås O, Toren K. Underlying contributing conditions to breathlessness among middle-aged individuals in the general population: a cross-sectional study. BMJ Open Respir Res 2021; 7:7/1/e000643. [PMID: 32978243 PMCID: PMC7520902 DOI: 10.1136/bmjresp-2020-000643] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 01/27/2023] Open
Abstract
Introduction Breathlessness is common in the general population and associated with poorer health. Prevalence, frequencies and overlap of underlying contributing conditions among individuals reporting breathlessness in the general population is unclear. The aim was to evaluate which conditions that were prevalent, overlapping and associated with breathlessness in a middle-aged general population. Method Cross-sectional analysis of individuals aged 50–65 years in the Swedish CArdioPulmonary bioImage Study pilot. Data from questionnaire, spirometry testing and fitness testing were used to identify underlying contributing conditions among participants reporting breathlessness (a modified Medical Research Scale (mMRC) score ≥1). Multivariate logistic regression was used to identify independent associations with breathlessness. Results 1097 participants were included; mean age 57.5 years, 50% women and 9.8% (n=108) reported breathlessness (mMRC ≥1). Main underlying contributing conditions were respiratory disease (57%), anxiety or depression (52%), obesity (43%) and heart disease or chest pain (35%). At least one contributing condition was found in 99.6% of all participants reporting breathlessness, while two or more conditions were present in 66%. Conclusion In a middle-aged general population, the main underlying contributing conditions to breathlessness were respiratory disease, anxiety or depression, obesity and heart disease or chest pain with a high level of overlap.
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Affiliation(s)
- Jacob Sandberg
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Mats Börjesson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Center for Health and Performance, University of Gothenburg, Gothenburg, Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Physiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kjell Toren
- Department of Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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22
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Lewthwaite H, Jensen D, Ekström M. How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:1581-1598. [PMID: 34113091 PMCID: PMC8184148 DOI: 10.2147/copd.s277523] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/09/2021] [Indexed: 12/17/2022] Open
Abstract
Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg's 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.
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Affiliation(s)
- Hayley Lewthwaite
- School of Environmental & Life Sciences, College of Engineering, Science and Environment, University of Newcastle, Ourimbah, Australia
- UniSA: Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, Australia
| | - Dennis Jensen
- Department of Kinesiology and Physical Education, McGill University, Montréal, Québec, Canada
- Research Institute of the McGill University Health Centre, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Research Centre for Physical Activity and Health, Faculty of Education, McGill University, Montréal, Canada
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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23
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Massart A, Hunt DP. Management of Refractory Breathlessness: a Review for General Internists. J Gen Intern Med 2021; 36:1035-1040. [PMID: 33469757 PMCID: PMC8041955 DOI: 10.1007/s11606-020-06439-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/10/2020] [Indexed: 12/14/2022]
Abstract
Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.
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Affiliation(s)
- Annie Massart
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA. .,, Atlanta, USA.
| | - Daniel P Hunt
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA
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24
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Rantala HA, Leivo-Korpela S, Lehto JT, Lehtimäki L. Dyspnea on Exercise Is Associated with Overall Symptom Burden in Patients with Chronic Respiratory Insufficiency. Palliat Med Rep 2021; 2:48-53. [PMID: 34223503 PMCID: PMC8241384 DOI: 10.1089/pmr.2020.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Patients with chronic respiratory insufficiency suffer from many symptoms together with dyspnea. Objective: We evaluated the association of dyspnea on exercise with other symptoms in patients with chronic respiratory insufficiency due to chronic obstructive pulmonary disease or interstitial lung disease. Design: This retrospective study included 101 patients in Tampere University Hospital, Finland. Dyspnea on exercise was assessed with modified Medical Research Council (mMRC) dyspnea questionnaire, and other symptoms were assessed with Edmonton Symptom Assessment System (ESAS) and Depression Scale (DEPS). The study was approved by Regional Ethics Committee of Tampere University Hospital, Finland (approval code R15180/December 1, 2015). Results: Patients with mMRC 4 (most severe dyspnea) compared with those with mMRC 0-3 reported higher symptom scores on ESAS in shortness of breath (median 8.0 [IQR 6.0-9.0] vs. 4.0 [2.0-6.0], p < 0.001), dry mouth (7.0 [4.0-8.0] vs. 3.0 [1.0-6.0], p < 0.001), tiredness (6.0 [3.0-7.0] vs. 3.0 [1.0-5.0], p < 0.001), loss of appetite (3.0 [0.0-6.0] vs. 1.0 [0.0-3.0], p = 0.001), insomnia (3.0 [1.0-7.0] vs. 2.0 [0.0-3.0], p = 0.027), anxiety (3.0 [0.0-5.5] vs. 1.0 [0.0-3.0], p = 0.007), and nausea (0.0 [0.0-2.0] vs. 0.0 [0.0-0.3], p = 0.027). Patients with mMRC 4 were more likely to reach the DEPS threshold for depression than those scoring mMRC 0-3 (42.1% vs. 20.8%, p = 0.028). Conclusions: Patients with chronic respiratory insufficiency need comprehensive symptom screening with relevant treatment, as they suffer from broad symptom burden worsening with increased dyspnea on exercise.
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Affiliation(s)
- Heidi A Rantala
- Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sirpa Leivo-Korpela
- Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Oncology, Palliative Care Centre, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
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25
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Verberkt CA, van den Beuken-van Everdingen MHJ, Dirksen CD, Schols JMGA, Wouters EFM, Janssen DJA. Cost-effectiveness of sustained-release morphine for refractory breathlessness in COPD: A randomized clinical trial. Respir Med 2021; 179:106330. [PMID: 33611087 DOI: 10.1016/j.rmed.2021.106330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic breathlessness is a frequent symptom in advanced Chronic Obstructive Pulmonary Disease (COPD) and has major impact on quality of life, daily activities and healthcare utilization. Morphine is used as palliative treatment of chronic breathlessness. The aim is to analyze cost-effectiveness of regular, low-dose morphine in patients with advanced COPD from a healthcare and societal perspective. METHODS In a randomized controlled trial, participants with advanced COPD were assigned to 10 mg regular, oral sustained-release morphine or placebo twice daily for four weeks. Quality of life (COPD Assessment Test; CAT), quality-adjusted life years (QALY's; EQ-5D-5L), healthcare costs, productivity, and patient and family costs were collected. Incremental cost-effectivity ratio's (ICERs) using healthcare costs and CAT scores, and incremental cost-utility ratio's (ICURs) using societal costs and QALY's were calculated. RESULTS Data of 106 of 124 participants were analyzed, of which 50 were in the morphine group (mean [SD] age 65.4 [8.0] years; 58 [55%] male). Both ICER and ICUR indicated dominance for morphine treatment. Sensitivity analyses substantiated these results. From a healthcare perspective, the probability that morphine is cost-effective at a willingness to pay €8000 for an minimal clinically important difference of 2 points increase in CAT score is 63%. From a societal perspective, the probability that morphine is cost-effective at a willingness to pay €20,000 per QALY is 78%. CONCLUSION Morphine for four weeks is cost-effective regarding the healthcare and the societal perspective. To estimate the long-term costs and effects of morphine treatment, a study of longer follow-up should be performed. TRIAL REGISTRATION ClinicalTrials.gov (NCT02429050).
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Affiliation(s)
- Cornelia A Verberkt
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands
| | | | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center, P.O. Box 5800, 6202AZ, Maastricht, the Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands; Department of Family Medicine, Care and Public Health Research Institute, P.O. Box 616, 6200MD, Maastricht University, Maastricht, the Netherlands
| | - Emiel F M Wouters
- Department of Research & Development, Ciro, P.O. Box 4009, 6080AA, Haelen, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202AZ, Maastricht, the Netherlands; Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands; Department of Research & Development, Ciro, P.O. Box 4009, 6080AA, Haelen, the Netherlands.
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26
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Schunk M, Le L, Syunyaeva Z, Haberland B, Tänzler S, Mansmann U, Schwarzkopf L, Seidl H, Streitwieser S, Hofmann M, Müller T, Weiß T, Morawietz P, Rehfuess EA, Huber RM, Berger U, Bausewein C. Effectiveness of a specialised breathlessness service for patients with advanced disease in Germany: a pragmatic fast-track randomised controlled trial (BreathEase). Eur Respir J 2021; 58:13993003.02139-2020. [PMID: 33509957 DOI: 10.1183/13993003.02139-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The effectiveness of the Munich Breathlessness Service (MBS), integrating palliative care, respiratory medicine and physiotherapy, was tested in the BreathEase trial in patients with chronic breathlessness in advanced disease and their carers. METHODS BreathEase was a single-blinded randomised controlled fast-track trial. The MBS was attended for 5-6 weeks; the control group started the MBS after 8 weeks of standard care. Randomisation was stratified by cancer and the presence of a carer. Primary outcomes were patients' mastery of breathlessness (Chronic Respiratory Disease Questionnaire (CRQ) Mastery), quality of life (CRQ QoL), symptom burden (Integrated Palliative care Outcome Scale (IPOS)) and carer burden (Zarit Burden Interview (ZBI)). Intention-to-treat (ITT) analyses were conducted with hierarchical testing. Effectiveness was investigated by linear regression on change scores, adjusting for baseline scores and stratification variables. Missing values were handled with multiple imputation. RESULTS 92 patients were randomised to the intervention group and 91 patients were randomised to the control group. Before the follow-up assessment after 8 weeks (T1), 17 and five patients dropped out from the intervention and control groups, respectively. Significant improvements in CRQ Mastery of 0.367 (95% CI 0.065-0.669) and CRQ QoL of 0.226 (95% CI 0.012-0.440) score units at T1 in favour of the intervention group were seen in the ITT analyses (n=183), but not in IPOS. Exploratory testing showed nonsignificant improvements in ZBI. CONCLUSIONS These findings demonstrate positive effects of the MBS in reducing burden caused by chronic breathlessness in advanced illness across a wide range of patients. Further evaluation in subgroups of patients and with a longitudinal perspective is needed.
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Affiliation(s)
- Michaela Schunk
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany .,Pettenkofer School of Public Health, Munich, Germany
| | - Lien Le
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Zulfiya Syunyaeva
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Birgit Haberland
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Tänzler
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,IFT (Institut für Therapieforschung), Munich, Germany
| | - Hildegard Seidl
- Pettenkofer School of Public Health, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,Quality Management and Gender Medicine, München Klinik gGmbH, Munich, Germany
| | - Sabine Streitwieser
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Miriam Hofmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Thomas Müller
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Tobias Weiß
- Atem-und Physiotherapie Solln, Munich, Germany
| | | | - Eva Annette Rehfuess
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Rudolf Maria Huber
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
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27
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Currow DC, Chang S, Grande ED, Ferreira DH, Kochovska S, Kinchin I, Johnson MJ, Ekstrom M. Quality of Life Changes With Duration of Chronic Breathlessness: A Random Sample of Community-Dwelling People. J Pain Symptom Manage 2020; 60:818-827.e4. [PMID: 32442480 DOI: 10.1016/j.jpainsymman.2020.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic breathlessness is associated with poorer quality of life (QoL). This population study aimed to define dimensions of QoL and duration and dominant causes of breathlessness that most diminished QoL. METHODS This cross-sectional, population-based, and randomized survey of adults (n = 2977) in South Australia collected data on demographics, modified Medical Research Council (mMRC) breathlessness, and QoL (EuroQoL five-dimension five-level [EQ-5D-5L] measure; Short Form 12 quality-of-life measure). Data weighted to the census were analyzed for relationships between EQ-5D-5L and its dimensions with mMRC. Regression models controlled for age, sex, education, rurality, and body mass index. RESULTS About 2883 responses were analyzed: 49% were males; mean age was 48 years (SD 19). As mMRC worsened, EQ-5D-5L and its dimensions worsened. More severe chronic breathlessness was iteratively associated with lower mobility, daily activities, and worse pain/discomfort. For self-care and anxiety/depression, impairment was only with the most severe breathlessness. Respondents who had chronic breathlessness for two to six years had the worst QoL scores. People who attributed their breathlessness to cardiac failure had poorer QoL. Respondents who reported a cardiac cause for their breathlessness had worse mobility, poorer usual activities, and more pain than the other causes. The regression analyses showed that worse chronic breathlessness was associated with worsening QoL in each dimension of EQ-5D-5L, with the exception of the self-care, which only worsened with the most severe breathlessness. CONCLUSIONS This is the first study to report on chronic breathlessness and impairment across dimensions of QoL and differences by its duration. Mobility, usual activity, and pain drive these reductions.
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Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia; Wolfson Palliative Care Research Centre, University of Hull, Hull, England.
| | - Sungwon Chang
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | | | - Diana H Ferreira
- Discipline Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Irina Kinchin
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Magnus Ekstrom
- Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
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28
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Kochovska S, Chang S, Morgan DD, Ferreira D, Sidhu M, Saleh Moussa R, Johnson MJ, Ekström M, Currow DC. Activities Forgone because of Chronic Breathlessness: A Cross-Sectional Population Prevalence Study. Palliat Med Rep 2020; 1:166-170. [PMID: 34223472 PMCID: PMC8241375 DOI: 10.1089/pmr.2020.0083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Chronic breathlessness is a prevalent disabling syndrome affecting many people for years. Identifying the impact of chronic breathlessness on people's activities in the general population is pivotal for designing symptom management strategies. Objective: This study aimed to evaluate the association between chronic breathlessness and activities respondents identify can no longer be undertaken (“activities forgone”). Design: This population-based cross-sectional online survey used a market research company's database of 30,000 registrants for each sex, generating the planned sample size—3000 adults reflecting Australia's 2016 Census by sex, age group, state of residence, and rurality. Setting/Subjects: The population of focus (n = 583) reported a modified Medical Research Council (mMRC) breathlessness scale ≥1 and experienced this breathlessness for ≥3 months. Measurements: Activities forgone were categorized by mMRC using coding derived from the Dyspnea Management Questionnaire domains. Activities were classified as “higher/lower intensity” using Human Energy Expenditure scale. Results: Respondents were male 50.3%; median age 50.0 (IQR 29.0); with 66% living in metropolitan areas; reporting 1749 activities forgone. For people with mMRC 1 (n = 533), 35% had not given up any activity, decreasing to 9% for mMRC 2 (n = 38) and 3% for mMRC 3–4 (n = 12). Intense sport (e.g., jogging and bike riding) was the top activity forgone: 42% (mMRC 1), 32% (mMRC 2), and 36% (mMRC 3–4). For respondents with mMRC 3–4, the next most prevalent activities forgone were “sexual activities” (14%), “lower intensity sports” (11%), and “other activities” (11%). Conclusions: People progressively reduce a wide range of activities because of their chronic breathlessness.
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Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Care Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Care Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Deidre D Morgan
- Flinders University, Palliative and Supportive Services, RePaDD, Bedford Park, South Australia, Australia
| | - Diana Ferreira
- Flinders University, Palliative and Supportive Services, Bedford Park, South Australia, Australia
| | - Manraaj Sidhu
- Australian national Palliative Care Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Rayan Saleh Moussa
- Cancer Symptom Trials, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
| | - Magnus Ekström
- Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Care Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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Li H, Shi K, Zhao Y, Du J, Hu D, Liu Z. TIMP-1 and MMP-9 expressions in COPD patients complicated with spontaneous pneumothorax and their correlations with treatment outcomes. Pak J Med Sci 2019; 36:192-197. [PMID: 32063958 PMCID: PMC6994862 DOI: 10.12669/pjms.36.2.1244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Objective: To study the expressions of TIMP-1 and MMP-9 in patients with chronic obstructive pulmonary disease (COPD) complicated with spontaneous pneumothorax, and their correlations with treatment outcomes. Methods: A total of 80 COPD patients complicated with spontaneous pneumothorax treated in our hospital from December 2015 to December 2017. The serum expressions of TIMP-1 and MMP-9 in 80 COPD patients complicated with spontaneous pneumothorax (COPD group) and 52 healthy volunteers (control group) were detected by ELISA. The correlations of TIMP-1 and MMP-9 expressions with arterial blood gas parameters as well as scores of MRC breathlessness scale and St. George’s Respiratory Questionnaire (SGRQ) were analyzed. Results: The serum expressions of TIMP-1 and MMP-9 of COPD group were significantly higher than those of control group (P<0.05), but the two groups had similar MMP-9/TIMP-1 ratios (P>0.05). For COPD group, TIMP-1 expression, MMP-9 expression, MMP-9/TIMP-1, Sa(O2) and p(O2) were not correlated (P>0.05). TIMP-1 expression was significantly positively correlated with MRC scale and SGRQ scores (P<0.05). Sa(O2), p(O2) and MRC scale score of low MMP-9 expression, low TIMP-1 expression and low MMP-9/TIMP-1 group were significantly improved compared with those of high MMP-9 expression, high TIMP-1 expression and high MMP-9/TIMP-1 group (P<0.05). MMP-9 expression, TIMP-1 expression or MMP-9/TIMP-1 was not correlated with improvement of SGRQ score. Pulmonary function improvement (Sa(O2) improvement rate ≥5% and/or p(O2) improvement rate ≥10%) was correlated with serum MMP-9 expression, baseline Sa(O2) and p(O2). Conclusion: Increase of serum TIMP-1 and MMP-9 expressions in COPD patients was correlated with symptoms and scores of quality of life, and the expressions were also correlated with short-term treatment reactivity.
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Affiliation(s)
- Hang Li
- Hang Li, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
| | - Kaihu Shi
- Kaihu Shi, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
| | - Yang Zhao
- Yang Zhao, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
| | - Jin Du
- Jin Du, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
| | - Dinghui Hu
- Dinghui Hu, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
| | - Zuntao Liu
- Zuntao Liu, Department of Thoracic and Cardiovascular Surgery, Nanjing Integrated Traditional Chinese and Western Medicine Hospital, Jiangsu Province, P. R. China
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Johnson MJ, Cockayne S, Currow DC, Bell K, Hicks K, Fairhurst C, Gabe R, Torgerson D, Jefferson L, Oxberry S, Ghosh J, Hogg KJ, Murphy J, Allgar V, Cleland JG, Clark AL. Oral modified release morphine for breathlessness in chronic heart failure: a randomized placebo-controlled trial. ESC Heart Fail 2019; 6:1149-1160. [PMID: 31389157 PMCID: PMC6989293 DOI: 10.1002/ehf2.12498] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/19/2019] [Accepted: 06/18/2019] [Indexed: 02/03/2023] Open
Abstract
AIMS Morphine is shown to relieve chronic breathlessness in chronic obstructive pulmonary disease. There are no definitive data in people with heart failure. We aimed to determine the effectiveness and cost-effectiveness of 12 weeks morphine therapy for the relief of chronic breathlessness in people with chronic heart failure compared with placebo. METHODS AND RESULTS Parallel group, double-blind, randomized, placebo-controlled, phase III trial of 20 mg daily oral modified release morphine was conducted in 13 sites in England and Scotland: hospital/community cardiology or palliative care outpatients. The primary analysis compared between-group numerical rating scale average breathlessness/24 hours at week 4 using a covariance pattern linear mixed model. Secondary outcomes included treatment-emergent harms (worse or new). The trial closed early due to slow recruitment, randomizing 45 participants [average age 72 (range 39-89) years; 84% men; 98% New York Heart Association class III]. For the primary analysis, the adjusted mean difference was 0.26 (95% confidence interval, -0.86 to 1.37) in favour of placebo. All other breathlessness measures improved in both groups (week 4 change-from-baseline) but by more in those assigned to morphine. Neither group was excessively drowsy at baseline or week 4. There were no between-group differences in quality of life (Kansas) or cognition (Montreal) at any time point. There was no exercise-related desaturation and no change between baseline and week 4 in either group. There was no change in vital signs at week 4. The natriuretic peptide measures fell in both groups but by more in the morphine group [morphine 2169 (1092, 3851) pg/mL vs. placebo 2851 (1694, 5437)] pg/mL. There was no excess serious adverse events in the morphine group. Treatment-emergent harms during the first week were more common in the morphine group; all apart from 1 were ≤ grade 2. CONCLUSIONS We could not answer our primary objectives due to inadequate power. However, we provide novel placebo-controlled medium-term benefit and safety data useful for clinical practice and future trial design. Morphine should only be prescribed in this population when other measures are unhelpful and with early management of side effects.
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Affiliation(s)
- Miriam J. Johnson
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
| | | | - David C. Currow
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
- IMPACCT, Faculty of HealthUniversity of Technology SydneyUltimoNSWAustralia
| | - Kerry Bell
- York Trials UnitUniversity of YorkYorkUK
| | - Kate Hicks
- York Trials UnitUniversity of YorkYorkUK
| | | | - Rhian Gabe
- Hull York Medical School and York Trials UnitUniversity of YorkYorkUK
| | | | | | - Stephen Oxberry
- Calderdale & Huddersfield Foundation TrustHuddersfield Royal InfirmaryHuddersfieldUK
| | - Justin Ghosh
- Department of CardiologyScarborough HospitalScarboroughUK
| | - Karen J. Hogg
- Department of CardiologyGlasgow Royal Infirmary, University of GlasgowGlasgowUK
| | - Jeremy Murphy
- Department of CardiologyDarlington Memorial HospitalDarlingtonUK
| | - Victoria Allgar
- Hull York Medical School and Department of Health SciencesUniversity of YorkYorkUK
| | - John G.F. Cleland
- Robertson Centre for Biostatistics & Clinical Trials, Institute of Health & Well‐beingUniversity of GlasgowGlasgowUK
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Ferry OR, Huang YC, Masel PJ, Hamilton M, Fong KM, Bowman RV, McKenzie SC, Yang IA. Diagnostic approach to chronic dyspnoea in adults. J Thorac Dis 2019; 11:S2117-S2128. [PMID: 31737340 DOI: 10.21037/jtd.2019.10.53] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.
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Affiliation(s)
- Olivia R Ferry
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Yao C Huang
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Philip J Masel
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Kwun M Fong
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Rayleen V Bowman
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Scott C McKenzie
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Cardiology Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Ian A Yang
- Thoracic Medicine Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Currow D, Louw S, McCloud P, Fazekas B, Plummer J, McDonald CF, Agar M, Clark K, McCaffrey N, Ekström MP. Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax 2019; 75:50-56. [PMID: 31558624 DOI: 10.1136/thoraxjnl-2019-213681] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Morphine may decrease the intensity of chronic breathlessness but data from a large randomised controlled trial (RCT) are lacking. This first, large, parallel-group trial aimed to test the efficacy and safety of regular, low-dose, sustained-release (SR) morphine compared with placebo for chronic breathlessness. METHODS Multisite (14 inpatient and outpatient cardiorespiratory and palliative care services in Australia), parallel-arm, double-blind RCT. Adults with chronic breathlessness (modified Medical Research Council≥2) were randomised to 20 mg daily oral SR morphine and laxative (intervention) or placebo and placebo laxative (control) for 7 days. Both groups could take ≤6 doses of 2.5 mg, 'as needed', immediate-release morphine (≤15 mg/24 hours) as required by the ethics review board. The primary endpoint was change from baseline in intensity of breathlessness now (0-100 mm visual analogue scale; two times per day diary) between groups. Secondary endpoints included: worst, best and average breathlessness; unpleasantness of breathlessness now, fatigue; quality of life; function; and harms. RESULTS Analysed by intention-to-treat, 284 participants were randomised to morphine (n=145) or placebo (n=139). There was no difference between arms for the primary endpoint (mean difference -0.15 mm (95% CI -4.59 to 4.29; p=0.95)), nor secondary endpoints. The placebo group used more doses of oral morphine solution during the treatment period (mean 8.7 vs 5.8 doses; p=0.001). The morphine group had more constipation and nausea/vomiting. There were no cases of respiratory depression nor obtundation. CONCLUSION No differences were observed between arms for breathlessness, but the intervention arm used less rescue immediate-release morphine. TRIAL REGISTRATION NUMBER ACTRN12609000806268.
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Affiliation(s)
- David Currow
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia .,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John Plummer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christine F McDonald
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Meera Agar
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, Saint Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nikki McCaffrey
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Deakin Health Economics, Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Magnus Pär Ekström
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
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Cheng CW, Wang CH, Chen WS, Wang CC, Cherng WJ. Predictors of long-term survival prior to permanent pacemaker implantation in octogenarians or older. Aging Clin Exp Res 2019; 31:1001-1009. [PMID: 30259339 PMCID: PMC6589145 DOI: 10.1007/s40520-018-1044-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 09/21/2018] [Indexed: 11/25/2022]
Abstract
Background There is an increased need for permanent pacemaker (PPM) implantation for older patients with multiple comorbidities. The current guidelines recommend that, before implanting PPM, clinicians should discuss life expectancy with patients and their families as part of the decision-making process. However, estimating individual life expectancy is always a challenge. Aims We investigated predictors of long-term survival prior to PPM implantation in patients aged 80 or older. Methods and results From September 2004 to September 2015, 100 patients aged ≥ 80 years who received PPM implantation were included for retrospective survival analysis. The end point was all-cause mortality. Follow-up duration was 4.0 ± 2.7 years. By the end of the study, 54 patients (54%) had died. Of the 54 who died, 40 patients (74.1%) died of non-cardiac causes. Their survival rates at 1, 2, 3, 5, and 7 years were 90%, 76%, 54%, 32%, and 16%, respectively. Patients with a longer length of hospital stay before PPM implantation (LOS-B) [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.02–1.05, p < 0.001], estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2 (HR 4.07, 95% CI 1.95–8.52, p < 0.001), body mass index (BMI) < 21 kg/m2 (HR 2.50, 95% CI 1.16–5.39, p = 0.02), and dyspnea as the major presenting symptom (HR 2.88, 95% CI 1.27–6.55, p = 0.01) were associated with lower cumulative survival. Conclusions Longer LOS-B, lower eGFR and BMI, and dyspnea as the major presenting symptom are pre-PPM implantation predictors of long-term survival in patients aged 80 or older.
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Affiliation(s)
- Chi-Wen Cheng
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, 222 Mai Chin Road, Keelung, Taiwan, ROC.
- Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC.
| | - Chao-Hung Wang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, 222 Mai Chin Road, Keelung, Taiwan, ROC
- Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
| | - Wei-Siang Chen
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, 222 Mai Chin Road, Keelung, Taiwan, ROC
| | - Chun-Chieh Wang
- Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC
| | - Wen-Jin Cherng
- Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC
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Ramalho SHR, Santos M, Claggett B, Matsushita K, Kitzman DW, Loehr L, Solomon SD, Skali H, Shah AM. Association of Undifferentiated Dyspnea in Late Life With Cardiovascular and Noncardiovascular Dysfunction: A Cross-sectional Analysis From the ARIC Study. JAMA Netw Open 2019; 2:e195321. [PMID: 31199443 PMCID: PMC6575149 DOI: 10.1001/jamanetworkopen.2019.5321] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022] Open
Abstract
Importance Undifferentiated dyspnea is common in late life, but the relative contribution of subclinical cardiac dysfunction is unknown. Impairments in cardiac structure and function may be characteristics of undifferentiated dyspnea in elderly people, providing potential insights into occult heart failure (HF). Objective To quantify the association of undifferentiated dyspnea with cardiac dysfunction after accounting for other potential contributors. Design, Setting, and Participants This cross-sectional study used data from Atherosclerosis Risk in Communities study participants 65 years and older who attended the fifth study visit (from 2011 to 2013) and had not been diagnosed with HF, chronic obstructive pulmonary disease, morbid obesity, or severe kidney disease. Analyses were conducted from October 2017 to June 2018. Exposures Dyspnea measured using the modified Medical Research Council scale, with a score less than 2 classified as none to mild and a score of 2 or more classified as moderate to severe. Main Outcomes and Measures Using multivariable logistic regression, the association of undifferentiated dyspnea was defined using cardiac structure, systolic and diastolic function, pulmonary pressure (echocardiography), pulmonary function (spirometry), glomerular filtration rate, hemoglobin, body mass index, depression, and physical performance. The population-attributable risk was calculated for each dysfunction metric. Results Among 4342 participants (mean [SD] age, 75.9 [5.0] years; 2533 [58.3%] women), 1173 (27.0%) had undifferentiated dyspnea. Moderate to severe dyspnea was present in 574 participants (13.2%) and was associated with left ventricular (LV) hypertrophy (odds ratio [OR], 1.53; 95% CI, 1.25-1.87; P < .001) and LV diastolic (OR, 1.46; 95% CI, 1.20-1.78; P < .001) and systolic (OR, 1.28; 95% CI, 1.05-1.56; P = .02) dysfunction. Moderate to severe dyspnea was also associated with obstructive (OR, 1.59; 95% CI, 1.28-1.99; P < .001) and restrictive (OR, 2.56; 95% CI, 1.99-3.27; P < .001) findings on spirometry, renal impairment (OR, 1.32; 95% CI, 1.08-1.61; P = .01), anemia (OR, 1.72; 95% CI, 1.39-2.12; P < .001), lower (OR, 2.77; 95% CI, 2.18-3.51; P < .001) and upper (OR, 1.82; 95% CI, 1.49-2.23; P < .001) extremity weakness, depression (OR, 3.01; 95% CI, 2.24-4.25; P < .001), and obesity (OR, 2.35; 95% CI, 1.95-2.83; P < .001). After accounting for these, moderate to severe dyspnea was associated with LV hypertrophy (OR, 1.30; 95% CI, 1.01-1.67; P = .04) and was not associated with systolic or diastolic function. In contrast, in the fully adjusted model, other organ system measures were associated with dyspnea, except for glomerular filtration rate and grip strength. The population-attributable risk of dyspnea associated with obesity alone was 22.6% compared with 5.8% for LV hypertrophy. Conclusions and Relevance Undifferentiated dyspnea is multifactorial in older adults, and this study showed an association with obesity. When accounting for other relevant organ systems, cardiovascular function poorly discriminated those with vs those without dyspnea. Therefore, dyspnea should not be assumed to represent occult HF in this population.
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Affiliation(s)
- Sergio H. R. Ramalho
- Health Sciences and Technologies Post-Graduation Program, University of Brasília, Brasília, Brazil
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mario Santos
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Laura Loehr
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amil M. Shah
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Swan F, Newey A, Bland M, Allgar V, Booth S, Bausewein C, Yorke J, Johnson M. Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses. Palliat Med 2019; 33:618-633. [PMID: 30848701 DOI: 10.1177/0269216319835393] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chronic breathlessness is a neglected symptom of advanced diseases. AIM To examine the effect of airflow for chronic breathlessness relief. DESIGN Exploratory systematic review and meta-analysis. DATA SOURCES Medline, CINAHL, AMED and Cochrane databases were searched (1985-2018) for observational studies or randomised controlled trials of airflow as intervention or comparator. Selection against predefined inclusion criteria, quality appraisal and data extraction was conducted by two independent reviewers with access to a third for unresolved differences. 'Before and after' breathlessness measures from airflow arms were analysed. Meta-analysis was carried out where possible. RESULTS In all, 16 of 78 studies (n = 929) were included: 11 randomised controlled trials of oxygen versus medical air, 4 randomised controlled trials and 1 fan cohort study. Three meta-analyses were possible: (1) Fan at rest in three studies (n = 111) offered significant benefit for breathlessness intensity (0-100 mm visual analogue scale and 0-10 numerical rating scale), mean difference -11.17 (95% confidence intervals (CI) -16.60 to -5.74), p = 0.06 I2 64%. (2) Medical air via nasal cannulae at rest in two studies (n = 89) improved breathlessness intensity (visual analogue scale), mean difference -12.0 mm, 95% CI -7.4 to -16.6, p < 0.0001 I2 = 0%. (3) Medical airflow during a constant load exercise test before and after rehabilitation (n = 29) in two studies improved breathlessness intensity (modified Borg scale, 0-10), mean difference -2.9, 95% CI -3.2 to -2.7, p < 0.0001 I2 = 0%. CONCLUSION Airflow appears to offer meaningful relief of chronic breathlessness and should be considered as an adjunct treatment in the management of breathlessness.
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Affiliation(s)
- Flavia Swan
- 1 Wolfson Palliative Care Research Centre, Institute for Clinical and Applied Health Research, Hull York Medical School (HYMS), University of Hull, Hull, UK
| | - Alison Newey
- 2 Community Palliative Care, Withington Community Hospital, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Martin Bland
- 3 Department of Health Sciences, University of York, York, UK
| | - Victoria Allgar
- 3 Department of Health Sciences, University of York, York, UK
| | - Sara Booth
- 4 Department of Oncology, University of Cambridge, Cambridge, UK
| | - Claudia Bausewein
- 5 Department of Palliative Medicine, Munich University Hospital, München, Germany
| | - Janelle Yorke
- 6 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK.,7 Christie Patient Centred Research Group (CPCR), The Christie NHS Foundation Trust, Manchester, UK
| | - Miriam Johnson
- 1 Wolfson Palliative Care Research Centre, Institute for Clinical and Applied Health Research, Hull York Medical School (HYMS), University of Hull, Hull, UK
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Swan F, English A, Allgar V, Hart SP, Johnson MJ. The Hand-Held Fan and the Calming Hand for People With Chronic Breathlessness: A Feasibility Trial. J Pain Symptom Manage 2019; 57:1051-1061.e1. [PMID: 30802635 DOI: 10.1016/j.jpainsymman.2019.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 11/29/2022]
Abstract
CONTEXT The battery-operated hand-held fan ("fan") and the Calming Hand (CH), a cognitive strategy, are interventions used in clinical practice to relieve chronic breathlessness. OBJECTIVE To test the feasibility of a Phase III randomized controlled trial (RCT) evaluating the impact of the fan and/or CH compared with exercise advice alone for the relief of chronic breathlessness due to respiratory conditions. METHODS A single-site, feasibility "2 × 2" factorial, nonblinded, mixed-methods RCT was performed. Participants randomly allocated to four groups: fan + exercise advice, CH + exercise advice, fan + CH + exercise advice, and exercise advice alone. Measures included recruitment, acceptability, data quality and study outcomes (baseline and day 28), modified Incremental Shuttle Walk Test (mISWT), recovery time from exertion-induced breathlessness, life-space questionnaire, General Self-Efficacy Scale, and breathlessness numerical rating scales. Willing participants and carers were interviewed at study end. RESULTS Recruitment/acceptability/data completion: 53 people were screened, 40 randomized and completed (mean age 72 years (SD 9.8), 70% male). There were few missing data (mISWT, n = 2). Recovery time (seconds) from exertion-induced breathlessness showed most improvement for the fan; mean reduction from baseline -33.5 vs. CH mean increase from baseline 5.7. This represents a recovery speed at day 28 (-20.4%) faster for the fan vs. 4.1% slower for the CH. Qualitative data indicated participants valued the faster recovery and identified the fan as a useful "medical" device but found the CH unhelpful. CONCLUSION A Phase III RCT is feasible. Mixed-methods data synthesis supports recovery time as a novel, meaningful outcome measure.
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Affiliation(s)
- Flavia Swan
- Wolfson Palliative Care Research Centre, Allam Medical Building, Hull York Medical School (HYMS), University of Hull, Hull, UK.
| | | | - Victoria Allgar
- Hull York Medical School (HYMS), Department of Health Sciences, University of York, Heslington, York, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School (HYMS), University of Hull, Hull, UK
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Ekström M, Williams M, Johnson MJ, Huang C, Currow DC. Agreement Between Breathlessness Severity and Unpleasantness in People With Chronic Breathlessness: A Longitudinal Clinical Study. J Pain Symptom Manage 2019; 57:715-723.e5. [PMID: 30639756 DOI: 10.1016/j.jpainsymman.2019.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
CONTEXT Chronic breathlessness is a cardinal symptom in cardiopulmonary disease where both overall intensity or severity (S) and unpleasantness (U) are commonly quantified. OBJECTIVE We aimed to evaluate agreement between breathlessness severity and unpleasantness over eight days in patients with chronic breathlessness. METHODS Longitudinal analysis of 265 patients with chronic breathlessness who rated current overall breathlessness severity and unpleasantness on a 0-100 mm visual analogue scale (VAS) in the morning and evening over eight days. A total of 3630 paired overall severity-unpleasantness (S-U) differences were analyzed; median 15 (IQR 13-16) per patient. Agreement was evaluated using Bland-Altman plots. Associations of the difference between severity and unpleasantness (S-U difference) with clinical factors and perceived quality of life were analyzed using multilevel linear regression adjusted for confounders. RESULTS Over eight days, severity and unpleasantness scores were highly correlated, had similar variability, and varied more between patients than within patients. The mean S-U difference was small at 2.1 mm. Agreement between overall severity and unpleasantness was similar or higher than expected from the variability in individual scores. The S-U difference was similar across evaluated factors including age, sex, diagnosis, morning/evening assessment, modified Medical Research Council breathlessness score, morphine treatment, and presence of different sensory qualities of breathlessness. Higher overall severity and unpleasantness associated with worse perceived quality of life in a similar way. CONCLUSION In patients with chronic breathlessness over eight days, overall severity and unpleasantness of breathlessness were comparable and associated to other clinical factors in a similar manner.
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Affiliation(s)
- Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden; ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Marie Williams
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| | - Chao Huang
- Hull York Medical School, Institute for Clinical and Applied Health Research, University of Hull, UK
| | - David C Currow
- ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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Ekström M, Johnson MJ, Taylor B, Luszcz M, Wohland P, Ferreira DH, Currow DC. Breathlessness and sexual activity in older adults: the Australian Longitudinal Study of Ageing. NPJ Prim Care Respir Med 2018; 28:20. [PMID: 29934520 PMCID: PMC6015074 DOI: 10.1038/s41533-018-0090-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022] Open
Abstract
Sexual activity is important to older adults (65 + ). Breathlessness affects about 25% of older adults but impact on sexual activity is unknown. We evaluated the relationships between breathlessness and sexual inactivity and self-reported health among older community-dwelling adults in the Australian Longitudinal Study of Ageing. Associations between self-reported breathlessness (hurrying on level ground or walking up a slight hill) at baseline, self-reported sexual activity, overall health and health compared to people of the same age were explored using logistic regression at baseline and 2 years, adjusted for potential confounders (age, sex, marital status, smoking status and co-morbidities). Of 798 participants (mean age 76.4 years [SD, 5.8] 65 to 103; 53% men, 73% married), 688 (86.2%) had 2-year follow-up data. People with breathlessness had higher prevalence and duration of sexual inactivity (77.7% vs. 65.6%; p < 0.001; 12 [IQR, 5-17] vs. 9.5 [IQR, 5-16] years; p = 0.043). Breathlessness was associated with more sexual inactivity, (adjusted OR 1.75; [95% CI] 1.24-2.45), worse health (adjusted OR 2.02; 1.53-2.67) and worse health compared to peers (adjusted OR 1.72; 1.25-2.38). Baseline breathlessness did not predict more sexual inactivity at 2 years. In conclusion, breathlessness contributes to sexual inactivity and worse perceived health in older adults, which calls for improved assessment and management.
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Affiliation(s)
- Magnus Ekström
- Department of Respiratory Medicine and Allergology, Institution for Clinical Sciences, Lund University, Lund, Sweden. .,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Bridget Taylor
- Sobell House Hospice, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Luszcz
- School of Psychology, and Centre for Ageing Studies, Flinders University, Adelaide, SA, Australia
| | - Pia Wohland
- Institute for Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Lennartsson C, Eyjólfsdóttir HS, Celeste RK, Fritzell J. Social class and infirmity. The role of social class over the life-course. SSM Popul Health 2018; 4:169-177. [PMID: 29854902 PMCID: PMC5976854 DOI: 10.1016/j.ssmph.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 11/17/2017] [Accepted: 12/12/2017] [Indexed: 11/25/2022] Open
Abstract
In an aging society, it is important to promote the compression of poor health. To do so, we need to know more about how life-course trajectories influence late-life health and health inequalities. In this study, we used a life-course perspective to examine how health and health inequalities in late-midlife and in late-life are influenced by socioeconomic position at different stages of the life course. We used a representative sample of the Swedish population born between 1925 and 1934 derived from the Swedish Level of Living Survey (LNU) and the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) to investigate the impact of socioeconomic position during childhood (social class of origin) and of socioeconomic position in young adulthood (social class of entry) and late-midlife (social class of destination) on infirmity in late-midlife (age 60) and late-life (age 80). The results of structural equation modelling showed that poor social class of origin had no direct effect on late-midlife and late-life infirmity, but the overall indirect effect through chains of risks was significant. Thus, late-midlife and late-life health inequalities are the result of complex pathways through different social and material conditions that are unevenly distributed over the life course. Our findings suggest that policies that break the chain of disadvantage may help reduce health inequalities in late-midlife and in late-life.
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Affiliation(s)
- Carin Lennartsson
- Aging Research Center, Karolinska Institutet & Stockholm University, Gävlegatan 16 SE-11330 Stockholm, Sweden
| | - Harpa Sif Eyjólfsdóttir
- Aging Research Center, Karolinska Institutet & Stockholm University, Gävlegatan 16 SE-11330 Stockholm, Sweden
| | - Roger Keller Celeste
- Department of Preventive and Social Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Johan Fritzell
- Aging Research Center, Karolinska Institutet & Stockholm University, Gävlegatan 16 SE-11330 Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW Breathlessness is a high-volume problem with 10% of adults experiencing the symptom daily placing a heavy burden on the health and wider economy. As it worsens, they enter the specialist and hospital-based symptom services where costs quickly escalate and people may find themselves in a place not of their choosing. For many, their care will be delivered by a disease or organ specialist and can find themselves passing between physicians without coordination for symptom support. General practitioners (GPs) will be familiar with this scenario and can often feel out of their depth. Recent advances in our thinking about breathlessness symptom management can offer opportunities and a sense of hope when the GP is faced with this situation. RECENT FINDINGS Original research, reviews and other findings over the last 12-18 months that pertain to the value that general practice and the wider primary care system can add, include opportunities to help people recognize they have a problem that can be treated. We present systems that support decisions made by primary healthcare professionals and an increasingly strong case that a solution is required in primary care for an ageing and frail population where breathlessness will be common. SUMMARY Primary care practitioners and leaders must start to realize the importance of recognizing and acting early in the life course of the person with breathlessness because its impact is enormous. They will need to work closely with public health colleagues and learn from specialists who have been doing this work usually with people near to the end of life translating the skills and knowledge further upstream to allow people to live well and remain near home and in their communities.
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Johnson MJ, Gozal D. Vicarious breathlessness: an inferential perceptual learned transposition process that may not be inconsequential to either patient or caregiver. Eur Respir J 2018; 51:51/4/1800306. [PMID: 29618605 DOI: 10.1183/13993003.00306-2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - David Gozal
- Sections of Pediatric Sleep Medicine and Pulmonology, Dept of Paediatrics, Biological Sciences Division, Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
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Unmasking chronic breathlessness. Curr Opin Support Palliat Care 2017; 11:139-140. [PMID: 28661902 DOI: 10.1097/spc.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Johnson MJ, Yorke J, Hansen-Flaschen J, Lansing R, Ekström M, Similowski T, Currow DC. Towards an expert consensus to delineate a clinical syndrome of chronic breathlessness. Eur Respir J 2017; 49:49/5/1602277. [PMID: 28546269 DOI: 10.1183/13993003.02277-2016] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/14/2017] [Indexed: 12/30/2022]
Abstract
Breathlessness that persists despite treatment for the underlying conditions is debilitating. Identifying this discrete entity as a clinical syndrome should raise awareness amongst patients, clinicians, service providers, researchers and research funders.Using the Delphi method, questions and statements were generated via expert group consultations and one-to-one interviews (n=17). These were subsequently circulated in three survey rounds (n=34, n=25, n=31) to an extended international group from various settings (clinical and laboratory; hospital, hospice and community) and working within the basic sciences and clinical specialties. The a priori target agreement for each question was 70%. Findings were discussed at a multinational workshop.The agreed term, chronic breathlessness syndrome, was defined as breathlessness that persists despite optimal treatment of the underlying pathophysiology and that results in disability. A stated duration was not needed for "chronic". Key terms for French and German translation were also discussed and the need for further consensus recognised, especially with regard to cultural and linguistic interpretation.We propose criteria for chronic breathlessness syndrome. Recognition is an important first step to address the therapeutic nihilism that has pervaded this neglected symptom and could empower patients and caregivers, improve clinical care, focus research, and encourage wider uptake of available and emerging evidence-based interventions.
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Affiliation(s)
| | - Janelle Yorke
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - John Hansen-Flaschen
- Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Lansing
- Harvard Medical School, Beth Israel Hospital, Boston, MA, USA
| | - Magnus Ekström
- Dept of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Thomas Similowski
- Service de Pneumologie et Reanimation Medicale, Groupe Hospitalier Pitie-Salpetriere Charles Foix, Paris, France
| | - David C Currow
- Hull York Medical School, University of Hull, Hull, UK.,University of Technology Sydney, Sydney, Australia
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