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American Journal of Respiratory and... Feb 2012Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been...
BACKGROUND
Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.
PURPOSE
The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.
METHODS
An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.
RESULTS
Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains.
CONCLUSIONS
Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
Topics: Adrenal Cortex Hormones; Analgesics, Opioid; Bronchodilator Agents; Dyspnea; Exercise Therapy; Humans; Magnetic Resonance Imaging; Oxygen Inhalation Therapy
PubMed: 22336677
DOI: 10.1164/rccm.201111-2042ST -
American Family Physician May 2020Dyspnea is a symptom arising from a complex interplay of diseases and physiologic states and is commonly encountered in primary care. It is considered chronic if present... (Review)
Review
Dyspnea is a symptom arising from a complex interplay of diseases and physiologic states and is commonly encountered in primary care. It is considered chronic if present for more than one month. As a symptom, dyspnea is a predictor for all-cause mortality. The likeliest causes of dyspnea are disease states involving the cardiac or pulmonary systems such as asthma, chronic obstructive pulmonary disease, heart failure, pneumonia, and coronary artery disease. A detailed history and physical examination should begin the workup; results should drive testing. Approaching testing in stages beginning with first-line tests, including a complete blood count, basic chemistry panel, electrocardiography, chest radiography, spirometry, and pulse oximetry, is recommended. If no cause is identified, second-line noninvasive testing such as echocardiography, cardiac stress tests, pulmonary function tests, and computed tomography scan of the lungs is suggested. Final options include more invasive tests that should be done in collaboration with specialty help. There are three main treatment and management goals: correctly identify the underlying disease process and treat appropriately, optimize recovery, and improve the dyspnea symptoms. The six-minute walk test can be helpful in measuring the effect of ongoing intervention. Care of patients with chronic dyspnea typically requires a multidisciplinary approach, which makes the primary care physician ideal for management.
Topics: Diagnosis, Differential; Dyspnea; Echocardiography; Exercise Test; Humans; Medical History Taking; Physical Examination; Primary Health Care; Respiratory Function Tests
PubMed: 32352727
DOI: No ID Found -
Current Oncology (Toronto, Ont.) Jun 2020Dyspnea is a symptom commonly experienced by cancer patients that causes significant suffering, worsens throughout a patient's disease trajectory, and can be more...
Dyspnea is a symptom commonly experienced by cancer patients that causes significant suffering, worsens throughout a patient's disease trajectory, and can be more difficult to manage than other symptoms. Assessment of dyspnea is best accomplished by a subjective description; physiologic measures are only weakly correlated with the patient's experience. It is important to consider a wide range of possible malignant and nonmalignant causes of dyspnea in cancer patients and to correct underlying causes where possible. For patients with refractory dyspnea, opioids are a safe and effective treatment. Benzodiazepines can be considered, but the evidence for their use is weak. Supplemental oxygen is beneficial if patients are hypoxemic, or if they have concurrent chronic obstructive pulmonary disease. Nonpharmacologic strategies such as fan therapy, exercise programs, and pulmonary rehabilitation can also be beneficial. One important diagnosis to consider in all cancer patients is venous thromboembolism. Prompt evaluation and treatment are vital to improving symptoms and outcomes for patients. Although dyspnea is common and potentially debilitating in cancer patients, it can be effectively managed with a structured approach to rule out reversible causes while concurrently treating the patient using appropriate therapeutic strategies.
Topics: Dyspnea; Humans; Palliative Care
PubMed: 32669923
DOI: 10.3747/co.27.6413 -
The Cochrane Database of Systematic... Feb 2021Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise-induced hypoxia. Pulmonary rehabilitation is often used to improve... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Interstitial lung disease (ILD) is characterised by reduced functional capacity, dyspnoea and exercise-induced hypoxia. Pulmonary rehabilitation is often used to improve symptoms, health-related quality of life and functional status in other chronic lung conditions. There is accumulating evidence for comparable effects of pulmonary rehabilitation in people with ILD. However, further information is needed to clarify the long-term benefit and to strengthen the rationale for pulmonary rehabilitation to be incorporated into standard clinical management of people with ILD. This review updates the results reported in 2014.
OBJECTIVES
To determine whether pulmonary rehabilitation in people with ILD has beneficial effects on exercise capacity, symptoms, quality of life and survival compared with no pulmonary rehabilitation in people with ILD. To assess the safety of pulmonary rehabilitation in people with ILD.
SEARCH METHODS
We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO) and PEDro from inception to April 2020. We searched the reference lists of relevant studies, international clinical trial registries and respiratory conference abstracts to look for qualifying studies.
SELECTION CRITERIA
We included randomised controlled trials and quasi-randomised controlled trials in which pulmonary rehabilitation was compared with no pulmonary rehabilitation or with other therapy in people with ILD of any origin.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We contacted study authors to request missing data and information regarding adverse effects. We specified a priori subgroup analyses for participants with idiopathic pulmonary fibrosis (IPF) and participants with severe lung disease (low diffusing capacity or desaturation during exercise). There were insufficient data to perform the prespecified subgroup analysis for type of exercise training modality.
MAIN RESULTS
For this update, we included an additional 12 studies resulting in a total of 21 studies. We included 16 studies in the meta-analysis (356 participants undertook pulmonary rehabilitation and 319 were control participants). The mean age of participants ranged from 36 to 72 years and included people with ILD of varying aetiology, sarcoidosis or IPF (with mean transfer factor of carbon dioxide (TLCO) % predicted ranging from 37% to 63%). Most pulmonary rehabilitation programmes were conducted in an outpatient setting, with a small number conducted in home-based, inpatient or tele-rehabilitation settings. The duration of pulmonary rehabilitation ranged from three to 48 weeks. There was a moderate risk of bias due to the absence of outcome assessor blinding and intention-to-treat analyses and the inadequate reporting of randomisation and allocation procedures in 60% of the studies. Pulmonary rehabilitation probably improves the six-minute walk distance (6MWD) with mean difference (MD) of 40.07 metres, 95% confidence interval (CI) 32.70 to 47.44; 585 participants; moderate-certainty evidence). There may be improvements in peak workload (MD 9.04 watts, 95% CI 6.07 to 12.0; 159 participants; low-certainty evidence), peak oxygen consumption (MD 1.28 mL/kg/minute, 95% CI 0.51 to 2.05; 94 participants; low-certainty evidence) and maximum ventilation (MD 7.21 L/minute, 95% CI 4.10 to 10.32; 94 participants; low-certainty evidence). In the subgroup of participants with IPF, there were comparable improvements in 6MWD (MD 37.25 metres, 95% CI 26.16 to 48.33; 278 participants; moderate-certainty evidence), peak workload (MD 9.94 watts, 95% CI 6.39 to 13.49; low-certainty evidence), VO (oxygen uptake) peak (MD 1.45 mL/kg/minute, 95% CI 0.51 to 2.40; low-certainty evidence) and maximum ventilation (MD 9.80 L/minute, 95% CI 6.06 to 13.53; 62 participants; low-certainty evidence). The effect of pulmonary rehabilitation on maximum heart rate was uncertain. Pulmonary rehabilitation may reduce dyspnoea in participants with ILD (standardised mean difference (SMD) -0.36, 95% CI -0.58 to -0.14; 348 participants; low-certainty evidence) and in the IPF subgroup (SMD -0.41, 95% CI -0.74 to -0.09; 155 participants; low-certainty evidence). Pulmonary rehabilitation probably improves health-related quality of life: there were improvements in all four domains of the Chronic Respiratory Disease Questionnaire (CRQ) and the St George's Respiratory Questionnaire (SGRQ) for participants with ILD and for the subgroup of people with IPF. The improvement in SGRQ Total score was -9.29 for participants with ILD (95% CI -11.06 to -7.52; 478 participants; moderate-certainty evidence) and -7.91 for participants with IPF (95% CI -10.55 to -5.26; 194 participants; moderate-certainty evidence). Five studies reported longer-term outcomes, with improvements in exercise capacity, dyspnoea and health-related quality of life still evident six to 12 months following the intervention period (6MWD: MD 32.43, 95% CI 15.58 to 49.28; 297 participants; moderate-certainty evidence; dyspnoea: MD -0.29, 95% CI -0.49 to -0.10; 335 participants; SGRQ Total score: MD -4.93, 95% CI -7.81 to -2.06; 240 participants; low-certainty evidence). In the subgroup of participants with IPF, there were improvements at six to 12 months following the intervention for dyspnoea and SGRQ Impact score. The effect of pulmonary rehabilitation on survival at long-term follow-up is uncertain. There were insufficient data to allow examination of the impact of disease severity or exercise training modality. Ten studies provided information on adverse events; however, there were no adverse events reported during rehabilitation. Four studies reported the death of one pulmonary rehabilitation participant; however, all four studies indicated this death was unrelated to the intervention received.
AUTHORS' CONCLUSIONS
Pulmonary rehabilitation can be performed safely in people with ILD. Pulmonary rehabilitation probably improves functional exercise capacity, dyspnoea and quality of life in the short term, with benefits also probable in IPF. Improvements in functional exercise capacity, dyspnoea and quality of life were sustained longer term. Dyspnoea and quality of life may be sustained in people with IPF. The certainty of evidence was low to moderate, due to inadequate reporting of methods, the lack of outcome assessment blinding and heterogeneity in some results. Further well-designed randomised trials are needed to determine the optimal exercise prescription, and to investigate ways to promote longer-lasting improvements, particularly for people with IPF.
Topics: Adult; Aged; Dyspnea; Exercise; Exercise Tolerance; Humans; Lung Diseases, Interstitial; Middle Aged; Quality of Life
PubMed: 34559419
DOI: 10.1002/14651858.CD006322.pub4 -
Respiratory Research Jan 2022Unexplained exertional dyspnoea or fatigue can arise from a number of underlying disorders and shows only a weak correlation with resting functional or imaging tests.... (Review)
Review
Unexplained exertional dyspnoea or fatigue can arise from a number of underlying disorders and shows only a weak correlation with resting functional or imaging tests. Noninvasive cardiopulmonary exercise testing (CPET) offers a unique, but still under-utilised and unrecognised, opportunity to study cardiopulmonary and metabolic changes simultaneously. CPET can distinguish between a normal and an abnormal exercise response and usually identifies which of multiple pathophysiological conditions alone or in combination is the leading cause of exercise intolerance. Therefore, it improves diagnostic accuracy and patient health care by directing more targeted diagnostics and facilitating treatment decisions. Consequently, CPET should be one of the early tests used to assess exercise intolerance. However, this test requires specific knowledge and there is still a major information gap for those physicians primarily interested in learning how to systematically analyse and interpret CPET findings. This article describes the underlying principles of exercise physiology and provides a practical guide to performing CPET and interpreting the results in adults.
Topics: Adult; Dyspnea; Exercise Tolerance; Humans; Practice Guidelines as Topic; Respiratory Function Tests
PubMed: 35022059
DOI: 10.1186/s12931-021-01895-6 -
European Respiratory Review : An... Sep 2016Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in... (Review)
Review
Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in excess of the magnitude of physiological respiratory or cardiac disease. We reviewed the literature and propose a classification system for the common dysfunctional breathing patterns described. The literature was searched using the terms: dysfunctional breathing, hyperventilation, Nijmegen questionnaire and thoraco-abdominal asynchrony. We have summarised the presentation, assessment and treatment of dysfunctional breathing, and propose that the following system be used for classification. 1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia. 2) Periodic deep sighing: frequent sighing with an irregular breathing pattern. 3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea. 4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration. 5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.This review highlights the common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing. Future work should aim to further investigate the prevalence, clinical associations and treatment of these presentations.
Topics: Comorbidity; Dyspnea; Humans; Lung; Predictive Value of Tests; Respiration Disorders; Respiratory Mechanics; Risk Factors; Terminology as Topic
PubMed: 27581828
DOI: 10.1183/16000617.0088-2015 -
Pulmonology 2019The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to... (Review)
Review
BACKGROUND AND OBJECTIVE
The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients.
METHODS
We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed.
RESULTS
Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers.
CONCLUSION
Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this.
Topics: Analgesics, Opioid; Chronic Disease; Diuretics; Dyspnea; Electric Stimulation Therapy; Exercise Therapy; Furosemide; Humans; Noninvasive Ventilation; Oxygen Inhalation Therapy; Respiratory Tract Diseases; Steroids
PubMed: 31129045
DOI: 10.1016/j.pulmoe.2019.04.002 -
Anesthesiology May 2022
Topics: Dyspnea; Humans
PubMed: 34610089
DOI: 10.1097/ALN.0000000000004014 -
American Journal of Respiratory and... Apr 2022
Topics: Dyspnea; Humans; Respiration, Artificial
PubMed: 35134318
DOI: 10.1164/rccm.202201-0078ED -
Respirology (Carlton, Vic.) Feb 2023
Topics: Humans; Dyspnea
PubMed: 36450342
DOI: 10.1111/resp.14426