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PubMed1991

[The effect of prior experience of dyspnea on measured degrees of dyspnea induced by obstruction in healthy persons. Methodology in the use of Borg's scale].

The object of the investigation was to assess the influence of previously experienced maximal dyspnoea on assessed values of dyspnoea in healthy volunteers. In these subjects threshold to medium dyspnoea was evoked by application of three different flow resistances of 1 or 2 or 4 kPa-1.s-1 for a period of 2 mins. Maximum dyspnoea was evoked by occlusion of the airways for a period of several breathes. The control and experimental group comprised a total of 16 healthy volunteers aged 21 to 22 years. To evaluate the dyspnoea the 10-point Borg visual analogue scale was used. It was revealed that the magnitude of different resistances in blind and random inclusion of these resistances was reliably differentiated by the subjects regardless whether they had a previous experience of maximal dyspnoea. A significantly higher grade of dyspnoea was, however, recorded in all three tested resistances in subjects who had a previous experience of dyspnoea. This phenomenon is explained by the sensation of anxiety and threatened vital function closely before the model obstruction in the experimental group. The authors recommend based on their own experience and data in the literature Borg's ventical scale for quantification of dyspnoea. When assessment are made it must be, however, stated how the examined subjects were instructed in advance and whether they had a previous experience of dyspnoea.

Adult↗
PubMed2001

Self-hypnosis for management of chronic dyspnea in pediatric patients.

INTRODUCTION: Hypnotherapy can be useful in the management of anxiety, discomfort, and psychosomatic symptoms, all of which may contribute to a complaint of dyspnea. Therefore, instruction in self-hypnosis was offered to 17 children and adolescents with chronic dyspnea, which had not resolved despite medical therapy, and who were documented to have normal lung function at rest. This report documents the result of this intervention. METHODS: A retrospective chart review identified all patients followed by a single pediatric pulmonologist (R.D.A.), with a chief complaint of chronic dyspnea from April 1998 through December 1999. These patients had been evaluated and treated for medical diseases according to their history, physical examination, and laboratory investigations. The pulmonologist offered to teach self-hypnosis to all of these patients, who comprise the cohort in this report. Chronic dyspnea was defined as recurrent difficulty breathing or shortness of breath at rest or with exertion, which had existed for at least 1 month in patients who had not suffered within a month from an acute pulmonary illness. The pulmonologist was trained in hypnosis through his attendance at three 20-hour workshops. Hypnosis was taught to individual patients in 1 or two 15- to 45-minute sessions. Patients were taught hypnotic self-induction techniques and imagery to achieve relaxation. Additionally, imagery relating to dyspnea was developed by coaching patients to change their imagined lung appearance from a dyspneic to a healthy state. Patients were encouraged to practice self-hypnosis regularly and to use lung imagery to eliminate dyspnea if it occurred. RESULTS: Seventeen patients (13 males and 4 females) with chronic dyspnea were documented to have normal pulmonary function at rest. Their mean age was 13.4 years (range: 8-18 years). Twelve of the 17 previously were diagnosed with other conditions, such as allergies, asthma, and gastroesophageal reflux. Fifteen of the 17 manifested at least 1 other symptom associated with their dyspnea, including an anxious appearance (4 patients); chest tightness or pain (5); cough (4); wheeze (3); difficulty with inspiration (2); hyperventilation (1); inspiratory noise, such as stridor, gasping, rasping, or squeak (8); dizziness (1); feeling something is stuck in the throat (2); parasthesias (4); and tachycardia (3). Of the 17 patients, 2 complained of dyspnea at rest only, 13 complained of dyspnea with activity only, and 2 complained of dyspnea both at rest and with activity. Nine patients reported that they frequently needed to discontinue their physical activity because of dyspnea. The mean duration of their dyspnea before learning self-hypnosis was 2 years (range: 1 month to 5 years). The dyspnea was of <6 months duration for 4 of the patients. For 9 of the 17 patients a potential psychosocial association with their dyspnea was identified: 3 developed symptoms at school only; 2 with exercise during competitive races only; 3 after a major disagreement between their parents; and 1 developed symptoms each time his family moved to a new neighborhood. Before presentation, 7 of the 17 patients received chronic inhaled antiinflammatory therapy, and 3 were using inhaled albuterol, as needed. All 17 patients had normal physical examinations, with the exception of healed scars on the chest and abdomen of 1 patient, a repaired cleft palate in 1 patient, and rhinitis in another. Four of the 17 underwent pulmonary function testing before and after exercise, 6 had chest radiographs, and 3 had electrocardiograms. All of these tests were normal. A patient with a history of psychogenic cough declined to learn self-hypnosis. Thirteen of the remaining 16 patients were taught to use self-hypnosis in 1 session. A second session was provided to 3 patients within 2 months. Thirteen of the 16 patients reported their dyspnea and any associated symptoms had resolved within 1 month of their final hypnosis instruction session. Eleven believed that resolution of their dyspnea was attributable to hypnosis, because their symptoms cleared immediately after they received hypnosis instruction (5 patients) or with its regular use (6). Two did not attribute resolution of dyspnea to hypnosis because they did not use it at home. The remaining 3 reported that their dyspnea had improved. Patients were followed for a mean 9 months (range: 2-15 months) after their final hypnosis session. Ten of the 16 regularly used self-hypnosis at home for at least 1 month after the final hypnosis session. There was no recurrence of dyspnea, associated symptoms, or onset of new symptoms in patients in whom the dyspnea resolved. Under supervision of the pediatric pulmonologist, 2 of 7 patients discontinued their chronic antiinflammatory therapy when they became asymptomatic after hypnosis. Subsequently, their pulmonary function remained normal. (ABSTRACT TRUNCATED)

Adolescent↗
PubMed1995

Dyspnea in ambulatory patients with SLE: prevalence, severity, and correlation with incremental exercise testing.

OBJECTIVE: We sought to determine the prevalence and severity of dyspnea, and to correlate dyspnea with clinical features and exercise limitation in ambulatory patients with systemic lupus erythematosus (SLE). METHODS: Twenty-five consecutive patients were evaluated with a validated pulmonary questionnaire, chest radiograph, 2-dimensional echocardiography, resting pulmonary function tests, and incremental exercise testing. RESULTS: Dyspnea was reported by 60% (95% CI 39-79) of patients; 20% (95% CI 7-40) had severe dyspnea (inability to dress without dyspnea) and 12% (95% CI 3-31) had moderate dyspnea (dyspnea after walking 100 yards). Compared to patients without dyspnea, patients with dyspnea were more likely to have had a history of clinical lupus involving the lung (80 vs 40%, p = 0.05), a lower total lung capacity (77.5 vs 94.8%, p = 0.002), and a reduced maximum oxygen consumption (VO2max of 53.4 vs 67.7%, p = 0.01). Patients with severe dyspnea and patients without dyspnea did not differ in duration of prednisone use, activity of disease, weight, or in frequency of Raynaud's phenomenon (p > 0.05). Only 4% of all patients had abnormal left ventricular motion on 2-dimensional echo; patients with moderate or severe dyspnea had normal left ventricular motion. Of the 5 patients with severe dyspnea, 4 (80%) had restrictive lung disease and 1 (20%) had an isolated diffusion defect. All patients with dyspnea had an abnormal exercise test, but so did 9/10 without dyspnea (p > 0.05). Severity of dyspnea correlated highly with maximum exercise tolerance measured by VO2max (R2 = 0.51, p = 0.0001). CONCLUSION: In ambulatory patients with SLE, dyspnea is common, frequently disabling, associated with a history of lupus involvement of the lung, and correlates highly with objective measures of exercise limitation.

Adult↗
PubMed1999

Assessment of dyspnea in advanced cancer patients.

Dyspnea, which has been defined as an "uncomfortable awareness of breathing," is a frequent and devastating symptom in advanced cancer patients. It has been reported to occur in 21-79% of patients evaluated a few days or weeks before death. In advanced cancer, the aim of effective management is to minimize the patient's perception of breathlessness, which depends in turn on a reliable assessment. Unfortunately, most of our knowledge and experience of dyspnea has been acquired through working with patients with chronic pulmonary disease, and there is a dearth of literature relating specifically to the assessment of dyspnea in advanced cancer. Dyspnea is a complex sensation including several dimensions, such as antecedents (physiological and psychological events or stimuli preceding the development of dyspnea), mediators (characteristics of individuals or their environment affecting the response), reactions to dyspnea, and consequences or outcomes that result once the individual has reacted to a stimulus. The literature gives us many tools to measure these aspects. For example, antecedents may be assessed by the British Medical Research Council Questionnaire, the American Thoracic Questionnaire (ATS-DLD-78) and the Dyspnea Interview Schedule. Mediators of dyspnea may be measured by the ATS-DLD-78, the Chronic Respiratory Questionnaire (CRQ), the Dyspnea Interview Schedule, the Pulmonary Functional Status Scale (PFSS) and the Therapy Impact Questionnaire (TIQ). Reactions to dyspnea may be assessed by the Dyspnea Visual Analogue Scale (DVAS), the TIQ and the Borg Scale, and the consequences of it by the TIQ, the Baseline Dyspnea Index (BDI), the Transition Dyspnea Index (TDI), and CRQ, and by the Oxygen Cost Diagram (OCD), the Dyspnea Interview Schedule and the Modified Medical Research Council Dyspnea Scale (MRC). No single assessment tool considers all the different components of dyspnea, and the final choice will depend on the purpose of the assessment, taking into account that the provision of quality of life is of paramount importance to patients who have limited time left to them and that the assessment should not therefore detract from the quality of life by being overlong, complicated or invasive.

Dyspnea↗
PubMed1999

A model of chronic dyspnea.

PURPOSE: To present an overview of dyspnea, differentiate chronic dyspnea from acute dyspnea, critique models of dyspnea found in the nursing literature, and propose a new model of chronic dyspnea to guide the care and evaluation of chronic dyspnea in patients living with chronic obstructive pulmonary disease (COPD). Dyspnea is the major symptom that impairs quality of life for nearly 16 million Americans who have COPD. METHODS AND SOURCES: Review of scholarly literature on dyspnea by searching CINAHL and MEDLINE (1980-1998) using dyspnea and chronic obstructive lung disease as key words. The search produced studies conducted by a variety of health care professions including those in nursing, medicine, exercise physiology, and respiratory therapy. FINDINGS: The existing models fail to differentiate between acute and chronic dyspnea. These models were found to be inadequate for guiding interventions to decrease the long-term adverse consequences of chronic dyspnea. CONCLUSIONS: A useful model of chronic dyspnea defines chronic dyspnea as distress with varying levels of intensity and long-term physical, psychologic, and sociocultural consequences. The proposed model has implications for both research and clinical practice by identifying the consequences of chronic dyspnea as outcome measures of the effectiveness of treatment.

Acute Disease↗
PubMed1998

Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease.

When dyspnea must be assessed clinically, there are three methods of assessment: the measurement of dyspnea with activities of daily living using clinical dyspnea ratings such as the modified Medical Research Council (MRC), the Baseline Dyspnea Index (BDI), and the Oxygen Cost Diagram (OCD); the measurement of dyspnea during exercise using the Borg scale; to assess the influence of dyspnea on health-related quality of life (HRQoL) using disease-specific questionnaires such as the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ). The purpose of the present cross-sectional study was to clarify relationships between dyspnea ratings and HRQoL questionnaires by applying factor analysis. One hundred sixty-one patients with mild to severe COPD completed pulmonary function tests, progressive cycle ergometer testing for exercise capacity, assessment of dyspnea, HRQoL, anxiety, and depression. Factor analysis demonstrated that the MRC, BDI, OCD, and Activity of the SGRQ, and Dyspnea of the CRQ, were grouped into the same factor, and the frequency distribution histograms of these five measures showed virtually the same distribution. The Borg scale at the end of maximum exercise was found to be a different factor. The MRC, BDI, OCD, and Activity in the SGRQ, and Dyspnea in the CRQ demonstrated the same pattern of correlation with physiologic data, and they had significant relationships with FEV1 (correlation coefficients [Rs] = 0.31 to 0. 48) and maximal oxygen uptake (Rs = 0.46 to 0.60). Disease-specific HRQoL questionnaires, the SGRQ and the CRQ, which contain a specific dimension for evaluating dyspnea, may be substituted for clinical dyspnea ratings in a cross-sectional assessment. Dyspnea rating at the end of exercise may provide further information regarding dyspnea.

Activities of Daily Living↗
PubMed2005

Dyspnea management in lung cancer: applying the evidence from chronic obstructive pulmonary disease.

PURPOSE/OBJECTIVES: To provide an overview of mechanisms of dyspnea and causes of dyspnea in chronic obstructive pulmonary disease (COPD) and lung cancer and to critically review current pharmacologic and nonpharmacologic management of dyspnea for COPD and lung cancer. DATA SOURCES: Published articles, abstracts, textbooks, and the authors' personal experiences with dyspnea management in COPD and lung cancer. DATA SYNTHESIS: The causes of dyspnea in cancer are more varied than the causes of dyspnea in COPD; however, many are similar, thus providing the justification for recommending best practice from COPD research to be used in lung cancer. Dyspnea in both diseases is treated by corticosteroids, bronchodilators, antianxiety drugs, local anesthetics, and oxygen. However, when dyspnea is severe, morphine is the first choice. Using specific breathing techniques, positioning, energy conservation, exercise, and some dietary modifications and nutrient supplements can help with dyspnea management. CONCLUSIONS: Pharmacologic and nonpharmacologic management of dyspnea in COPD can be applied to dyspnea related to lung cancer. Further research in the management of dyspnea in lung cancer is required, particularly controlled studies with larger sample sizes, to determine the effectiveness of the application of COPD dyspnea management in lung cancer. IMPLICATIONS FOR NURSING: Previous studies provide a guideline for applying dyspnea management for COPD to cancer. The theoretical frameworks used in previous studies can be modified for conducting further study.

Adrenal Cortex Hormones↗
PubMed1998

Validity of the numeric rating scale as a measure of dyspnea.

BACKGROUND: Dyspnea, a devastating sign, is rarely monitored by clinicians. One reason may be the lack of a valid measurement scale that is easy to use in a clinical setting. OBJECTIVES: To establish the validity of the numeric rating scale as a measure of present dyspnea (dyspnea at rest). METHODS: A total of 188 patients with chronic obstructive pulmonary disease rated their present dyspnea by using the Visual Analog Dyspnea Scale and the numeric rating scale. They also rated their usual dyspnea (dyspnea during the past week). Demographic information was collected from each patient's chart, and pulmonary status was assessed with portable spirometry, pulse oximetry, or both. RESULTS: Concurrent validity of the numeric rating scale was supported by the high correlation of its scores with scores from the Visual Analog Dyspnea Scale. Conversion of the numeric rating scale to a 0-to-100 scale and comparison with the visual analog scale (by using a paired t test to determine if the correlated scores were similar for clinical decision making) showed that scores were not significantly different. A paired t test showed a difference in scores on the numeric rating scale obtained before and after ambulation, supporting the construct validity of the numeric rating scale. Scores on the numeric rating scale for present dyspnea were poorly correlated with ratings of usual dyspnea, indicating that present dyspnea and usual dyspnea are different constructs. CONCLUSION: Present and usual dyspnea are different constructs. The numeric rating scale is a valid measure of present dyspnea.

Adult↗
PubMed1999

Management of dyspnea in advanced cancer patients.

Dyspnea is a frequent and devastating symptom among advanced cancer patients and is often difficult to control. However, there has been considerably less emphasis in the literature on the appropriate characterization and management of this symptom than of other cancer-related symptoms. The purpose of this paper is to review issues relating to the prevalence, causes, prognosis and treatment of dyspnea in patients with advanced cancer. A Medline search of the literature published from 1966 to February 1999 was conducted. Dyspnea occurs in 21-78.6% of advanced cancer patients and is reported to be from moderate to severe in 10-63% of the patients. The frequency and severity of dyspnea increase with the progression of the disease and/ or when death is approaching. Lung cancer patients with dyspnea have shorter survival than patients with other types of cancer. Dyspnea can be a direct effect of the cancer, an effect of therapy or not related to the cancer or therapy. In addition to cancer, patients may suffer from chronic obstructive pulmonary disease, congestive heart failure, nonmalignant pleural effusion, pneumonitis, air flow obstruction, or bronchospasm associated with asthma. In the absence of lung or heart disease, dyspnea may be a clinical expression of the syndrome of overwhelming cachexia and asthenia or of severe asthenia. Many different causes may co-exist in a patient. Whenever possible, an attempt should be made to treat underlying cancer. Radiotherapy and chemotherapy may relieve dyspnea also in patients who fail to achieve a major objective response. Symptomatic measures in addition to specific treatments for the underlying cancer and/or other pulmonary and cardiovascular diseases are indicated. Oxygen therapy has proved effective in hypoxemic and nonhypoxemic patients. The role of transfusion therapy to relieve anemia-related dyspnea in advanced and terminal cancer patients is still controversial. Oral, subcutaneous and intravenous opioids are effective but underused in these patients, whereas currently available evidence does not support the clinical use of nebulized opioids. While benzodiazepines are frequently used in patients with dyspnea, these drugs were ineffective in four out of five randomized controlled trials. Other components of the symptom expression are better managed by supportive counseling, occupational therapy or physiotherapy. While the mechanism of breathing and the consequences of different pathologic conditions for both respiratory function and gas exchange are well known, the genesis and pathophysiology of dyspnea as a symptom are much less well understood. Palliative care assessment should be focused on dyspnea as a symptom rather than on the functional and gas exchange abnormalities. Increased research on the appropriate management of dyspnea is needed.

Dyspnea↗
PubMedDate not supplied

Diagnosis of heart failure in older adults: predictive value of dyspnea at rest.

The objective of this study was to describe the predictive value of dyspnea at rest in the diagnosis of heart failure in older adults. We have conducted a retrospective chart review of older adults hospitalized with heart failure in 11 hospitals in Alabama, US. We defined dyspnea at rest as dyspnea not accompanied by activities, sleep, or lying down. We confirmed diagnosis of heart failure using modified Framingham criteria (based on available variables). We estimated values for sensitivity, specificity, predictive value positive and likelihood ratio positive of dyspnea at rest along with their 95% confidence intervals (95% CI). Patients had a mean (+/-S.D.) age 79 (+/-7.5) years, were 60% female and 18% African-American. The prevalence (pre-test probability) of heart failure was 77%. Dyspnea at rest was reported by 975 (89%) patients. Dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea were, respectively, reported by 279 (26%), 356 (33%) and 230 (21%) patients. The sensitivity, specificity and positive predictive value (post-test probability) of dyspnea at rest were, respectively, 92% (95% CI = 90 - 94%), 19% (95% CI = 14 - 24%) and 79% (95% CI = 77 - 82%). Patients with dyspnea at rest were 13% (likelihood = 1.13; 95% CI = 1.06 - 1.20) more likely to have heart failure than those without. Presence of any three of the symptoms of dyspnea at rest, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue and lower extremity edema increased the positive predictive value to 90% (95% CI = 87 - 93%). Dyspnea at rest was the commonest symptom among elderly hospitalized HF patients and had high sensitivity, but low specificity and positive predictive value, which increased in the presence of other symptoms.

Aged↗