Dyspneic Symptoms Research Articles

A Case report of Cardiac Beriberi: A Commonly Misdiagnosed Disease

Thiamine deficiency, or beriberi, is relatively rare in countries like Somalia, where alcohol consumption is uncommon and is usually related to alcohol abuse and chronic illnesses such as cancer. Despite that fact, it is necessary to ask the patients about their bad habits to unmask the etiology of the disease. A 30-year-old male who had been abusing alcohol and smoking heavily for the last six years presented with lower extremity edema, fatigue on exertion, and heart palpitations within a month. Previously there was no known chronic disease and immunosuppression drugs use, nor any documented family history of any heart disease. Upon inspection, He had a chronically ill-looking appearance but was oriented to time, place, and person. His vital signs were a blood pressure of 115/80 mm Hg, heart rate of 110 beats/min, and body temperature of 36.5℃. Peripheral oxygen saturation was around 97% without oxygen support, despite having subjective dyspneic symptoms. Transthoracic echocardiography showed LV global hypokinesia with severe reduction in LV systolic function (as demonstrated by an LV ejection fraction of 30%). Empirical oral Thiamine 200mg replacement was initiated emergently as a thiamine test was not available. Within ten days of thiamin supplement and heart failure medications, including furosemide 20mg, Aldactone 25mg, and carvedilol 6.25mg, the ejection fraction improved up to 45% also, the fatigues and dyspnea were also highly improved. We identified that heavy alcoholic drinking induced heart failure with reduced ejection fraction and that thiamine supplements improved these circumstances.

A Case of Multidisciplinary Approach to Post-Radiotherapy Dilative Cardiomyopathy Undergoing Elective Cesarean Delivery: Anesthetic and Intensive Care Management

Cardiovascular diseases are the most common non-obstetric cause of maternal death. These cases became more common thanks to the improvement in cardiovascular therapies. A multidisciplinary team is necessary to manage these pregnancies. A 32 years old women at the 25th week of gestation for acute heart failure in pre-existing left ventricular dysfunction induced by radio-chemotherapy admitted to the Coronary Unit of IRCCS Policlinico Universitario Agostino Gemelli for worsening of dyspneic symptoms and anuria not responding to diuretic therapy. At the echocardiogram: ejection fraction 30%, enlarged left atrium, systolic pulmonary arterial pressure 38 mmHg, bilateral pleural effusion, bilateral diffused pulmonary B lines. A multidisciplinary team composed by cardiologists, gynecologists, anesthesiologists, cardiac surgeons, neonatologists and bioethicists decided for an elective cesarean delivery at the 27th week of gestation in the hybrid cardio-thoracic operating theater. Anesthesia was provided by combined spinal-epidural technique under invasive continuous hemodynamic monitoring with the Edwards Lifesciences HemoSphere with Hypotension Prediction Index (HPI) and ForeSight technology (Edwards Lifesciences, Irvine, USA) through catheterization of the left radial artery. The femoral arteries were left available for extracorporeal circulation. Continuous norepinephrine infusion was started once liquor was collected in the spinal needle at a 0.1 mcg/kg/minute through a central line and was continued until the end of surgery. Fluid management consisted of a total of 200 ml of crystalloids. HPI values never reached alarm values (maximum value =10). The patient was discharged home on the 5th day after delivery with good hemodynamic compensation. The baby was intubated at birth and then gradually weaned from mechanical ventilation, then discharged.

Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients.

As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.

Assessment of Immune-Related Interstitial Lung Disease in Patients With NSCLC Treated with Immune Checkpoint Inhibitors: A Multicenter Prospective Study.

Programmed cell death protein 1 immune checkpoint inhibitors (ICIs) have been reported to improve the survival of patients with NSCLC. On the expansion of clinical administration for a variety of cancers, immune-related adverse events have been typically recognized to be associated with ICIs, therefore, necessitating the monitoring and management of these patients. Among immune-related adverse events, immune-related interstitial lung disease (ir-ILD) is a serious complication that interrupts treatment and can occasionally be fatal. However, no prospective studies have investigated the incidence of ir-ILD and associated risk factors for its development in the clinical setting. This is a prospective cohort study consisting of patients with NSCLC treated with ICIs. Baseline characteristics, including laboratory data, pulmonary function tests, daily symptoms of dyspnea defined by the modified Medical Research Council, and antitumor response were assessed. Among the 138 patients with NSCLC who received anti-programmed cell death protein 1 monotherapy, 20 patients (14.5%) had ir-ILD within median 51.5 days (interquartile range: 29-147). This was approximately three times higher than those in clinical trials. A total of 11 patients (55.0%), including all eight patients with high-grade ir-ILD (≥grade 3), developed ir-ILD within 60 days. Impaired spirometry, decreased forced vital capacity and forced expiratory volume in 1 second, and daily symptoms of dyspnea measured using the modified Medical Research Council scale were identified as risk factors for ir-ILD development. In addition, combination assessment of forced vital capacity and forced expiratory volume in 1 second successfully classified patients at risk for ir-ILD development. The incidence of ir-ILD was substantially higher in the clinical setting. Assessment of spirometry and daily dyspneic symptoms before ICI treatment may be useful in monitoring and managing patients with NSCLC.

Bifocal Right Ventricular Pacing: Alternative to Biventricular Pacing for Cardiac Resynchronization Therapy?

A 59-year-old patient with dilated cardiomyopathy, severe systolic left ventricular dysfunction and drug-refractory advanced heart failure (New York Heart Association-NYHA class III-IV symptoms) and prior history of mitral valve replacement was scheduled for implantation of a biventricular pacing system (cardiac resynchronization therapy-defibrillator or CRT-D device). The coronary sinus was cannulated after some effort and a venous coronary angiogram was performed. Although a posterolateral cardiac venous branch was identified to accommodate the left ventricular pacing lead, placement of the lead in this tributary was accompanied by phrenic nerve stimulation, which could not be remedied by moving to more proximal positions where the lead could not be stabilized. Having no other option except for sending the patient to surgery for epicardial lead placement, albeit most difficult and high-risk procedure due to prior history of cardiac surgery, we attempted bifocal right ventricular pacing by placing the composite pacing-defibrillating lead at a low septal position and the left ventricular lead at a very high right ventricular (RV) outflow tract position. The procedure was otherwise uncomplicated and the patient’s post-procedural course remained uneventful. The patient had a good clinical response to this type of bifocal RV pacing over the subsequent days and months with amelioration of his dyspneic symptoms and improvement of his quality of life. At the three-year follow-up he remains in NYHA class II category.

Experiential, autonomic, and respiratory correlates of CO2 reactivity in individuals with high and low anxiety sensitivity

Psychometric studies indicate that anxiety sensitivity (AS) is a risk factor for anxiety disorders such as panic disorder (PD). To better understand the psychophysiological basis of AS and its relation to clinical anxiety, we examined whether high-AS individuals show similarly elevated reactivity to inhalations of carbon dioxide (CO2) as previously reported for PD and social phobia in this task. Healthy individuals with high and low AS were exposed to eight standardized inhalations of 20% CO2-enriched air, preceded and followed by inhalations of room air. Anxiety and dyspnea, in addition to autonomic and respiratory responses were measured every 15s. Throughout the task, high AS participants showed a respiratory pattern of faster, shallower breathing and reduced inhalation of CO2 indicative of anticipatory or contextual anxiety. In addition, they showed elevated dyspnea responses to the second set of air inhalations accompanied by elevated heart rate, which could be due to sensitization or conditioning. Respiratory abnormalities seem to be common to high AS individuals and PD patients when considering previous findings with this task. Similarly, sensitization or conditioning of anxious and dyspneic symptoms might be common to high AS and clinical anxiety. Respiratory conditionability deserves greater attention in anxiety disorder research.

Efficacy of Guided Imagery With Theta Music for Advanced Cancer Patients With Dyspnea: A Pilot Study

Dyspnea is a frequent and devastating symptom among advanced cancer patients for which improved and low-cost palliative techniques are needed. A one-group repeated measures research design investigated the efficacy of guided imagery (GI) with theta music (M) on dyspnea in advanced cancer patients. The intervention consisted of four periods: (a) pretest; (b) intervention with peaceful non-M; (c) intervention with 10 min of GI with M (GI/M), with the first and last 3 min being M only (i.e., the middle 4 min was GI/M); and (d) posttest. Dyspnea outcome was measured with the Modified Borg Scale (MBS) for self-reported evaluation of dyspneic symptoms. Physiological parameters measured were pulse oxygen saturation (SpO(2)), end-tidal CO( 2) (EtCO(2)), heart rate (HR), and respiratory rate (RR). Posttest qualitative data were obtained via interview for subjective patient experience. Participants included 53 patients, 33% with lung cancer. GI/M produced a significant decrease in MBS scores; 90% of the subjects gave positive qualitative reviews of GI/M. SpO(2) did not change significantly over time. GI/M significantly increased EtCO(2), decreased RR, and decreased HR. This study demonstrates that GI/M is a useful intervention for palliative care of patients with dyspnea. M alone was demonstrated to be effective, while soothing non-M was not effective. GI/M was more effective than M alone. GI/M should be considered low-cost end-of-life palliative care for dyspnea.

Changes in respiratory function after thyroplastic surgery

Conclusions. A certain degree of subclinical extrathoracic airway compromise may ensue after thyroplastic surgery, although none of the patients reported the presence of dyspneic symptoms in their normal daily lives. Objectives: To determine the effects of thyroplastic surgery on respiratory function and compare them with the improvement of vocal function. Patients and methods: The study included 53 patients; 7 had type I thyroplasty (type I), 9 had arytenoid adduction (AA), 10 had AA with type I, and 27 had AA with neuromuscular pedicle flap implantation (NMP). Phonatory and respiratory functions were measured preoperatively and postoperatively. The presence of dyspnea during daily activities was determined postoperatively. Results: The difference between the pre- and postoperative values was statistically significant in five comparisons. Forced expiratory volume in 1 s/forced expiratory volume (FEV1%) in the AA with type I group, FEV1/peak expiratory flow rate (PEFR) in the AA group, and PEFR in the three groups (type I, AA, and AA with NMP). Forty-six patients associated with AA were combined for statistical analysis. The differences were statistically significant for FEV1%, PEFR, and FEV1/PEFR. Changes in maximum phonation time (MPT) were found to have a significant correlation with changes in FEV1/PEFR. All the patients denied episodes of dyspnea during their normal daily activities.

The Difference of Interpretations of Cardiopulmonary Exercise Testing According to Interpretative Algorithms and Exercise Methods

Background : Recently, cardiopulmonary exercise testing (CPX) has become a popular diagnostic method for differentiating the main cause of exertional dyspnea or exercise limitation. We evaluated the difference in the CPX results according to interpretative algorithms and the methals of exercise in Korea. Method : Sixty-six patients with chronic lung disease and 48 adults with dyspneic symptoms, but with no abnormalities in a spirometry performed symptom limited CPX, were included in this study. The results were interpreted using both Wasserman's(WA) and Eschenbacher's algorithm (EA), and a comparison between both algorithms was made. Thirty-three healthy medical students performed the CPX with a cycle ergometer and treadmill. The results were interpreted with EA and the concurrence in interpretations was evaluated accord ing to the methods of exercise. Results : 1. In patients with chronic lung disease, the overall concordance rate between the two algorithms was 63.6%. The concordance rates waw 69.8% in patients with obstructive, 25.0% in those with restrictive, and 66.7% in those with mixed pulmonary insufficiency. In patients with dyspneic symptoms but normal findings in resting spirometry, the concordance rate was 60.4%. 2. In healthy medical students, in results inter preted with EA, the concordance rate between the cycle ergometer and treadmill exercise was 25.0%. Conclusion : Both interpretative algorithms and methods of exercise may affect the CPX results. In using CPX as a diagnostic test for the causes of dyspnea in the Korean population. the interpretative algorithms and method of exercise need to be standardized, and a predictive max equation needs to be established.

Breaking the news in amyotrophic lateral sclerosis.

Telling the diagnosis to patients with amyotrophic lateral sclerosis (ALS) is a daunting task for any neurologist. Obviously, breaking the news in ALS is not a standardizable procedure. However, proven techniques exist to reduce the trauma to the patient and ease the burden on the doctor, thus reducing the risk of burnout and the tendency to 'pull away' from the patient. Such communication skills are of fundamental importance to clinical practice and should be more prominent in medical teaching. The way the patient is told the diagnosis is now recognized to be the first and one of the most delicate steps in palliative care. Information is best offered in a stepwise fashion at the patient's pace with an emphasis on positive aspects, and in the presence of the patient's family. Reviewing available therapeutic options and current research efforts may foster hope for the future, while pointing out that almost all symptoms of ALS can be alleviated by palliative therapy may help to reduce fears. Encouraging patients to ask questions and disclose anxieties is important for their psychological wellbeing. Available options for mechanical ventilation should be reviewed early enough to allow for unhurried decision-making. We believe that the terminal phase of the disease should be discussed at the latest when dyspneic symptoms appear, in order to prevent unwarranted fears of 'choking to death'.

Considerations in patient education in amyotrophic lateral sclerosis (ALS)

Given the relentless progression of amytrophic lateral sclerosis (ALS) and the lack of causative therapy, breaking the news to ALS patients and their families is a daunting task for any physician. Obviously, such a task cannot be standardized. However, it is now recognized to be the first and one of the most sensitive and important steps in palliative care. Information should be offered in a stepwise fashion, in the presence of the patient's family. All questions from the patient should be discussed openly, with emphasis on the positive aspects. Available therapeutic options should be reviewed, pointing out the fact that all symptoms of ALS can be alleviated by palliative therapy. At the onset of dyspneic symptoms, the terminal phase of the disease and the option of mechanical ventilation should be discussed.

Vocal Cord Dysfunction Presenting as “Steroid-Dependent” Asthma

Objective: To describe a case of paroxysmal vocal cord dysfunction (PVCD) in a patient presenting with an initial diagnosis of severe asthma. Case Summary: A 42-year-old obese white woman with a 5-year history of severe asthma symptoms was referred to The Ohio State University Comprehensive Asthma Outpatient Clinic. The patient said she had experienced frequent “asthma attacks” despite increased use of multiple asthma medications. Additionally, she often required nebulization therapy with bronchodilators and supplemental oxygen, and had a variable response. During the clinic visit, the patient presented with clear airways uncharacteristic of a person with severe asthma. A diagnosis of PVCD was made on the basis of results of videolaryngostroboscopy, and asthma medications were gradually discontinued. Setting: The Ohio State University Comprehensive Asthma Outpatient Clinic. Discussion: Patients with PVCD often present with symptoms characteristic of asthma. As a result, misdiagnosis of severe asthma often occurs, and the patient undergoes unnecessary treatment. The cornerstone for diagnosis of PVCD is laryngoscopic viewing of the adducted vocal cord during an acute attack. Following diagnosis, treatment for PVCD includes a multidisciplinary approach that includes speech therapy and psychiatric counseling. Pharmacologic therapy in patients with pure PVCD is not required, thus preventing medication-related morbidity and associated costs. Conclusions: PVCD must be considered in patients who are refractory to asthma therapy and have dyspneic symptoms out of proportion to observed clinical findings. We suggest that all patients with episodes of acute asthma undergo objective testing to document acute airway obstruction. Oral corticosteroid therapy and treatment-associated morbidity can be avoided in patients with PVCD if the appropriate diagnosis is made early.

Effects of exposure to NO2or SO2on bronchopulmonary reaction induced byCandida albicansin guinea pigs

The effects of NO2 or SO2 on the bronchopulmonary reactions induced by Candida albicans in guinea pigs were evaluated. Thirty-six guinea pigs (3 groups of 12 animals each) were sensitized with intraperitoneal injection of 10 mg of C. albicans, given twice. Two groups of animals were exposed to about 5 ppm of NO2 or SO2 for 4 h/d, 5 d/wk; this exposure was conducted a total of 30 times during the study. The third group served as the control and was not exposed to these pollutants. Two weeks after the second sensitization, all the animals were subjected to inhalation exposure to C. albicans. For 42 h after the antigen challenge, the respiratory rates and expiration/inspiration ratios of the animals were automatically monitored. The number of animals showing tachypnea was significantly higher in the NO2 exposure group than in the control from 15 h after antigen challenge. In the SO2 exposure group, the number of animals showing prolonged expiration or prolonged inspiration, or both, was significantly higher than that in the control group, and the symptoms were observed from approximately 15 h after antigen challenge. These findings showed that delayed-type dyspneic symptoms in guinea pigs were increased by exposure to NO2 or SO2, although the symptoms and degree of dyspnea were different for the two gases.