1
|
Sunjaya AP, Poulos LM, Di Tanna GL, Lung T, Marks GB, Reddel HK, Jenkins CR. The health and economic burden of breathlessness, Australia, 2019: a national survey. Med J Aust 2024. [PMID: 39193783 DOI: 10.5694/mja2.52425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 05/06/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE To examine the impact of breathlessness on quality of life, health care use, productivity loss, and economic costs in Australia. STUDY DESIGN National internet-based survey of Australian adults drawn from a web-based survey panel (National Breathlessness Survey). PARTICIPANTS, SETTING Australian adults (18 years or older), nationally representative by age group, gender, state of residence, and postcode-based socio-economic status (Index of Relative Socioeconomic Disadvantage quintile), 13-30 October 2019. MAIN OUTCOME MEASURES Quality of life assessed with the EQ-5D 5-level version (EQ-5D-5L) and visual analogue scale (EQ-VAS), health care use, productivity loss, and societal cost, each by severity of breathlessness (modified Medical Research Council [mMRC] dyspnoea scale; mMRC grade 1: mild breathlessness; mMRC grades 2-4: clinically important breathlessness). RESULTS Of 10 072 adults who completed the survey, mild breathlessness was reported by 3044 respondents (30.2%), and clinically important breathlessness by 961 (9.5%). The mean EQ-VAS score was 74.8 points (95% confidence interval [CI], 74.3-75.3 points) and the mean EQ-5D-5L score 0.846 (95% CI, 0.841-0.850) for respondents with mMRC grade 0 breathlessness; for each measure, the mean value declined with increasing severity of breathlessness (trends: each P < 0.001). Respondents with clinically important breathlessness were more likely than those with mild breathlessness to report non-urgent general practitioner visits, urgent general practitioner visits, and specialist visits (exception: mMRC scores of 4) during the preceding year. Among the 2839 respondents of working age, the likelihood of being employed declined with increasing breathlessness severity (mMRC grades 4 v 1: adjusted odds ratio, 0.34; 95% CI, 0.22-0.53). Adjusted mean annual societal cost per person was $1413 (95% CI, $1326-1501) for respondents with mMRC grade 1 breathlessness, $2065 (95% CI, $1766-2365) at mMRC grade 2, $1795 (95% CI, $1371-2218) at mMRC grade 3, and $2075 (95% CI, $1389-2762) at mMRC grade 4. CONCLUSION Breathlessness imposes major burdens on individuals, the health care system, and the economy.
Collapse
Affiliation(s)
- Anthony P Sunjaya
- The George Institute for Global Health, Sydney, NSW
- University of New South Wales, Sydney, NSW
| | - Leanne M Poulos
- Australian Centre for Airways disease Monitoring, Woolcock Institute of Medical Research, Sydney, NSW
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Sydney, NSW
- University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Thomas Lung
- The George Institute for Global Health, Sydney, NSW
- Sydney School of Public Health, the University of Sydney, Sydney, NSW
| | - Guy B Marks
- Sydney Local Health District, Sydney, NSW
- Liverpool Hospital, Sydney, NSW
| | - Helen K Reddel
- Australian Centre for Airways disease Monitoring, Woolcock Institute of Medical Research, Sydney, NSW
- Sydney Local Health District, Sydney, NSW
- Macquarie Medical School, Macquarie University, Sydney, NSW
- The University of Sydney, Sydney, NSW
| | - Christine R Jenkins
- The George Institute for Global Health, Sydney, NSW
- The University of Sydney, Sydney, NSW
| |
Collapse
|
2
|
Sunjaya A, Martin A, Arnott C, Jenkins C. Management of chronic breathlessness in primary care: what do GPs, non-GP specialists, and allied health professionals think? Aust J Prim Health 2023; 29:375-384. [PMID: 36683165 DOI: 10.1071/py22018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 12/19/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND To explore the perspectives of GPs, non-GP specialists, and allied health professionals on the role of primary care in diagnosing and managing chronic breathlessness, the barriers faced, and the resources needed to optimise care of patients with chronic breathlessness. METHODS This was a qualitative study involving focus group discussions that included 35GPs, non-GP specialists, and allied health professionals. Topics explored included: (1) views on the role of primary care in diagnosing and managing chronic breathlessness; (2) barriers to optimal assessment in primary care; and (3) facilitators to further optimise the care of patients with chronic breathlessness. RESULTS All participants considered that primary care has a central role to play in the assessment and management of chronic breathlessness, but greater access to referral services, suitable funding structures, and upskilling on the use of diagnostic tests such as spirometry and electrocardiography are required for this to be realised. Both GPs and non-GP specialists described great potential for developing better linkages, including new ways of referral and online consultations, greater ease of referral to allied health services, even if conducted virtually, for patients with functional causes of breathlessness. Participants identified a need to develop integrated breathlessness clinics for patients referred by GPs, which would ensure patients receive optimal care in the shortest possible time frame. CONCLUSIONS GPs are crucial to achieving optimal care for breathless patients, especially given the multifactorial and multimorbid nature of breathlessness; however, there are significant gaps in services and resources at present that limit their ability to perform this role.
Collapse
Affiliation(s)
- Anthony Sunjaya
- Respiratory Program, The George Institute for Global Health, Sydney, NSW 2050, Australia; and Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Allison Martin
- Respiratory Program, The George Institute for Global Health, Sydney, NSW 2050, Australia; and Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Clare Arnott
- Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; and Cardiovascular Division, The George Institute for Global Health, Sydney, NSW 2050, Australia
| | - Christine Jenkins
- Respiratory Program, The George Institute for Global Health, Sydney, NSW 2050, Australia; and Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| |
Collapse
|
3
|
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]
|
4
|
Ferreira DH, Kochovska S, McNeill R, Currow DC. Current pharmacological strategies for symptomatic reduction of persistent breathlessness - a literature review. Expert Opin Pharmacother 2023; 24:233-244. [PMID: 36525673 DOI: 10.1080/14656566.2022.2160239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Persistent breathlessness is a debilitating symptom that is prevalent in the community, particularly in people with chronic and life-limiting illnesses. Treatment includes different steps, including pharmacological treatment aiming to improve the symptom and optimize people's wellbeing. AREAS COVERED PubMed and Google Scholar were screened using 'chronic breathlessness' OR 'persistent breathlessness,' AND 'pharmacological treatment,' OR 'opioids.' This review focuses on pharmacological treatments to reduce persistent breathlessness and discusses possible mechanisms involved in the process of breathlessness reduction through pharmacotherapy. Research gaps in the field of persistent breathlessness research are outlined, and future research directions are suggested. EXPERT OPINION Regular, low-dose (≤30 mg/day), sustained-release morphine is recommended as the first-line pharmacological treatment for persistent breathlessness. Inter-individual variation in response needs to be investigated in future studies in order to optimize clinical outcomes. This includes 1) better understanding the centrally mediated mechanisms associated with persisting breathlessness and response to pharmacological therapies, 2) understanding benefit from the perspective of people experiencing persistent breathlessness, small and meaningful gains in physical activity.
Collapse
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, 2007, Ultimo, Australia
| | - Richard McNeill
- Department of palliative care, Nurse Maude Hospice, 8014, Christchurch, New Zealand.,Department of Medicine, University of Otago, 8011, Christchurch, New Zealand
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| |
Collapse
|
5
|
A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness. NPJ Prim Care Respir Med 2022; 32:29. [PMID: 35987745 PMCID: PMC9392800 DOI: 10.1038/s41533-022-00291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractBreathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.
Collapse
|
6
|
Tinti S, Parati M, De Maria B, Urbano N, Sardo V, Falcone G, Terzoni S, Alberti A, Destrebecq A. Multi-Dimensional Dyspnea-Related Scales Validated in Individuals With Cardio-Respiratory and Cancer Diseases. A Systematic Review of Psychometric Properties. J Pain Symptom Manage 2022; 63:e46-e58. [PMID: 34358643 DOI: 10.1016/j.jpainsymman.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/21/2022]
Abstract
CONTEXT In order to examine the multi-dimensional nature of dyspnea and its impact on the activities of daily living (ADLs) in patients with cardio-respiratory and cancer diseases, validated measures are needed. OBJECTIVES Our aim was to identify all the multi-dimensional clinical scales assessing dyspnea and its impact on ADLs in patients with cardio-respiratory and cancer diseases, and to critically appraise their psychometric properties. METHODS Five databases were systematically searched up to July 2020. Eligible criteria were: the examination of at least one psychometric property, and the recruitment of adults with a cardio-respiratory or cancer disease in non-emergency settings. The characteristics and psychometric properties of the studies included were presented through a narrative synthesis. The methodological quality of the studies and evidence synthesis were rated using the "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" criteria. RESULTS Forty-three studies, for which eight assessment scales had been identified, were included in the review. At the time of the review, three multi-dimensional assessment scales were available for assessing dyspnea symptoms, and five multi-dimensional scales were available to examine the impact of dyspnea on ADLs. Although the use of these scales has rapidly grown, evidence of psychometric properties has been reported as limited in most of the scales. CONCLUSION Despite the potential of the identified scales, further studies are needed to strength evidence on the validity and reliability of the multi-dimensional dyspnea scales. Furthermore, more studies appraising the content validity and responsiveness of the scales are specifically recommended.
Collapse
Affiliation(s)
- Stefania Tinti
- Department of Biomedicine and Prevention (S.T.), University of Rome ''Tor Vergata'', Rome, Italy.
| | - Monica Parati
- Department of Electronics, Information and Bioengineering, Neuroengineering and Medical Robotics Laboratory (M.P.), Politecnico di Milano, Milan, Italy; IRCCS Istituti Clinici Scientifici Maugeri (M.P., B.D.M.), Milan, Italy
| | - Beatrice De Maria
- IRCCS Istituti Clinici Scientifici Maugeri (M.P., B.D.M.), Milan, Italy
| | - Nicla Urbano
- ASST-Rhodense (N.U.), Garbagnate Milanese, Milan, Italy
| | - Vivian Sardo
- ASST-Rhodense, Palliative Care and Pain Therapy Department (V.S., G.F.), Garbagnate Milanese, Milan, Italy
| | - Graziella Falcone
- ASST-Rhodense, Palliative Care and Pain Therapy Department (V.S., G.F.), Garbagnate Milanese, Milan, Italy
| | - Stefano Terzoni
- ASST-Santi Paolo e Carlo (S.T.), University of Milan, Milan, Italy
| | - Annalisa Alberti
- ASST-Rhodense Bachelor School of Nursing (A.A.), Rho, Milan, Italy
| | - Anne Destrebecq
- Department of Biomedical Sciences for Health (A.D.), University of Milan, Milan, Italy
| |
Collapse
|
7
|
Currow DC, Chang S, Ekström M, Hutchinson A, Luckett T, Kochovska S, Hay P, Touyz S, Dal Grande E, Johnson MJ. Health service utilisation associated with chronic breathlessness: random population sample. ERJ Open Res 2021; 7:00415-2021. [PMID: 34651042 PMCID: PMC8503326 DOI: 10.1183/23120541.00415-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most health service utilisation studies are of people with specific diagnoses or demographic characteristics, and rarely of specific chronic symptoms. The aim of this study was to establish whether population-level health service utilisation increases in people with chronic breathlessness. METHODS A cross-sectional analysis was carried out of the South Australian Health Omnibus Survey 2017, a multi-stage, clustered area, systematic sampling survey of adults where questions are administered face-to-face in respondents' homes. Self-report of health service utilisation in the previous 3 months (medical consultations, emergency department, hospital admission), chronic breathlessness (severity, duration, modified Medical Research Council (mMRC) breathlessness scale) and demographic data were used to predict self-reported health service utilisation. RESULTS A total of 2898 people were included (49.0% male; median age 48.0 years (IQR 32.0-63.0); 64.1% educated beyond school; 55.4% in work; 73.5% had outpatient contact; 6.3% had a hospital admission in the previous 3 months). Chronic breathlessness (mMRC ≥1) was reported by 8.8% of respondents. In bivariable analyses, people with greater contact with health services were older, and a higher proportion were overweight/obese and had more severe chronic breathlessness. In multivariable analyses, chronic breathlessness and older age were positively associated with outpatient care and inpatient care, and people with chronic breathlessness were hospitalised for longer (incidence rate ratio 2.5; 95% CI 1.4-4.5). CONCLUSION There is a significant association between worse chronic breathlessness and increased health service utilisation. There is a need for greater understanding of factors that initiate contact with health services.
Collapse
Affiliation(s)
- 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
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Magnus Ekström
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith South, NSW, Australia
| | - Stephen Touyz
- School of Psychology, University of Sydney, Camperdown, NSW, Australia
| | | | - Miriam J. Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| |
Collapse
|
8
|
Spathis A, Burkin J, Moffat C, Tuffnell R, Barclay S, Mant J, Booth S. Cutting through complexity: the Breathing, Thinking, Functioning clinical model is an educational tool that facilitates chronic breathlessness management. NPJ Prim Care Respir Med 2021; 31:25. [PMID: 33972569 PMCID: PMC8110567 DOI: 10.1038/s41533-021-00237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/07/2021] [Indexed: 02/03/2023] Open
Abstract
Chronic breathlessness is a distressing symptom that is challenging to manage. The Breathing, Thinking, Functioning clinical model is an educational tool developed to support breathlessness management. Health professionals report that the model increases clinician and patient understanding of this complex symptom, and provides a simple and structured approach to personalised self-management.
Collapse
Affiliation(s)
- Anna Spathis
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. .,University of Cambridge, Cambridge, UK.
| | - Julie Burkin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Catherine Moffat
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rachel Tuffnell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Sara Booth
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,University of Cambridge, Cambridge, UK
| |
Collapse
|
9
|
Tinti S, De Maria B, Parati M, Terzoni S, Rossi MC, Da Col D, Pairona G, Longhi C, Giudici E, Pidone I, Alberti A, Sofia M, Ramponi I, Urbano N, Tanaka K, Destrebecq A. Italian Version of Cancer Dyspnea Scale: Cultural-Linguistic and Clinical Validation in Patients With Advanced Cancer Disease in Palliative Care Settings. J Pain Symptom Manage 2021; 61:571-578.e1. [PMID: 33059018 DOI: 10.1016/j.jpainsymman.2020.10.008] [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: 07/13/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT The Cancer Dyspnea Scale (CDS) is a self-reported multidimensional tool used for the assessment of dyspnea, a subjective experience of breathing discomfort, in patients with cancer. The scale describes dyspnea using three distinct factors: physical, psychological, and discomfort at rest. OBJECTIVES To crossculturally validate the Italian version of CDS (CDS-IT) and examine its content validity, feasibility, internal consistency, and construct validity in patients with advanced cancer. METHODS A cross-sectional study was conducted. CDS-IT was forward-backward translated, and its content was validated among a group of experts. Cronbach's α coefficients were used to assess the internal consistency. Construct validity was examined in terms of structural validity through confirmatory factor analysis, and convergent validity was examined with Visual Analogue Scale Dyspnea through the Pearson's correlation coefficient (r). Cancer Quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care) and Italian Palliative Outcome Scale were also tested. RESULTS The CDS-IT was crossculturally validated and showed satisfactory content validity. A total of 101 patients (mean age = 76 [SD = 12]; 53% females) were recruited in palliative care settings. CDS-IT reported a good internal consistency in the total score and its factors (α = 0.74-0.83). The factor analysis corresponded acceptably but not completely with the original study. CDS-IT strongly correlated with Visual Analogue Scale Dyspnea (r = 0.68) and moderately with Italian Palliative Outcome Scale and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (r = 0.33-0.36, respectively). CONCLUSION The study findings supported the crosscultural validity of the CDS-IT. Its feasibility, internal consistency, and construct validity are satisfactory for clinical practice. The CDS-IT is available to health care professionals as a useful tool to assess dyspnea in patients with cancer.
Collapse
Affiliation(s)
- Stefania Tinti
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.
| | | | - Monica Parati
- IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Neuroengineering and Medical Robotics Laboratory, Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Stefano Terzoni
- ASST- Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Maria Cristiana Rossi
- ASST-Rhodense, Palliative Care, Hospice and Pain Therapy Department, Garbagnate Milanese, Milan, Italy
| | - Daria Da Col
- ASST Grande Ospedale Metropolitano Niguarda, Palliative Care - Hospice, Milan, Italy
| | - Giulia Pairona
- ASST Grande Ospedale Metropolitano Niguarda, Palliative Care - Hospice, Milan, Italy
| | - Carla Longhi
- ASST-Lariana, Palliative Care - Hospice, Mariano Comense, Como, Italy
| | - Elisa Giudici
- ASST-Lariana, Palliative Care - Hospice, Mariano Comense, Como, Italy
| | - Irene Pidone
- ASST-Lariana, Palliative Care - Hospice, Mariano Comense, Como, Italy
| | - Annalisa Alberti
- ASST-Rhodense Bachelor School of Nursing, University of Milan, Rho, Milan, Italy
| | - Michele Sofia
- ASST-Rhodense, Palliative Care, Hospice and Pain Therapy Department, Garbagnate Milanese, Milan, Italy
| | - Ida Ramponi
- ASST-Rhodense, Garbagnate Milanese, Milan, Italy
| | - Nicla Urbano
- ASST-Rhodense, Garbagnate Milanese, Milan, Italy
| | - Keiko Tanaka
- Palliative Care Department Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Anne Destrebecq
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
10
|
Barnes-Harris MMM, Daniel S, Venkateswaran C, Hutchinson A, Johnson MJ. How Physicians in South India Recognize, Assess, and Manage People with Chronic Breathlessness Syndrome: A Thematic Analysis. Indian J Palliat Care 2021; 27:54-61. [PMID: 34035618 PMCID: PMC8121231 DOI: 10.4103/ijpc.ijpc_139_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Chronic breathlessness syndrome has been defined to help clinicians actively seek, and patients legitimately present with, persistent breathlessness, and to drive services and research. However, views from low- to middle-income countries were not included. We aimed to explore the views of hospital physicians regarding chronic breathlessness syndrome, its recognition and management. METHODS This was a secondary analysis of qualitative data collected during a service development project. Three focus groups of physicians caring for patients with chronic breathlessness in a single tertiary hospital in South India were conducted in English, audio-recorded, transcribed, and subjected to thematic analysis. RESULTS Fifteen physicians from oncology, palliative care, cardiology, and respiratory specialties participated. Three major themes (impact, invisibility, and purpose) were generated. Findings mirrored those in high-income countries. Chronic breathlessness, as defined, was seen as prevalent, with a major impact on patients, families, and physicians. Nonpalliative care physicians described therapeutic helplessness with poor awareness and/or ability to manage breathlessness accompanied by active avoidance. This helplessness, a perceived lack of assessment tools and lack of access to palliative care contributed to the "invisibility" of chronic breathlessness. Most participants agreed with the name of chronic breathlessness syndrome. All agreed that systematic identification would foster education regarding assessment and management and support service development and research. CONCLUSIONS Chronic breathlessness syndrome is recognized in South India but, as in higher-income countries, risks being invisible due to the lack of awareness of therapeutic interventions. A named and defined syndrome was seen as a way to improve identification and management.
Collapse
Affiliation(s)
- Matilda MM Barnes-Harris
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, HU6 7RX, UK
| | - Sunitha Daniel
- Department of Palliative Medicine, General Hospital Ernakulam, Kochi, India
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Chitra Venkateswaran
- Department of Psychiatry, Believers Church Medical College, Thiruvalla, Kerala, India
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Currow DC, Johnson MJ, Pollack A, Ferreira DH, Kochovska S, Ekström M, Harrison C. Breathlessness and opioid prescribing in COPD in general practice: a cross-sectional, observational study. ERJ Open Res 2020; 6:00299-2019. [PMID: 32775398 PMCID: PMC7402382 DOI: 10.1183/23120541.00299-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/15/2020] [Indexed: 12/05/2022] Open
Abstract
Chronic breathlessness is a disabling syndrome, prevalent in people with advanced chronic obstructive pulmonary disease (COPD). Regular, low-dose, oral sustained-release morphine is approved in Australia to reduce symptomatic chronic breathlessness. We aimed to determine the current prescribing patterns of opioids for chronic breathlessness in COPD in Australian general practice and to define any associated patient and practitioner characteristics. Five years (2011 to 2016) of the Bettering the Evaluation and Care of Health database, an Australian national, continual, cross-sectional study of clinical care in general practice were used. The database included 100 consecutive clinical encounters from almost 1000 general practitioners annually (n=488 100 encounters). Descriptive analyses with subsequent regression models were generated. Breathlessness as a patient-defined reason for encounter was identified in 621 of 4522 encounters where COPD was managed. Opioids were prescribed in 309 of 4522 encounters where COPD was managed (6.8%; (95% CI) 6.1-7.6), of which only 17 were prescribed for breathlessness, and the rest for other conditions almost entirely related to pain. Patient age (45-64 years versus age 80+ years, OR 1.68; 1.19-2.36), Commonwealth Concession Card holders (OR 1.70; 1.23-2.34) and socioeconomic disadvantage (OR 1.30; 1.01-1.68) were associated with increased likelihood of opioid prescription at COPD encounters. The rate of opioid prescriptions rose over the 5 years of study. In primary care encounters for COPD, opioids were prescribed in 6.8% of cases, but almost never for breathlessness. These data create a baseline against which to compare changes in prescribing as the treatment of chronic breathlessness evolves.
Collapse
Affiliation(s)
- David C. Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Miriam J. Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Allan Pollack
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Diana H. Ferreira
- Discipline Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Magnus Ekström
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Christopher Harrison
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Sydney, Australia
| |
Collapse
|
13
|
Elliott-Button HL, Johnson MJ, Nwulu U, Clark J. Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis. J Pain Symptom Manage 2020; 59:724-733.e19. [PMID: 31655187 DOI: 10.1016/j.jpainsymman.2019.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 01/09/2023]
Abstract
CONTEXT Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment. OBJECTIVE The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings. METHODS This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma. RESULTS Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care. CONCLUSION Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.
Collapse
Affiliation(s)
- Helene L Elliott-Button
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Ugochinyere Nwulu
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Joseph Clark
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| |
Collapse
|
14
|
Barais M, Fossard E, Dany A, Montier T, Stolper E, Van Royen P. Accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study. BMJ Open 2020; 10:e034348. [PMID: 32075841 PMCID: PMC7044836 DOI: 10.1136/bmjopen-2019-034348] [Citation(s) in RCA: 9] [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: 01/31/2023] Open
Abstract
OBJECTIVES Dyspnoea and chest pain are symptoms shared with multiple pathologies ranging from the benign to life-threatening diseases. A Gut Feelings Questionnaire (GFQ) has been validated to measure the general practitioner's (GPs) sense of alarm or sense of reassurance. The aim of the study was to estimate the diagnostic test accuracy of GPs' sense of alarm when confronted with dyspnoea and chest pain. DESIGN AND SETTINGS Prospective observational study in general practice. PARTICIPANTS Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or chest pain, were considered for enrolment. These GPs had to complete the GFQ immediately after the consultation. PRIMARY OUTCOME MEASURES Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the International Classification of Primary Care (ICPC)-2 classification. The index test was the sense of alarm and the reference standard was the final diagnosis at 4 weeks. RESULTS 25 GPs filled in 235 GFQ questionnaires. The positive likelihood ratio for the sense of alarm was 2.12 (95% CI 1.49 to 2.82), the negative likelihood ratio was 0.55 (95% CI 0.37 to 0.77). CONCLUSIONS Where the physician experienced a sense of alarm when a patient consulted him/her for dyspnoea and/or chest pain, the post-test odds that this patient had, in fact, a life-threatening disease was about twice as high as the pretest odds. TRIAL REGISTRATION NUMBER NCT02932982.
Collapse
Affiliation(s)
- Marie Barais
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Emilie Fossard
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Antoine Dany
- Department of Public Health, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Tristan Montier
- Inserm UMR1078, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Erik Stolper
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
| | - Paul Van Royen
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
| |
Collapse
|
15
|
Currow DC, Chang S, Reddel HK, Kochovska S, Ferreira D, Kinchin I, Johnson M, Ekström M. Breathlessness, Anxiety, Depression, and Function-The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults. J Pain Symptom Manage 2020; 59:197-205.e2. [PMID: 31654741 DOI: 10.1016/j.jpainsymman.2019.09.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 01/23/2023]
Abstract
CONTEXT Breathlessness is associated with depression, but its relationship to anxiety or impaired function is less clear. OBJECTIVES This study evaluated associations between chronic breathlessness and anxiety, depression, and functional status in the general population. METHODS This cross-sectional study of consenting adults (18 years and older) used an online survey. Quota sampling (n = 3000) was used reflecting the 2016 national census for sex, age, and place of residence. Other data included Four-Item Patient Health Questionnaire for depression and anxiety, the modified Medical Research Council (mMRC) Breathlessness Scale, and the Australia-modified Karnofsky Performance Scale. Multinomial logistic regression assessed predictors. RESULTS About 2977 respondents had all relevant scores (female 51.2%; median age 45.0 [range 18-92]). Prevalence of breathlessness (mMRC ≥2) was 2.4%, anxiety 6.0%, depression 2.7%, coexisting anxiety/depression 6.1%, and poorer functional status (Australia-modified Karnofsky Performance Scale ≤60) 1.6%. In multinomial regression, depression, anxiety, and coexisting anxiety/depression were predicted by younger age, longer duration of breathlessness, and poorer functional status. The highest proportions of people with breathlessness were found in the coexisting anxiety/depression group (10.6%) and depression only group (8.8%). Poorest function was in the coexisting anxiety/depression group with 11.6%. The relationship between poorer functional status and coexisting anxiety/depression was significant (odds ratio 0.90; 95% CI 0.89, 0.92). Adjusted odds ratio for breathlessness and depression only was 3.0 (95% CI 1.2, 7.8). CONCLUSION Clinically important breathlessness (mMRC ≥2) was associated with depression, anxiety, and coexisting anxiety/depression. Poorer function that is associated with psychological morbidity in the general population requires further research.
Collapse
Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; Wolfson Palliative Care Research Centre, University of Hull, Hull, England; Australian National Palliative 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 Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; Australian National Palliative Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Diana Ferreira
- Flinders University, Flinders Drive, Bedford Park, South Australia, Australia
| | - Irina Kinchin
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Magnus Ekström
- Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| |
Collapse
|
16
|
Fröhlich G, Schorn K, Fröhlich H. [Dyspnea : A challenging symptom in the primary care setting]. Internist (Berl) 2020; 61:21-35. [PMID: 31889210 DOI: 10.1007/s00108-019-00720-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Dyspnea is a very common symptom leading to visits to a general physician (GP). Correct differential diagnosis is the major challenge for the GP. There are no guidelines on dyspnea. This review provides an overview of the main causal diseases for dyspnea, presents methods for history taking and differential diagnosis, and specifies the role of GPs in the primary care setting in the case of dyspnea.
Collapse
Affiliation(s)
- Georg Fröhlich
- Internistisch-hausärztliche Praxis mit Schwerpunkt Diabetes, Vorhonig 5, 65620, Waldbrunn, Deutschland.
| | - Kai Schorn
- Hausärztliche Gemeinschaftspraxis, Berlin, Deutschland
| | - Heike Fröhlich
- Internistisch-hausärztliche Praxis mit Schwerpunkt Diabetes, Vorhonig 5, 65620, Waldbrunn, Deutschland
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Pesola GR, Terla V, Malik N, Ahsan H. Chronic dyspnoea: finding the cause to reduce mortality. J Thorac Dis 2018; 10:S4057-S4060. [PMID: 30631554 DOI: 10.21037/jtd.2018.09.60] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Gene R Pesola
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Section of Pulmonary/Critical Care Medicine, Department of Medicine, Harlem Hospital, Columbia University, New York, NY, USA
| | - Vikhyath Terla
- Section of Pulmonary/Critical Care Medicine, Department of Medicine, Harlem Hospital, Columbia University, New York, NY, USA
| | - Nasir Malik
- Section of Pulmonary/Critical Care Medicine, Department of Medicine, Harlem Hospital, Columbia University, New York, NY, USA
| | - Habibul Ahsan
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| |
Collapse
|
19
|
Johnson MJ, Fallon M. Chronic breathlessness: time for Cinderella to go to the ball! Eur Respir J 2018; 52:52/3/1801452. [DOI: 10.1183/13993003.01452-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/07/2018] [Indexed: 12/16/2022]
|
20
|
Huang YC, Ferry OR, McKenzie SC, Bowman RV, Hamilton M, Masel PJ, Fong KM, Yang IA. Diagnosis of the cause of chronic dyspnoea in primary and tertiary care: characterizing diagnostic confidence. J Thorac Dis 2018; 10:3745-3756. [PMID: 30069373 DOI: 10.21037/jtd.2018.05.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Chronic dyspnoea (breathlessness) in adults is a common symptom, the exact cause of which may be difficult to diagnose on initial presentation. We characterised the diagnostic complexity of chronic dyspnoea in primary care and tertiary care. Methods This retrospective observational study screened consecutive referral letters of all adult patients referred to cardiology or respiratory clinics at a tertiary referral hospital, during May to June 2015. For patients referred due to chronic dyspnoea, data were analysed from the initial referral letter and subsequent specialist clinic letters for the 6-month time period after referral. Results Of 1,370 patient referrals, 122 patients (mean age 63 y, 55% female) were referred due to chronic dyspnoea. One hundred and five patients (86%) were referred from primary care and 17 (14%) from other hospital clinics. Sixty-one percent were referred with an evident diagnosis (referrer was confident of the initial diagnosis), whereas 39% had non-evident or unclear diagnoses. By 6 months after referral, a definitive final diagnosis had been determined by the specialist clinics in 62% of patients. The majority of patients had been referred appropriately to a cardiology or respiratory clinic, based on the final diagnosis. However, only 26% of diagnoses were fully concordant between the initial referrer diagnosis and the final specialist clinic diagnosis, with 26% being partially concordant and 48% non-concordant. Diagnostic certainty of the referrer was associated with concordance of diagnosis between the referrer and specialist clinic (P<0.001). Conclusions In adult patients referred due to chronic dyspnoea to hospital specialist clinics, there is considerable diagnostic uncertainty about its aetiology, for both referring doctors and specialist clinics. These results demonstrate the current difficulty in diagnosing the cause of chronic dyspnoea in adults, and highlight the need for evidence-based diagnostic pathways.
Collapse
Affiliation(s)
- 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, Queensland, Australia
| | - 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, Queensland, Australia
| | - Scott C McKenzie
- Faculty of Medicine, The University of Queensland, Queensland, Australia.,Cardiology Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, 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, Queensland, 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, Queensland, 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, Queensland, 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, Queensland, Australia
| |
Collapse
|
21
|
Hutchinson A, Pickering A, Williams P, Bland JM, Johnson MJ. Breathlessness and presentation to the emergency department: a survey and clinical record review. BMC Pulm Med 2017; 17:53. [PMID: 28320369 PMCID: PMC5360046 DOI: 10.1186/s12890-017-0396-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breathlessness is a frequently occurring symptom of cardiorespiratory conditions and is a common cause of emergency department presentation. The aim of this study was to estimate the prevalence of acute-on-chronic breathlessness as a cause for presentation to the major emergencies area of the emergency department. METHODS A prospective patient self-report survey and clinical record review of consecutive attendees to the major emergencies area of the emergency department in a single tertiary hospital between 12/5/14 and 29/5/14 was conducted. Eligible patients were clinically stable and had mental capacity to provide data. RESULTS There were 2,041 presentations during the study period, of whom 1,345 (66%) were eligible. There was a 90% survey response rate (1,212/1,345); 424/1,212 (35%) self-reported breathlessness most days over the past month of whom 245 gave breathlessness as a reason for this presentation. Therefore, the prevalence of acute-on-chronic breathlessness as a reason to present to the major emergencies area was 20.2% (245/1,212, 95% CI 17.9% to 22.5%). During this period there were 4,692 major and minor presentations; breathlessness was therefore a cause of at least 5.2% (245/4,692, 95% CI 4.6 to 5.9%) of all emergency department presentations. CONCLUSIONS This study found that one in five ambulance presentations to the ED were due to acute-on-chronic breathlessness. Most patients had non-malignant underlying conditions, had experienced considerable breathlessness for an extended period, had discussed breathlessness with their GP and presented out of daytime hours. Others were often involved in their decision to present. This represents clinically significant burden for patients, their family carers and the emergency health services.
Collapse
Affiliation(s)
- Ann Hutchinson
- Hull York Medical School, University of Hull, Hull, HU6 7RX, UK.
| | | | | | | | | |
Collapse
|
22
|
Campbell ML, Kero KK, Templin TN. Mild, moderate, and severe intensity cut-points for the Respiratory Distress Observation Scale. Heart Lung 2017; 46:14-17. [DOI: 10.1016/j.hrtlng.2016.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022]
|
23
|
von Winckelmann K, Renier W, Thompson M, Buntinx F. The frequency and outcome of acute dyspnoea in primary care: An observational study. Eur J Gen Pract 2016; 22:240-246. [PMID: 27652899 DOI: 10.1080/13814788.2016.1213809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Little is known about the occurrence of acute dyspnoea in primary care and its underlying causes. OBJECTIVES What are the occurrence and most frequent causes of acute dyspnoea in primary care, predictors of referral, hospitalization, death and possible underlying causes? METHODS Twenty-five general practitioners (GPs) in Flanders (Belgium) recorded patient contacts for four periods of two weeks during one year. They recorded patients presenting with acute dyspnoea, location of contact (surgery versus home visit), new dyspnoea versus exacerbation, tentative diagnosis, referral to a specialist and hospital, and one month later final diagnosis, its justification, referral, hospitalization and death. RESULTS Twenty-two GPs recorded 14,620 patient contacts. Acute dyspnoea was encountered in 317 patient-doctor contacts (2.2%; 95%CI: 1.9-2.4), without significant association between the acute dyspnoea frequency, and age and gender. Immediate referral and hospitalization were most frequent in patients 61 to 90 years old. Forty-five patients (14.2%; 95%CI: 10.4-18.0) were referred to a specialist immediately and an additional 34 (10.7%; 95%CI: 7.3-14.1) by one month follow-up. Fourteen patients (4.4%) were hospitalized immediately, and 11 (3.5%) within one month. Six patients (1.9%), all 61 to 90 years old, died within one month. CONCLUSION Dyspnoea occurs in about two per cent of consultations. Serious cases are rare and are much more likely in the older age group. Twenty-five per cent of the contacts concerning acute or worsening dyspnoea were referred to a specialist or hospitalized. In daily practice, the risk of immediate referral, hospitalization and death is higher in men and older patients, especially if the contact is at the patient's home. [Box: see text].
Collapse
Affiliation(s)
- Karin von Winckelmann
- a Department of General Practice, Department of Public Health and Primary Care , KU Leuven , Leuven , Belgium
| | - Walter Renier
- a Department of General Practice, Department of Public Health and Primary Care , KU Leuven , Leuven , Belgium
| | - Matthew Thompson
- b Department of Primary Health Care , University of Oxford , Old Road Campus , Oxford , UK
| | - Frank Buntinx
- a Department of General Practice, Department of Public Health and Primary Care , KU Leuven , Leuven , Belgium.,c Research Institute CAPHRI , University of Maastricht , The Netherlands
| |
Collapse
|
24
|
Smith AK, Currow DC, Abernethy AP, Johnson MJ, Miao Y, Boscardin WJ, Ritchie CS. Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study. J Am Geriatr Soc 2016; 64:2035-2041. [PMID: 27603500 DOI: 10.1111/jgs.14313] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and outcomes of breathlessness in older Americans. SETTING Community-dwelling older adults. PARTICIPANTS Individuals aged 70 and older in the nationally representative Health and Retirement Study (2008, follow-up through 2012) (N = 3,671; mean age 78). MEASUREMENTS Breathlessness was assessed by asking the question, "How often do you become short of breath while awake?" Responses of often or sometimes were considered to represent a level of breathlessness sufficient to warrant clinical attention. The prevalence of breathlessness is described overall and in subpopulations, then rates of associated symptoms, well-being, and health services use of participants who were breathless are compared with rates of those who were not. The risk of decline in activities of daily living (ADLs) and death through 2012 was estimated by creating a multivariable Cox proportional hazards model, adjusting for age, sex, race and ethnicity, and education. RESULTS Twenty-five percent of participants reported breathlessness. The prevalence of breathlessness was higher in certain subpopulations: chronic lung disease (63%), multimorbidity (≥2 chronic conditions) (45%), current smokers (38%), heart disease (36%), obesity (body mass index ≥30.0 kg/m2 ) (33%), and education less than high school (32%). Breathlessness was associated with higher rates of depression, anxiety, and severe fatigue; lower ratings of well-being; and higher rates of clinic and emergency department visits and hospitalizations (all P < .001). Breathlessness predicted ADL decline over 5 years (adjusted hazard ratio (aHR) = 1.43, 95% confidence interval (CI) = 1.22-1.68) and death (aHR 1.62, 95% CI = 1.32-2.02). CONCLUSION One in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40% greater risk of worsened function and 60% greater risk of death over the next 5 years.
Collapse
Affiliation(s)
- Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California. .,San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - David C Currow
- Discipline of Supportive and Palliative Care, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P Abernethy
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Division of Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina
| | - Miriam J Johnson
- Hull York Medical School, The University of Hull, Hull, East Yorkshire, United Kingdom
| | - Yinghui Miao
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Discipline of Supportive and Palliative Care, Flinders University, Bedford Park, South Australia, Australia
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Jewish Home of San Francisco, San Francisco, California
| |
Collapse
|
25
|
Johnson MJ, Bland JM, Gahbauer EA, Ekström M, Sinnarajah A, Gill TM, Currow DC. Breathlessness in Elderly Adults During the Last Year of Life Sufficient to Restrict Activity: Prevalence, Pattern, and Associated Factors. J Am Geriatr Soc 2016; 64:73-80. [PMID: 26782854 PMCID: PMC4719155 DOI: 10.1111/jgs.13865] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate relationships between age, clinical characteristics, and breathlessness sufficient to have people spend at least half a day a month in bed or to cut down on their usual activities (restricting breathlessness) during the last year of life. DESIGN Secondary data analysis. SETTING General community. PARTICIPANTS Nondisabled persons aged 70 and older (N=754). MEASUREMENTS Monthly telephone interviews were conducted to determine the occurrence of restricting breathlessness. The primary outcome was percentage of months with restricting breathlessness reported during the last year of life. RESULTS Data regarding breathlessness were available for 548 of 589 (93.0%) participants who died (mean age 86.7, range 71-106; 38.8% male) between enrollment (March 1998 to October 1999) and June 2013; 311 of these (56.8%) reported restricting breathlessness at some point during the last year of life, but none reported it every month. Frequency increased in the months closer to death, irrespective of cause. Restricting breathlessness was associated with anxiety (0.25 percentage points greater in months with breathlessness per percentage point months reported anxiety, 95% confidence interval (CI)=0.16-0.34, P<.001), depression (0.14, 95% CI=0.05-0.24, P=.003), and mobility problems (0.07, 0.03-0.1, P<.001). Percentage months of restricting breathlessness was greater if chronic lung disease was noted at the most-recent comprehensive assessment (6.62 percentage points, 95% CI=4.31-8.94, P<.001), heart failure (3.34 percentage points, 95% CI=0.71-5.97, P=.01), and ex-smoker status (3.01 percentage points, 95% CI=0.94-5.07, P=.004) but decreased with older age (-0.19 percentage points, 95% CI=-0.37 to -0.02, P=.03). CONCLUSION Restricting breathlessness increased in this elderly population in the months preceding death from any cause. Breathlessness should be assessed and managed in the context of poor prognosis.
Collapse
Affiliation(s)
| | | | - Evelyne A. Gahbauer
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Magnus Ekström
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Aynharan Sinnarajah
- Palliative & End of Life Care, Alberta Health Services (AHS) - Calgary Zone, Canada
| | - Thomas M. Gill
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - David C. Currow
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia
| |
Collapse
|
26
|
Viniol A, Beidatsch D, Frese T, Bergmann M, Grevenrath P, Schmidt L, Schwarm S, Haasenritter J, Bösner S, Becker A. Studies of the symptom dyspnoea: a systematic review. BMC FAMILY PRACTICE 2015; 16:152. [PMID: 26498502 PMCID: PMC4619993 DOI: 10.1186/s12875-015-0373-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/15/2015] [Indexed: 12/15/2022]
Abstract
Background To deal with patients suffering from dyspnoea, it is crucial for general practitioners to know the prevalences of different diseases causing dyspnoea in the respective area and season, the likelihood of avoidable life-threatening conditions and of worsening or recovery from disease. Aim Aim of our project was to conduct a systematic review of symptom-evaluating studies on the prevalence, aetiology, and prognosis of dyspnoea as presented to GPs in a primary care setting. Methods We did a systematic review of symptom-evaluating studies on dyspnoea in primary care. For this we included all studies investigating the complaint “dyspnoea” as a primary or secondary consulting reason in general practice. Apart from qualitative studies, all kind of study designs independent from type of data assessment, outcome measurement or study quality were included. Symptom-evaluating studies from other settings than primary care and studies which exclusively included children (age <18 years) were excluded from the review. Studies selecting patients prior to recruitment, e.g. because of an increased probability for a particular diagnosis, were also excluded. Results This systematic review identified 6 symptom evaluating studies on dyspnoea in the primary care setting. The prevalence of dyspnoea as reason for consultation ranges from 0.87 to 2.59 % in general practice. Among all dyspnoea patients 2.7 % (CI 2.2–3.3) suffer from pneumonia. Further specification of underlying aetiologies seems difficult due to the studies’ heterogeneity showing a great variety of probabilities. Conclusion There is a great lack of empirical evidence on the prevalence, aetiology and prognosis of dyspnoea in general practice. This might yield uncertainty in diagnosis and evaluation of dyspnoea in primary care.
Collapse
Affiliation(s)
- Annika Viniol
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Dominik Beidatsch
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Thomas Frese
- Department of General Practice / Family Medicine, University of Leipzig, Ph.-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Milena Bergmann
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Paula Grevenrath
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Laura Schmidt
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Sonja Schwarm
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Jörg Haasenritter
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Stefan Bösner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Annette Becker
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| |
Collapse
|
27
|
Johnson MJ, Currow DC, Booth S. Prevalence and assessment of breathlessness in the clinical setting. Expert Rev Respir Med 2014; 8:151-61. [DOI: 10.1586/17476348.2014.879530] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|