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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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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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Schwartzstein RM, Campbell ML. Dyspnea and Mechanical Ventilation: The Emperor Has No Clothes. Am J Respir Crit Care Med 2022; 205:864-865. [PMID: 35134318 PMCID: PMC9838635 DOI: 10.1164/rccm.202201-0078ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Richard M. Schwartzstein
- Division of Pulmonary, Critical Care and Sleep MedicineBeth Israel Deaconess Medical CenterBoston, Massachusetts
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Abstract
The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.
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Affiliation(s)
- Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States; Faculty of Health Sciences, Virginia Tech, Blacksburg, VA, United States.
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Demoule A, Similowski T. Respiratory Suffering in the ICU: Time for Our Next Great Cause. Am J Respir Crit Care Med 2019; 199:1302-1304. [PMID: 30562045 PMCID: PMC6543714 DOI: 10.1164/rccm.201812-2248ed] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Alexandre Demoule
- 1 Service de Pneumologie, Médecine Intensive et Réanimation Hôpital Pitié-Salpêtrière Paris, France and.,2 INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique Sorbonne Université Paris, France
| | - Thomas Similowski
- 1 Service de Pneumologie, Médecine Intensive et Réanimation Hôpital Pitié-Salpêtrière Paris, France and.,2 INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique Sorbonne Université Paris, France
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Abstract
This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.
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Affiliation(s)
- Martin Dres
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and
| | - Jordi Mancebo
- 3 Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Gerard F Curley
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and.,4 Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; and
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Haugdahl HS, Dahlberg H, Klepstad P, Storli SL. The breath of life. Patients' experiences of breathing during and after mechanical ventilation. Intensive Crit Care Nurs 2017; 40:85-93. [PMID: 28341400 DOI: 10.1016/j.iccn.2017.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Breathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients' self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV. METHOD A qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews. FINDINGS Four out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through. CONCLUSION Breathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients' and clinicians assessments of breathlessness. The results suggest patients' own reports of breathing should form part of nursing interventions and follow-up to support patients' quest for meaning.
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Affiliation(s)
- Hege S Haugdahl
- UiT The Arctic University of Norway, Tromsø, Norway; Nord University, Levanger, Norway; Nord-Trøndelag Hospital Trust, Levanger, Norway.
| | | | - Pål Klepstad
- St. Olav University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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von Leupoldt A, Reijnders T, Schuler M, Wittmann M, Jelusic D, Schultz K. Validity of a Self-administered Questionnaire Version of the Transition Dyspnea Index in Patients with COPD. COPD 2016; 14:66-71. [PMID: 27841688 DOI: 10.1080/15412555.2016.1246522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The transition dyspnea index (TDI) is among the most widely used instruments in chronic obstructive pulmonary disease (COPD) patients to measure changes in dyspnea over time. In its original version it is used as guideline for a structured interview to assess the impact of daily activities on dyspnea in the three subdomains: functional impairment, magnitude of task, and magnitude of effort. However, the TDI is sometimes used as a self-administered paper-and-pencil questionnaire. The validity of this questionnaire format has not been tested, which was the aim of the present study. We tested 190 patients with COPD at start and end of a 3-week inpatient pulmonary rehabilitation program (PR). Dyspnea was assessed with the modified Medical Research Council Scale (mMRC), a questionnaire version of the TDI, and an interview version of the TDI. Group means for the TDI questionnaire and interview version were widely comparable for the TDI summary score and the three TDI subdomains. The scores of both TDI versions were strongly correlated and showed comparable, but only weak, correlations with changes during PR in spirometric lung function and mMRC. Improvement in dyspnea after PR was observed in 89% of patients when using the summary score of the questionnaire TDI, but only in 34% of patients when using the mMRC. The results suggest that a self-administered questionnaire format of the TDI is an adequate instrument for assessing changes in activity-related dyspnea during PR in patients with COPD. The responsiveness of this instrument to effects of PR appears greater than the responsiveness of the mMRC.
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Affiliation(s)
| | | | - Michael Schuler
- b Department for Medical Psychology and Psychotherapy, Medical Sociology and Rehabilitation Science , University of Würzburg , Würzburg , Germany
| | - Michael Wittmann
- c Clinic Bad Reichenhall, Centre for Rehabilitation, Pneumology and Orthopedics , Bad Reichenhall , Germany
| | - Danijel Jelusic
- c Clinic Bad Reichenhall, Centre for Rehabilitation, Pneumology and Orthopedics , Bad Reichenhall , Germany
| | - Konrad Schultz
- c Clinic Bad Reichenhall, Centre for Rehabilitation, Pneumology and Orthopedics , Bad Reichenhall , Germany
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Alhenc-Gelas F. Take a deep breath and check your heart. J Diabetes Complications 2016; 30:758-9. [PMID: 27020537 DOI: 10.1016/j.jdiacomp.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 11/23/2022]
Affiliation(s)
- Francois Alhenc-Gelas
- Institut national de la Sante et de la recherche Medicale, Paris-Descartes University, Pierre et Marie Curie University, Centre de Recherche des Cordeliers (INSERM U1138), 15 rue de l'Ecole de Medecine, 75006, Paris, France.
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Xiao S, Bastianpillai J, Ratneswaran C, Pengo MF, Luo Y, Jolley CJ, Moxham J, Steier J. Continuous Positive Airway Pressure and Breathlessness in Obese Patients with Obstructive Sleep Apnea: A Pilot Study. Sleep 2016; 39:1201-10. [PMID: 27091534 DOI: 10.5665/sleep.5832] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/04/2016] [Indexed: 12/28/2022] Open
Abstract
STUDY OBJECTIVES Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA). However, long-term compliance with CPAP is limited. We tested the hypothesis that CPAP levels routinely used during sleep increase neural respiratory drive (NRD) and breathlessness, which may discourage compliance. METHODS This was an observational physiological cohort study in a respiratory physiology and sleep unit, University Hospital. Patients with a body mass index (BMI) > 25 kg/m(2) and confirmed OSA were studied supine and awake on CPAP (4-20 cm H2O, increments of 2 cm H2O/3 min). We measured NRD during awake CPAP titration in obese subjects to quantify the response to the load of the respiratory system and compared it to the CPAP used for nocturnal treatment, with the modified Borg Scale (mBorg) for dyspnea recorded (from 0 to 10 points, with higher numbers indicating more breathlessness). RESULTS Fifteen patients (age 48 ± 10 years, 12 male, BMI 38.9 ± 5.8 kg/m(2)) with OSA (AHI 32.2 ± 21.1/h, 95(th) percentile of CPAP 14.1 ± 3.8 cm H2O) were studied and NRD (electromyogram of the parasternal intercostals, EMGpara; EMG of the external oblique, EMGabdomen) was recorded (awake, supine). Awake, EMGpara declined from baseline to 70.2% ± 17.1% when CPAP of 10.7 ± 3.4 cm H2O (P = 0.026) was applied. Further increase in CPAP led to a rise in EMGpara and increased breathlessness (P = 0.02). CPAP compliance (nights used) correlated negatively with mBorg scores (r = -0.738, P = 0.006). CONCLUSIONS Awake, the respiratory system is maximally offloaded with lower than therapeutic CPAP levels in obese patients with OSA. Levels of NRD observed at effective CPAP levels while asleep are associated with breathlessness which may limit long-term CPAP compliance.
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Affiliation(s)
- Sichang Xiao
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Johan Bastianpillai
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Culadeeban Ratneswaran
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Martino F Pengo
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,University of Padua, Italy
| | | | - Caroline J Jolley
- King's College London, Faculty of Life Sciences and Medicine, London, UK
| | - John Moxham
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,King's Health Partners, London, UK
| | - Joerg Steier
- King's College London, Faculty of Life Sciences and Medicine, London, UK.,Guy's and St Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK.,King's Health Partners, London, UK
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