Rating Dyspnea and Pain: "No" is Not Always "Zero"

Nurses routinely assess pain in hospitalized patients; similar assessment of dyspnea is increasing. Most nurses start with a yes-no question when assessing pain or dyspnea; many record "no" as a zero rating, skipping the rating scale. We tested the hypothesis that recording "no" answers as "zero" fails to detect the symptoms that would have been detected with a rating scale. Nurses asked 60 patients yes-no questions about the presence of dyspnea and pain, then asked patients to rate the symptoms using a 0-10 scale. All "yes" answers were followed by a concordant rating (i.e., greater than zero). More than 25% of "no" answers were followed by a discordant rating (> zero). Documenting "no" as "zero" missed information potentially useful in care planning; patients who rate dyspnea above zero are at greater risk of adverse outcomes. This information can also provide opportunity to start a discussion with patients who may benefit from symptom management.

Cost-effectiveness of twice-daily indacaterol/glycopyrrolate inhalation powder for the treatment of moderate to severe COPD in the US

Background

Indacaterol 27.5 µg/glycopyrrolate 15.6 µg (IND/GLY 27.5/15.6 µg) inhalation powder, a twice-daily, fixed-dose combination of a long-acting beta2-agonist (LABA) and a long-acting antimuscarinic antagonist (LAMA), is indicated in the US for long-term maintenance treatment of airflow obstruction in patients with COPD. The safety and efficacy of IND/GLY 27.5/15.6 µg have been established, but cost-effectiveness is not yet known. This study compared the cost-effectiveness of IND/GLY 27.5/15.6 µg with other long-acting COPD maintenance therapies.

Methods

A Markov model was constructed from the US payer perspective. Health states were defined as mild (post-bronchodilator FEV₁ ≥80% of predicted), moderate (50% ≤FEV₁ <80% of predicted), severe (30% ≤FEV₁ <50% of predicted), and very severe (FEV₁ <30% of predicted) COPD. Patients entering the model transitioned through health states based on placebo-adjusted change from baseline in trough FEV₁ for each comparator at week 12. Comparators included other US Food and Drug Administration-approved LABA/LAMA fixed-dose combinations as well as commonly prescribed LAMA and LABA/inhaled corticosteroid agents. One-way and probabilistic sensitivity analyses were conducted to test the model assumptions and the overall robustness of the results.

Results

Using the model, IND/GLY 27.5/15.6 µg treatment for 12 weeks resulted in total costs of US $23,375 vs US $9,365 for placebo. Compared with placebo, IND/GLY 27.5/15.6 treatment resulted in the highest improvement in FEV₁ across all comparators and the lowest cost per decline in 100 mL FEV₁. IND/GLY 27.5/15.6 µg was also among the most cost-effective treatment option as measured by St George's Respiratory Questionnaire response rate, at US $3,518 per additional responder at 12 weeks compared with placebo. In addition, IND/GLY 27.5/15.6 µg had the lowest cost per severe exacerbation avoided vs placebo across all comparators (US $87,686).

Conclusion

This model, developed from the US payer perspective with a 5-year time horizon, found IND/GLY 27.5/15.6 µg to be a cost-effective treatment option for patients with moderate to severe COPD.

Overview of mechanical ventilatory support and management of patient- and ventilator-related responses

Nurses must be knowledgeable about the function and limitations of ventilator modes, causes of respiratory distress and dyssynchrony with the ventilator, and appropriate management in order to provide high-quality patient-centered care. Prompt recognition of problems and action by the nurse may resolve acute respiratory distress, dyspnea, and increased work of breathing and prevent adverse events. This article presents an overview of mechanical ventilation modes and the assessment and management of dyspnea and patient-ventilator dyssynchrony. Strategies to manage patients' responses to mechanical ventilatory support and recommendations for staff education also are presented.

Dyspnea in the thoracic trauma patient: a human response to illness

Dyspnea is one of the most common presenting symptoms in thoracic trauma patients; therefore, trauma nurses require extensive knowledge of this symptom. The Human Response to Illness model provides an organizing framework to establish a comprehensive understanding of the human response of dyspnea following thoracic trauma. The model is used to describe the physiological, pathophysiological, behavioral, and experiential perspectives of dyspnea in thoracic trauma, while considering personal and environmental factors. This comprehensive overview will provide the trauma nurse with appropriate evidence-based rationale for interventions in the management of acute dyspnea in the thoracic trauma population.