The language of medically unexplained dyspnea

Physiotherapy assessment of breathing pattern disorder: a qualitative evaluation

OBJECTIVES

To explore physiotherapists' opinions of physiotherapy assessment of Breathing Pattern Disorder (BPD).

METHODS

Qualitative study using focus groups (FGs) with reflexive thematic analysis and survey methods. The survey was distributed via social media and email to UK specialist physiotherapy interest groups. Two FGs, conducted in different settings, included physiotherapists based in hospital outpatients/community, private practice and higher education.

RESULTS

One-hundred-and-three physiotherapists completed the survey. Respondents identified a lack of consensus in how to define BPD, but some agreement in the components to include in assessment. Fifteen physiotherapists participated in the FGs. Three themes emerged from FG discussions: (1) nomenclature and language of breathing, (2) BPD and breathlessness and (3) The value of assessment of breathlessness.

CONCLUSION

The inconsistent nomenclature of dysfunctional breathing pattern impacts assessment, management and understanding of the diagnosis. Clarity in diagnosis, informing consistency in assessment, is fundamental to improving recognition and treatment of BPD. The findings are useful in the planning of education, training, future research and guideline development in BPD assessment.

Increased physiological dead space at exercise is a marker of mild pulmonary or cardiovascular disease in dyspneic subjects

Background: The characteristics of cardiopulmonary exercise testing (CPET)-derived parameters for the differential diagnosis of exertional dyspnea are not well known.

Objectives: We hypothesized that increased physiological dead space ventilation (VD/Vt) is a marker for mild pulmonary or cardiovascular disease in patients with exertional dyspnea.

Design: We used receiver operating characteristic analysis to determine the performance of individual CPET parameters for identifying subjects with either mild pulmonary or cardiovascular disease, among 77 subjects with mild-to-moderate exertional dyspnea (modified Medical Research Council scale 1–2).

Results: In comparison with subjects without disease, subjects with pulmonary disease (n = 31) had higher VE/V′CO₂ slope, higher VD/Vt, and lower ventilatory reserve. Subjects with cardiovascular disease (n = 14) had lower heart rate and cardiovascular double product and higher VD/Vt at peak exercise. At a threshold of 28%, the sensitivity and specificity of VD/Vt at peak exercise for identifying pulmonary or cardiovascular disease were 89% (95% CI: 64–98%) and 72% (95% CI: 46–89%), respectively.

Conclusions: Increased physiological VD/Vt at exercise is a sensitive and specific marker of mild pulmonary or cardiovascular disease in dyspneic subjects.

Retrospective memory for symptoms in patients with medically unexplained symptoms

OBJECTIVE

Clinical assessment and diagnostic processes heavily rely on memory-based symptom reports. The current study investigated memory for symptoms and the peak-end effect for dyspnea in patients with medically unexplained symptoms and healthy participants.

METHODS

Female patients with medically unexplained dyspnea (MUD) (n=22) and matched healthy controls (n=22) participated in two dyspnea induction trials (short, long). Dyspnea ratings were collected: (1) continuously during symptom induction (concurrent with respiratory measures), (2) immediately after the experiment, and (3) after 2weeks. Symptoms, negative affect, and anxiety were assessed at baseline and after every trial. The mediating role of state anxiety in symptom reporting was assessed. The peak-end effect was tested with forced-choice questions measuring relative preference for the trials.

RESULTS

Compared to controls, dyspnea induction resulted in higher levels of symptoms, anxiety, concurrent dyspnea ratings, and minute ventilation in the patient group. In both groups, immediate retrospective ratings were higher than averaged concurrent ratings. No further increase in dyspnea ratings was observed at 2-week recall. Retrospective dyspnea ratings were mediated by both state anxiety and concurrent dyspnea ratings. Patients did not show a peak-end effect, whereas controls did.

CONCLUSION

The findings show that patients' experience of a dyspneic episode is subject to immediate memory bias, but does not change over a longer time period. The results also highlight the importance of affective state during symptom experience for both symptom perception and memory.

A 56-Year-Old, Otherwise Healthy Woman Presenting With Light-headedness and Progressive Shortness of Breath

A 56-year-old white woman was referred to the pulmonary clinic for evaluation of unexplained shortness of breath. She enjoyed good health until 3 months prior to this visit when she reported experiencing recurrent episodes of shortness of breath and oppressive retrosternal chest discomfort with radiation to the neck. Episodes lasting 5 to 10 min often occurred at rest and were inconsistently related to physical activity. These symptoms became progressively worse and were often associated with light-headedness and presyncope. Her past medical history was uneventful apart from a prior diagnosis of breast cysts and suspected prolactinoma. Her symptoms escalated to such a level that she was forced to seek urgent medical attention at our institutional ED on two separate occasions in the preceding weeks. These visits precipitated a number of investigations and, eventually, a referral to the pulmonary clinic.

Physical symptoms in outpatients with psychiatric disorders consulting the general internal medicine division at a Japanese university hospital

PURPOSE

General practitioners have an important role in diagnosing a variety of patients, including psychiatric patients with complicated symptoms. We evaluated the relationship between physical symptoms and psychiatric disorders in general internal medicine (GIM) outpatients in a Japanese university hospital.

MATERIALS AND METHODS

We coded the symptoms and diagnoses of outpatients from medical documents using the International Classification of Primary Care, second edition (ICPC-2). The participants were new outpatients who consulted the GIM outpatient division at Jichi Medical University Hospital in Tochigi, Japan from January-June, 2012. We reviewed all medical documents and noted symptoms and diagnoses. These were coded using ICPC-2.

RESULTS

A total of 1,194 participants were evaluated, 148 (12.4%) of whom were diagnosed as having psychiatric disorders. The prevalence of depression, anxiety disorder, and somatization was 19.6% (number [n] =29), 14.9% (n=22), and 14.2% (n=21), respectively, among the participants with psychiatric disorders. The presence of several particular symptoms was associated with having a psychiatric disorder as compared with the absence of these symptoms after adjusting for sex, age, and the presence of multiple symptoms (odds ratio [OR] =4.98 [95% confidence interval {CI}: 1.66-14.89] for palpitation; OR =4.36 [95% CI: 2.05-9.39] for dyspnea; OR =3.46 [95% CI: 1.43-8.36] for tiredness; and OR =2.99 [95% CI: 1.75-5.13] for headache).

CONCLUSION

Not only the psychiatric symptoms, but also some physical symptoms, were associated with psychiatric disorders in GIM outpatients at our university hospital. These results may be of help to general practitioners in appropriately approaching and managing patients with psychiatric disorders.

Reliability and validity of the multidimensional dyspnea profile

BACKGROUND

Most measures of dyspnea assess a single aspect (intensity or distress) of the symptom. We developed the Multidimensional Dyspnea Profile (MDP) to measure qualities and intensities of the sensory dimension and components of the affective dimension. The MDP is not indexed to a particular activity and can be applied at rest, during exertion, or during clinical care. We report on the development and testing of the MDP in patients with a variety of acute and chronic cardiopulmonary conditions.

METHODS

One hundred fifty-one adults admitted to the ED with breathing symptoms completed the MDP three times in the ED, twice at least 1 h apart (T1, T2), and near discharge from the ED (T3). Measures were repeated in 68 patients twice in a follow-up session 4 to 6 weeks later (T4-T5). The ED sample was 56% men with a mean age of 53 ± 15 years; the follow-up sample was similar.

RESULTS

Factor analysis resulted in a two-factor solution with a total explained variance of 63%, 74%, and 72% at T1, T2, and T3, respectively. One domain related to primary sensory qualities and immediate unpleasantness, and the second encompassed emotional response. For the two domains, Cronbach α ranged from 0.82 to 0.95, and the intraclass correlation coefficient ranged from 0.91 to 0.98. Repeated-measures analysis was significant for change (T1, T3, T4), showing responsiveness to change in MDP domains with treatment (F([2,66]) = 19.67, P > .001).

CONCLUSIONS

These analyses support the reliability, validity, and responsiveness to clinical change of the MDP with two domains in an acute care and follow-up setting.

Validation of a three-factor measurement model of dyspnea in hospitalized adults with heart failure

OBJECTIVE

The purpose of this study was to validate a 3-factor measurement model of dyspnea sensory quality (WORK-EFFORT, TIGHTNESS, SMOTHERING-AIR HUNGER) originally derived in patients with exacerbated chronic obstructive pulmonary disease.

METHODS

In this validation study, adult patients with heart failure were enrolled after hospital admission (median hospital day 1) and asked to rate the intensity of dyspnea sensory quality descriptors on the day of enrollment (study day 1; N = 119) and in a recall version for the day of admission (study day 0; n = 97).

RESULTS

Confirmatory factor analysis demonstrated good model fit for both days. Cronbach's α for each factor was greater than .87 for both study days.

CONCLUSION

This is the first study to validate a previously specified measurement model of dyspnea sensory quality in an independent sample. Results indicate that measurement of dyspnea sensory quality in exacerbated cardiopulmonary disease does not necessarily require disease-specific questionnaires.