Breathlessness In Patients Research Articles

Dyspnoea in a patient with cirrhosis

This is an introduction to the Gut tutorial Dyspnoea in a patient with cirrhosis hosted on BMJ Learning—the best available learning website for medical professionals from the BMJ Group. Clinical...

Review: walking aids, chest-wall vibration, and neuroelectrical muscle stimulation relieve breathlessness in COPD

C Bausewein Dr C Bausewein, King’s College London, London, UK; claudia.bausewein@kcl.ac.uk In advanced disease, do non-pharmacological and non-invasive interventions relieve breathlessness? Studies selected evaluated non-pharmacological or non-invasive interventions for breathlessness...

N-Terminal pro B-type natriuretic peptide testing for short-term prognosis in breathless older adults

Background Amino-terminal pro–brain natriuretic peptide (NT-proBNP) is useful for the triage of patients with dyspnea. Our aim was to determine whether NT-proBNP levels could predict in-hospital outcome in breathless elderly patients. Methods At admission, NT-proBNP plasma concentrations were determined in 324 dyspneic patients aged 75 years and older. The association between NT-proBNP values and in-hospital mortality was assessed. Results Median NT-proBNP concentrations were not different in deceased patients (n = 43, 13%) compared to that of survivors (n = 281, 87%) (4354 vs 2499 pg/mL, respectively; P = .06). To predict in-hospital mortality, the optimum threshold of NT-proBNP was 3855 pg/mL, as defined by the receiver operating characteristic (ROC) curve, with a nonsignificant area under the ROC curve of 0.59. Mortality was significantly higher in patients (n = 139) with NT-proBNP levels 3855 pg/mL or higher (17.9% vs 9.7%, P = .045). After multivariate analysis, NT-proBNP level 3855 pg/mL or higher at admission was predictive of mortality (odds ratio, 2.41; 95% confidence interval, 1.02-5.68; P = .04). Conclusion NT-proBNP higher than 3855 pg/mL is associated with in-hospital mortality in patients aged 75 years and older admitted for dyspnea.

Access to Services for Patients with Chronic Obstructive Pulmonary Disease: The Invisibility of Breathlessness

The aim of this study was to explore the experience of breathlessness in patients with chronic obstructive pulmonary disease (COPD) through patients' accounts of their interactions with services. The study has a qualitative design based on Grounded Theory. Data were collected through semistructured, in-depth interviews over the period of July 2005 to March 2006. This was complemented by participant observation during outpatient consultations. NVivo software was used to manage and analyze the data. The study is part of a wider program, “Improving Breathlessness.” Data were collected in a large inner city teaching hospital and the community in London. A purposive sample of 18 COPD patients was selected. Fourteen patients were recruited from outpatient clinics in the hospital, four patients via a family doctor's surgery. Patients with moderate or severe COPD, who were experiencing problems with breathlessness, were included. The results showed that the low access to services by COPD patients is due to the nature of breathlessness itself, with its slow and surreptitious onset; patient interactions with the social environment assigning stigma to breathlessness; and the way the symptom is addressed by institutions, such as health care services, which discredit the patient's experience. The concept that best captures the experience of breathlessness is “invisibility.” Problems with access to care are an additional dimension of suffering added to the illness experience. A palliative care approach is promoted and essential priorities identified to reduce barriers to access.

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer

Background:Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available.Method:Patients...

Relief of Incident Dyspnea in Palliative Cancer Patients: A Pilot, Randomized, Controlled Trial Comparing Nebulized Hydromorphone, Systemic Hydromorphone, and Nebulized Saline

Acute episodic breathlessness in patients receiving palliative care is a distressing symptom with little evidence-base to inform management. This pilot, double-blind, controlled, crossover study compared the effects of nebulized hydromorphone, systemic hydromorphone and nebulized saline for the relief of episodic breathlessness in advanced cancer patients. On three occasions of acute breathlessness, patients randomly received either nebulized hydromorphone, a systemic breakthrough dose of hydromorphone or nebulized saline together with a blinding agent. Breathlessness was scored before and 10, 20, 30, and 60 minutes post-treatment completion using a 100 mm visual analog scale. Twenty patients completed the trial. Ratings did not differ significantly across pretest treatments. Change in ratings from pretest to 10 minutes after completion of nebulization (about 20 minutes after administration of systemic hydromorphone) indicated that each of the treatments resulted in statistically significant improvements in breathlessness, with no significant differences between treatments. Over time, breathlessness decreased significantly for all treatments, with no significant differences between treatments. Only nebulized hydromorphone produced a rapid improvement in breathlessness that reached a magnitude considered to be clinically important. Interpretation of these results is considered in relation to our definition of clinical significance, the dose of hydromorphone used and the possibility of a placebo effect. This study can serve to inform the design of future trials to investigate the management of incident breathlessness.

The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy

Intractable breathlessness is a common, devastating symptom of advanced cancer causing distress and isolation for patients and families. In advanced cancer, breathlessness is complex and usually multifactorial and its severity unrelated to measurable pulmonary function or disease status. Therapeutic advances in the clinical management of dyspnea are limited and it remains difficult to treat successfully. There is growing interest in the palliation of breathlessness, and recent work has shown that a systematic, evidence-based approach by a committed multidisciplinary team can improve lives considerably. Where such care is lacking it may be owing to therapeutic nihilism in clinicians untrained in the management of chronic breathlessness and unaware that there are options other than endurance. Optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family) with the use of parenteral opioids and sedation at the end of life when appropriate. Effective care centers on the patient's needs and goals. Priorities in breathlessness research include studies on: neuroimaging, the effectiveness of new interventions, the efficacy, safety, and dosing regimens of opioids, the contribution of deconditioning, and the effect of preventing or reversing breathlessness.

Prognostic role of echocardiography and brain natriuretic peptide in symptomatic breathless patients in the community

Brain natriuretic peptide (BNP), left ventricular (LV) systolic function, and mitral filling pattern (MFP) are prognostic indicators in patients with heart failure (HF). This study evaluated the potential role of E/Ea for predicting cardiovascular (CV) events in patients with suspected HF. This non-invasive measure of LV filling pressure has been shown to predict outcome in more advanced HF, but not in mild HF in the community. Two hundred and twenty-eight elderly symptomatic general practice patients (dyspnoea/oedema) were recruited and underwent clinical evaluation, NT-proBNP assay, and comprehensive echocardiography. The Kaplan-Meier analysis of time to first CV hospitalization or CV death was performed for 1 year after presentation according to nominated thresholds of LV systolic function, NT-proBNP, MFP, and E/Ea ratio. Mean age was 70.3 +/- 7.3 years, mean NT-proBNP was 111.4 +/- 185.8, and 148 (65%) were female. Twenty-six patients (11%) experienced a CV event within 18 months of baseline (6 deaths and 20 admissions). Time to first CV event predicted by NT-proBNP (P < 0.0001), MFP (P = 0.009), and E:Ea (P = 0.0076), but not EF (P = 0.098). When NT-proBNP was elevated, E:Ea >15 identified a group of patients with lower survival (P < 0.0001). Both E/Ea and NT-proBNP predicted hospitalization and when used in a two-step approach (NT-proBNP first, followed by E/Ea), the combination of both (elevated NT-proBNP and elevated E/Ea) identified those patients at highest risk, thus supporting a complementary approach for echocardiography and NT-proBNP in patients with HF symptoms.

Cardiorespiratory Requirements of the 6-Min Walk Test in Older Patients with Left Ventricular Systolic Dysfunction and No Major Structural Heart Disease

The six-minute walk test (6-MWT) is widely used to assess functional status in patients with chronic heart failure (CHF). The aims of the present study were: (1) to compare metabolic gas exchange during the 6-MWT in older patients with left ventricular systolic dysfunction (LVSD) and in breathless patients with no major structural heart disease (MSHD); (2) to determine the exercise intensity of the 6-MWT relative to peak oxygen uptake; (3) to establish the accuracy and reproducibility of the Metamax 3B ergospirometer during an incremental workload. Twenty four older patients with LVSD (19 male; age 76 +/- 5 years; BMI 27 +/- 4), and 18 patients with no MSHD (12 male; age 75 +/- 8 years; BMI 27 +/- 4) attended on consecutive days at the same time. Patients completed a 6-MWT with metabolic gas exchange measurements using the Metamax 3B portable ergospirometer, and an incremental cycle ergometry test using both the Metamax 3B and Oxycon Pro metabolic cart. Patients returned and performed a second 6-MWT and an incremental treadmill test, metabolic gas exchange was measured with the Metamax 3B. In patients with LVSD, the 6-MWT was performed at a higher fraction of maximal exercise capacity (p = 0.02). The 6-MWT was performed below the anaerobic threshold in patients with LVSD (83 %) and in patients with no MSHD (61 %). The Metamax 3B showed satisfactory to high accuracy at 10 W and 20 W in patients with LVSD (r = 0.77 - 0.97, p < 0.05), and no MSHD (r = 0.76 - 0.94, p < 0.05). Metabolic gas exchange variables measured during the 6-MWT showed satisfactory to high day-to-day reproducibility in patients with LVSD (ICC = 0.75 - 0.98), but a higher variability was evident in participants with no MSHD (ICC = 0.62 - 0.97). The Metamax 3B portable ergospirometer is an accurate and reproducible device during submaximal, fixed rate exercise in older patients with LVSD and no MSHD. In elderly patients with LVSD and no MSHD, the 6-MWT should not be considered a maximal test of exercise capacity but rather a test of submaximal exercise performance. Our study demonstrates that the 6-MWT takes place at a higher proportion of peak oxygen uptake in patients with LVSD compared to those with no MSHD, and may be one reason why fatigue is a more prominent symptom in these patients.

Promoting quality of life for patients with moderate to severe COPD

Understanding key components of good practice in the management of moderate and severe COPD is important for nurses working in the community. This article reviews the available evidence, which highlights the importance of smoking cessation, allowing breathless patients time to express themselves, encouraging exercise and timely palliative care. Additionally, evidence suggests that hospital-at-home can provide a safe alternative to hospital care and is the preference of some. However, more research is needed to provide evidence regarding the most effective smoking cessation programmes.

NT-proBNP levels, echocardiographic findings, and outcomes in breathless patients: results from the ProBNP Investigation of Dyspnoea in the Emergency Department (PRIDE) echocardiographic substudy

The objective of this study was to determine the integrative utility of measuring plasma NT-proBNP levels with echocardiography in the evaluation of dyspnoeic patients. Of 599 emergency department patients enrolled in a clinical study of NT-proBNP at a tertiary-care hospital, 134 (22%) had echocardiographic results available for analysis. Echocardiographic parameters correlating with NT-proBNP levels were determined using multivariable linear-regression analysis. Independent predictors of 1-year mortality were determined using Cox-proportional hazard analysis. Independent relationships were found between NT-proBNP levels and ejection fraction (P = 0.012), tissue Doppler early and late mitral annular diastolic velocities (P = 0.007 and 0.018), right ventricular (RV) hypokinesis (P = 0.006), and tricuspid regurgitation severity (P < 0.001) and velocity (P = 0.007). An NT-proBNP level <300 pg/mL had a negative predictive value of 91% for significant left ventricular systolic and diastolic dysfunction. Overall 1-year mortality was 20.1% and was independently predicted by NT-proBNP level [HR 8.65, 95% confidence interval (CI) 2.7-27.8, P = 0.0003], ejection fraction (HR 0.95, 95% CI 0.91-0.99, P = 0.009), RV dilation (HR 2.98, 95% CI 1.05-12.8, P = 0.04), and systolic blood pressure (HR 0.97, 95% CI 0.96-0.99, P = 0.01). NT-proBNP levels correlate with, and provide important prognostic information beyond, echocardiographic parameters of cardiac structure and function. Routine NT-proBNP testing may thus be useful to triage patients to more timely or deferred echocardiographic evaluation.

Simple sequential treatment for primary spontaneous pneumothorax: one step closer

Primary spontaneous pneumothorax (PSP) remains a significant clinical problem in emergency departments and respiratory medicine units. The management of minimally symptomatic patients presenting with their first small PSP on a chest radiograph is straightforward; a period of simple observation with follow-up chest radiography will usually suffice. Attempts to prevent recurrence at this stage are generally not recommended, as 50–70% of these patients will not have a recurrence 1–3. However, despite literature replete with discussions on the assessment and management of PSP, no standard approach to symptomatic or “large” PSPs has been universally adopted. Two significant guidelines for management of pneumothoraces have addressed this problem, one of which was evidence-based and the other consensus-based 4, 5. Objectives for managing these patients should be straightforward. Ideally, a diagnosis and treatment algorithm should be adopted that would predict those who need intervention. It should facilitate the treatment and discharge of a significant proportion of these patients in the emergency department without the need for hospital admission. It should also allow for continuing management of patients who require in-patient pleural drainage without further invasive procedures, until it becomes apparent that they have a persistent air leak necessitating surgical intervention. Finally, these young and otherwise fit patients should be managed in a setting that allows them to remain mobile during their pleural drainage. Predicting which patients require treatment for their PSPs seems relatively straightforward. Breathless patients or those with persistent significant chest pain should not be left without intervention, regardless of the size of the pneumothorax on the chest radiograph 4, 6. What is less apparent is when to intervene in clinically stable patients with large pneumothoraces. The definition of what constitutes a large pneumothorax varies, with the American College of Chest Physicians (ACCP) defining it as ≥3 cm …

Amino-Terminal Pro-Brain Natriuretic Peptide for the Diagnosis of Acute Heart Failure in Patients With Previous Obstructive Airway Disease

We evaluate results from amino-terminal pro-brain natriuretic peptide (NT-proBNP) testing with or without those of clinical judgment for the evaluation of dyspneic patients with previous chronic obstructive pulmonary disease or asthma. As a secondary analysis of previously collected observational data from a convenience sample of 599 breathless patients, 216 patients with previous chronic obstructive pulmonary disease or asthma who presented to the emergency department were analyzed according to results of NT-proBNP, clinical impression, and their final diagnosis. Test performance of NT-proBNP in these patients with chronic obstructive pulmonary disease or asthma was examined for the group as a whole, as well as in patients with and without previous heart failure. NT-proBNP results were compared to clinician-estimated likelihood for heart failure using receiver operating curves and as a function of NT-proBNP plus clinical evaluation. The final diagnosis was determined by 2 independent cardiologists blinded to NT-proBNP using all available data from the 60-day follow-up period. Overall, 55 patients (25%) had acute heart failure; the median value of NT-proBNP was higher in these patients compared with those without acute heart failure (2,238 vs 178 pg/mL); use of cut points of 450 pg/mL for patients younger than 50 years and 900 pg/mL for patients 50 years or older yielded a sensitivity of 87% (95% confidence interval [CI] 72% to 93%) and a specificity of 84% (95% CI 76% to 88%). In patients without previous heart failure (n=164), median NT-proBNP levels were also higher in patients with heart failure of new onset compared with those with chronic obstructive pulmonary disease or asthma exacerbation (1561 versus 168 pg/mL). High clinical suspicion for acute heart failure (probability >80%) detected only 23% of patients with new-onset heart failure, whereas 82% of these patients had elevated NT-proBNP levels. In patients who had both previous acute heart failure and chronic obstructive pulmonary disease or asthma (n=52), median NT-proBNP levels were significantly higher in those with acute heart failure (4,435 pg/mL) than patients with chronic obstructive pulmonary disease or asthma exacerbation (536 pg/mL). In patients with acute-on-chronic heart failure, NT-proBNP levels were elevated in 91%, whereas clinical impression considered only 39% of cases as high likelihood for acute heart failure. NT-proBNP may be a useful adjunct to standard clinical evaluation of dyspneic patients with previous obstructive airway disease.

Utility of Amino-Terminal Pro–Brain Natriuretic Peptide Testing for Prediction of 1-Year Mortality in Patients With Dyspnea Treated in the Emergency Department

Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for diagnosis and triage of patients with dyspnea, but its role for predicting outcomes in such patients remains undefined. A total of 599 breathless patients treated in the emergency department were prospectively enrolled, and a sample of blood was obtained for NT-proBNP measurements. After 1 year, the vital status of each patient was ascertained, and the association between NT-proBNP values at presentation and mortality was assessed. At 1 year, 91 patients (15.2%) had died. Median NT-proBNP concentrations at presentation among decedents were significantly higher than those of survivors (3277 vs 299 pg/mL; P<.001). The optimal NT-proBNP cut point for predicting 1-year mortality was 986 pg/mL. In a multivariable model, an NT-proBNP concentration greater than 986 pg/mL at presentation was the single strongest predictor of death at 1 year (hazard ratio [HR], 2.88; 95% confidence interval, 1.64-5.06; P<.001), independent of a diagnosis of heart failure. Other factors associated with death included age (by decade; HR, 1.20), heart rate (by decile; HR, 1.13), urea nitrogen level (by decile; HR, 1.20), systolic blood pressure less than 100 mm Hg (HR, 1.94), heart murmur (HR, 1.92), and New York Heart Association classification (HR, 1.38 for each increase in class). The NT-proBNP concentration alone had an area under the receiver operating characteristic curve (AUC) of 0.76 for predicting mortality; the other significant covariates combined had an AUC of 0.80. The final model for predicting death, combining NT-proBNP with other covariates associated with mortality, had a superior AUC of 0.82. In addition to assisting in emergency department diagnosis and triage, NT-proBNP concentrations at presentation are strongly predictive of 1-year mortality in dyspneic patients.

A Rare Case of Cardiac Tamponade Due to Metastatic Cancer of the Prostate

Cardiac tamponade is a potentially life-threatening condition that is not uncommon in the oncology setting. Massive pericardial effusion occurring due to metastatic prostatic carcinoma is very rare and only a handful of cases have been reported in literature till date. We report one such case, review literature and stress on keeping this rare diagnosis as one of cause of breathlessness in patients with prostate cancer.

The use of B‐type natriuretic peptide in the management of elderly patients with acute dyspnoea ( J Intern Med 2005;258:77–85)

Dear Sir, The findings of the above study [1] would have been more readily applicable to routine clinical practice if the radiographic stigmata of acute left ventricular failure (LVF) had also been documented, using parameters which have not only been found to be positively correlated with B-type atrial natriuretic factor, but have also proved to be highly predictive of LVF itself [2]. Coupled with a categorization of the patients into those with subnormal left ventricular ejection fraction (LVEF) and those with intact LVEF, the inclusion of radiographic stigmata as well as the radiographic response to antifailure therapy would have considerably enhanced our understanding of left ventricular diastolic failure in addition to validating the therapeutic trial as an alternative diagnostic tool in the evaluation of the acutely breathless patient with normal LVEF. No conflict of interest was declared.

Managing breathlessness

Kay Holt explains the diagnosis and treatment options when managing breathlessness in patients

Palliative care for breathless patients in the community

Breathlessness is one of the commonest symptoms experienced by people receiving palliative care. However, misunderstanding of the nature of palliative care may hinder assessment, management and evaluation of care and may contribute to the fear associated with living with breathlessness in the community. Knowledge of related anatomy and physiology of breathlessness is vital in informing nursing care and interventions. Pharmacological interventions have their place, but the focus of nursing care should be on systematic holistic assessment. Using this, nurses should adopt a proactive role in supporting and helping patients to adapt to change by maximizing coping strategies.

Core–peripheral temperature gradient as a diagnostic test in dyspnoea

Objectives: To evaluate whether the core–peripheral temperature gradient could be used to distinguish between cardiac and respiratory causes of dyspnoea. Methods: In total, 50 patients were enrolled in the study,...

Use of Upper Limb Exercise to Assess Breathlessness in Patients with Cancer: Tolerability, Repeatability, and Sensitivity

We report the development of an arm exercise test to assess breathlessness in patients with lung cancer who are breathless at low levels of exertion. Exercise consisted of raising the arm over 40 cm, either the dominant arm only (n = 10) or both arms alternating at minute intervals (n = 12). Subjects breathed through a mouthpiece, and ventilation ( V ˙ E) and oxygen uptake ( V ˙ O 2) were measured. Following familiarization, three tests were performed over one week to explore repeatability, and sensitivity was assessed in a fourth test. Arm exercise was generally well tolerated and increased breathlessness, V ˙ E, and V ˙ O 2. The commonest factor limiting exercise was arm fatigue, although four patients in the two-arm test also reported breathlessness. Repeatability for breathlessness score and V ˙ E was best in the two-arm test. The added resistance used to assess sensitivity could not be detected. The two-arm test offers a potential means of assessing the effects of an intervention on breathlessness and E in patients for whom a cycle or treadmill exercise test is unsuitable.