Pathophysiology of dyspnea in COPD

Dyspnea refers to the sensation of breathlessness, shortness of breath, or difficulty breathing that is commonly observed in patients with respiratory and cardiac disease. In the United States alone, dyspnea is reported in up to 4 million all-cause emergency room visits annually. Dyspnea can be a symptom of several different underlying physical conditions, typically involving the lung and heart. Indeed, it is an important symptom in chronic obstructive pulmonary disease (COPD), where it is associated with limited physical activity, increased anxiety and depression, decreased health-related quality of life (HRQoL), and reduced survival. Currently there is no single physiological correlate that will accurately predict dyspnea, particularly because the mechanisms that contribute to respiratory discomfort can vary between diseases and between individuals experiencing breathlessness who have been diagnosed with the same disease. Therefore, various subjective clinical and psychophysical scales and questionnaires are typically used to measure or predict dyspnea. It is the goal of this review to discuss the pathophysiological mechanisms leading to dyspnea, particularly those associated with COPD, the physical and psychological impact on patients, assessment approaches, and modalities currently used to treat it.     

Use of self-efficacy and dyspnea perceptions to predict functional performance in people with COPD.

This correlational and comparative study explored whether self-reports of self-efficacy and dyspnea perceptions predict the perceived level of functional performance in adults who have chronic obstructive pulmonary disease (COPD). The convenience sample included 97 Caucasian men (52) and women (45). Participants had to have a forced expiratory volume in 1 second (FEV1) of less than 70% predicted, and a FEV1/forced vital capacity (FVC) of less than 70%. Participants were recruited from pulmonary function laboratories and from better breather support groups in a Midwestern state. Three standardized, self-report instruments, COPD Self-Efficacy Scale (CSES), the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ), and Functional Performance Inventory (FPI) were used to measure the participants' self-report of their perceptions of self-efficacy, dyspnea, and functional performance. Dyspnea predicted 38.1% of the variance in functional performance, with self-efficacy contributing an additional 6.5% to the variance in the total sample. Self-efficacy predicted 36.5% of the variance in functional performance in men, with dyspnea contributing an additional 7.2% to the variance. However, in women, only dyspnea was a significant predictor of functional performance, at 48.5% when both dyspnea and self-efficacy were entered as independent variables. To improve patients' perceptions of functional performance, nurses can use methods such as breathing techniques and upper- and lower-body exercises that increase optimal management of dyspnea. Nurses may increase the self-efficacy of managing dyspnea by helping patients master breathing techniques and exercise through coaching and providing vicarious experiences through patient support groups or pulmonary rehabilitation programs.     

有氧运动对老年慢性阻塞性肺疾病康复的影响

[目的]观察有氧运动对老年慢性阻塞性肺疾病(COPD)呼吸困难和生活质量的影响。[方法]将86例老年COPD病人随机分成观察组42例和对照组44例,对照组给予常规治疗和一般康复护理,观察组在对照组的基础上给予有氧运动康复干预,疗程均为12周,对两组病人在康复前后测评呼吸困难分级和圣乔治呼吸问卷(SGRQ)评分进行比较。[结果]两组病人在康复治疗后的呼吸困难评分和SGRQ总分均较治疗前降低,差异有统计学意义(P0.01),观察组治疗后的呼吸困难改善效果更为突出,与对照组相比评分差异有统计学意义(P0.05)。[结论]有氧运动可改善老年COPD病人的呼吸困难、提高病人的生活质量。     

Relationship between symptoms and functional performance in COPD

We studied the relationships among functional performance and three symptoms--dyspnea, fatigue, and sleep difficulty--in a sample of 100 people with chronic obstructive pulmonary disease (COPD). All participants had an FEV(1) 60% or less of the predicted level for age, sex, and height. Consistent with the Theory of Unpleasant Symptoms, dyspnea correlated with both fatigue and sleep difficulty. Dyspnea and fatigue both had moderate negative correlations with functional performance, while sleep difficulty had a small nonsignificant negative correlation with functional performance. After controlling for age and oxygen use, dyspnea was the only symptom to predict variance in functional performance significantly. Of the three symptoms studied, only dyspnea was related to both the other symptoms and to functional performance. Focusing on dyspnea may be the best way to improve both symptom experience and functional performance in people with COPD.     

Daily functioning of dyspnea,self-esteem and physical self in patients with moderate COPD before,during and after a first inpatient rehabilitation program

Purpose. Inpatient rehabilitation improves dyspnea and increases self-esteem between admission and discharge in patients with moderate chronic obstructive pulmonary disease (COPD). Some researchers nevertheless argue that the changes may be due to nursing effects and thus that scores will decrease quickly at home after discharge. This study assessed the change in dyspnea, self-esteem and physical self mean scores and stability in patients with moderate COPD during three consecutive four-week periods: at home, during an inpatient rehabilitation program, and again at home post-discharge.

Methods. Twenty-three consecutive patients [63.9 years (SD 6.6)] with moderate COPD [FEV₁ = 55.8% (SD 13.2)] were included. The participants responded to the Physical Self Inventory and rated dyspnea using a visual analogue scale twice a day. Exercise tolerance was assessed with the six-minute walk test (6MWT) at admission and discharge.

Results. 6MWT performance improved between admission and discharge [452.3 m. (SD 74.0) vs. 503.3 m. (SD 80.4), p < 0.001]. Dyspnea ratings improved (p < 0.001), as did the self-esteem and physical self scores between the two home periods (p < 0.001). The group showed less instability (SD and range) in their assessments of physical self-worth at home post-discharge compared to pre-admission (p < 0.01). Before rehabilitation, the correlation coefficients between dyspnea, and self-esteem, the perceptions of physical condition and attractive body were all significant. After rehabilitation, the coefficients between dyspnea, and perceived physical condition, physical strength and sport competence were significant (p < 0.05).

Conclusions. The results suggest that a first rehabilitation program increases the mean physical self scores in patients with moderate COPD and decreases their instability; the program also improves dyspnea. However, the impact of rehabilitation was greater on specific perceptions of physical abilities than on the global self-esteem. Randomized controlled trials are needed to confirm these changes, which were probably due to rehabilitation program.     

血浆N-末端脑钠肽前体水平对急性呼吸困难的诊断意义

目的:探讨血浆N-末端脑钠肽前体(NT-proBNP)水平变化在急性心源性呼吸困难(心力衰竭)与非心源性呼吸困难患者中诊断和鉴别诊断的临床意义。方法:选取以呼吸困难为主诉来我院急诊的患者110例,分为心源性呼吸困难组64例,非心源性呼吸困难组46例,采用酶联免疫吸附法(ELISA)检测血浆NT-proBNP水平。结果:心源性呼吸困难各亚组与非心源性呼吸困难组血浆NT-proBNP水平差异有统计学意义(P<0.01);心源性呼吸困难组中不同NYHA心功能分级的患者血浆NT-proBNP水平差异有统计学意义(P<0.01),心功能分级越差,NT-proBNP水平越高;以NT-proBNP水平600ng/L作为临界值,血浆NT-proBNP水平对于心源性呼吸困难诊断的敏感性很高(93.75%),但特异性略差(69.56%)。结论:快速检测血浆NT-proBNP用来诊断心力衰竭特别是左心衰可靠、稳定、敏感、快捷,可作为急性呼吸困难病因鉴别的一个重要检查方法。     

Evaluating the effects of music on dyspnea during exercise in individuals with chronic obstructive pulmonary disease: a pilot study.

In this study, we examined the effects of music on the dyspnea and anxiety experienced by people with chronic obstructive pulmonary disease (COPD) when they are walking. A crossover design was used. Patients walked for 10 minutes without music and for 10 minutes while listening to music. The order of the interventions was determined by chance. The levels of perceived dyspnea (modified Borg scale) and anxiety (State-Trait Anxiety Inventory-State) were measured at baseline (before a 6-minute walk), at pretest (after that walk and before the 10-minute walks), and after the walks. Thirty subjects with a mean age of 70 +/- 7 years participated in the study. There were no differences in dyspnea or anxiety levels between the walks with music and with no music (p > 0.05). Despite some positive trends, this study did not provide conclusive evidence to support the efficacy of listening to music during exercise; further research is needed to support this intervention.     

足反射区疗法对稳定期COPD患者运动耐力和呼吸困难症状的影响

目的 探讨足反射区疗法对稳定期慢性阻塞性肺疾病(COPD)患者运动耐力和呼吸困难症状的影响.方法 将60例稳定期COPD患者随机分为试验组与对照组.对照组进行常规护理,试验组在对照组的基础上进行足反射区疗法干预3个月.干预前后对两组患者的运动耐力和呼吸困难症状进行评价比较.结果 干预3个月后试验组测量6 min步行距离(6 MWD)明显提高(提高幅度为31.77±10.89 m),且将试验组与对照组试验后6 MWD的提高幅度即6 MWD差值进行组间比较,二者存在统计学显著差异(P<0.01);试验组患者的呼吸困难症状改善情况明显优于对照组,差异有统计学意义(P<0.05).结论 足反射区疗法能提高稳定期COPD患者的运动耐力,改善呼吸困难症状.     

心钠素对急性呼吸困难的诊断和鉴别诊断意义

目的：探讨心钠素在急性呼吸困难中的诊断和鉴别诊断意义。方法：急性呼吸困难患者110例,测定血浆心钠素水平,以ANP=0．29pg／I,为阳性界定值对其诊断心衰的价值进行评价。结果：心衰患者ANP明显高于非心衰患者,以ANP=0．29pg／L为阳性界定值,ANP诊断心源性呼吸困难的敏感性为95．00％,特异性为88．64％,阳性预测值为86．36％,阴性预测值为95．12％。结论：ANP对于诊断和鉴别诊断急性呼吸困难,具有重要意义。     

连续无创血流动力学监护在呼吸困难鉴别诊断中的作用

目的　探讨连续无创血流动力学 (IQ )监护在呼吸困难病因鉴别诊断中的作用。方法　根据患者出院诊断分为肺源性呼吸困难组 (对照组 ,4 8例 )和心源性呼吸困难组 (心力衰竭组 ,38例 )。在患者入院时及病愈后分别进行 IQ监护 ,比较出院与入院诊断的符合情况及两次 IQ指标的变化。结果　 1临床诊断 :在入院时 ,心力衰竭组有 7例被漏诊 ,诊断为肺炎 (5例 )和慢性阻塞性肺疾病 (COPD,2例 ) ;对照组中有 1例(气胸 )误诊为心力衰竭。 2心功能指标 :心力衰竭组基础阻抗 (Zo)、阻抗变化最大速率 (dz/ dt m ax)、Heather指数 (HI)显著低于对照组 (P均 <0 .0 0 1) ,其值分别为 (19.0± 3.5 ) Ω比 (2 8.8± 5 .5 ) Ω,(0 .76± 0 .4 2 ) Ω/ s比(1.4 0± 0 .72 )Ω / s和 (7.0 4± 4 .2 5 )Ω / s2 比 (13.6 0± 6 .36 )Ω / s2 。在呼吸困难的患者中 ,若 Zo值≤ 2 2Ω ,诊断心力衰竭的敏感度为 79% ,特异度为 94 % ;若 Zo值≤ 18Ω ,则诊断心力衰竭的敏感度为 4 7% ,特异度为 10 0 %。3组内比较 :对照组治疗前后心功能指标没有明显变化 ,心力衰竭组中 Zo、dz/ dt m ax、HI、每搏出量 (SV )、加速收缩指数 (ACI)在病愈后有上升恢复趋势 ,皆具统计学意义。 4左室射血前期 (PEP)、左室射血时间 (VET)在上述各组中均无     

呼吸操训练对慢性阻塞性肺疾病患者预后的影响研究

目的 观察呼吸操训练对慢性阻塞性肺疾病(COPD)患者肺功能、生活质量及急性发作次数的影响.方法 干预组及对照组各30例,观察时间为1年.对照组采用常规护理方法,观察组在此基础上进行呼吸功能训练护理干预,两组均在出院前和出院后1年检测肺功能和生活质量,同时通过电话、复诊、上门随访等方法随访1年,记录患者病情变化情况.结果 经1年干预后,干预组患者的肺功能、生活质量、急性加重及再次住院的频率与干预前、对照组比较有明显改善,差异具有统计学意义(P<0.05).结论 呼吸操训练能改善COPD患者肺功能,延缓肺功能进一步恶化,提高患者的生活质量,改善预后,值得临床推广.

Abstract：

Objective To observe breathing exercises for patients with COPD on pulmonary function, quality of life and the number of acute attacks.Methods Sixty patients with COPD were randomly divided into intervention group (n=30) and control group (n=30) for 1-year observation period. Traditional care was applied in control group,and breathing exercises nursing intervention was added to intervention group.In both groups, the patients' pulmonary function and quality of life were measured before and after discharge for 1 year.The progress of patients' conditions were recorded by telephone, return visit, follow-up visits for 1 year.Results After intervention by 1 year, in intervention group the patients' lung function, quality of life and the number of exacerbation and readmission were significant improved as compared to control group and before intervention, the difference was statistically significant (P<0.05).Conclusions The breathing exercises can improve pulmonary function, delay further deterioration of lung function, improve quality of life of patients and the prognosis, it is worthy of promotion.     

Effects of morphine on the dyspnea of terminal cancer patients

We report, an open, uncontrolled study designed to assess the effects of subcutaneous (SC) morphine on dyspnea of terminal cancer. Twenty patients with dyspnea caused by restrictive respiratory failure received an SC dose of morphine of 5 mg (5 patients who were not receiving narcotics), or equivalent to 2.5 times their regular dose (15 patients who were receiving narcotics for pain). Dyspnea (D) and pain (15 cases) were measured before the dose and every 15 min for 150 min after the injection using a visual analog scale 0–100. Respiratory rate (RR), respiratory effort (RE) (score 1–6), arterial saturation of O₂ (SO₂) and end-tidal PACO₂ were determined before and 45 min after SC morphine. D, RR, RE, SO₂, and PACO₂ were 68 ± 32, 32 ± 7; 3.5 ± 1.8, 87 ± 10, and 31 ± 12, respectively, before SC morphine, and 34 ± 25 (P < 0.001), 31 ± 9 (P:NS), 3.2 ± 1.9 (P:NS), 86 ± 11 (P:NS), and, 33 ± 9 (P:NS), respectively, 45 min after SC morphine. Nineteen of 20 patients (95%) reported improved dyspnea after morphine. We conclude that morphine appears to improve dyspnea without causing a significant deterioration in respiratory function in terminal cancer patients. Double-blind placebo controlled studies are needed in this population.     

Cardiometabolic biomarkers are predictors of readmission and death in patients hospitalized for acute dyspnea

Background

Acute dyspnea affects a large heterogeneous patient group with high mortality and readmission rates.

Usefulness of B-type natriuretic peptide in elderly patients with acute dyspnea

Objective Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is particularly difficult in elderly patients. The aim of our study was to evaluate B-type natriuretic peptide (BNP) in patients older than 65 years presenting with acute dyspnea.Design Prospective study.Setting Medical emergency department of a 2000-bed urban teaching hospital.Patients Patients aged over 65 years presenting with acute dyspnea and a respiratory rate more than 25/min or a PaO₂ below 70 mmHg, SpO₂ less than 92%, PaCO₂ higher than 45 mmHg with pH less than 7.35, were included. BNP levels, measured blind at admission were compared with the final diagnosis (CPE or no CPE) as defined by experts.Intervention None.Measurements and results Three hundred eight patients (mean age of 80 years) were enrolled in the study. The median BNP was 575 pg/ml [95% confidence interval (CI): 410–898] in the CPE group (n=141) versus 75 pg/ml (95% CI: 59–98) in the no CPE group (n=167) (p<0.001). The best threshold value of BNP was 250 pg/ml, with a sensitivity and specificity for CPE of 0.78 (95% CI: 0.71–0.84) and 0.90 (95% CI: 0.84–0.93), respectively. The area under the ROC curve was 0.874±0.081 (p<0.001). The accuracy of BNP-assisted diagnosis was higher than that of the emergency physician (0.84 versus 0.77, p<0.05).Conclusion Analysis of BNP is useful in elderly patients with acute dyspnea, but the threshold value is higher than that previously determined.Presented, in part, at the 30^th annual congress of the Société de Réanimation de Langue Française, Paris, January 2002 (abstract no. SP 94).     

氟西汀治疗甲状腺功能亢进伴情感障碍患者的临床观察

目的　探讨氟西汀对甲状腺功能亢进患者情感障碍的疗效。方法　将 5 0例符合《中国精神障碍分类与诊断标准》第3版 (CCMD 3)抑郁症诊断标准的甲状腺功能亢进患者随机分为研究组 2 5例 ,在应用治疗甲状腺功能亢进药物的基础上联合抗抑郁剂氟西汀 2 0mg·d-1;对照组 2 5例 ,仅应用治疗甲状腺功能亢进药物治疗。疗程 8w。采用SDS ,SAS评定疗前及治疗4、8w末抑郁焦虑症状减分率 ,并于治疗前及治疗 8w末测定TT3 、TT4含量评定甲状腺功能亢进疗效 ,全部数据采用t检验。结果　经 8w治疗 ,研究组各期SDS、SAS评分及TT3、TT4值较对照组下降明显 ,差异有显著性 (P <0 .0 5～ 0 .0 1) ;两组疗前与疗后 8w末SDS、SAS、TT3、TT4比较 ,差异有极显著性 (P <0 .0 1)。结论　氟西汀不仅能改善甲状腺功能亢进患者的抑郁、焦虑情绪 ,还能促使原发病的康复     

医院焦虑抑郁量表对慢性阻塞性肺疾病患者焦虑抑郁情绪筛查价值的研究

目的：探讨医院焦虑抑郁量表在慢性阻塞性肺疾病（chronic obstructive pulmonary disease,COPD）患者焦虑、抑郁情绪筛查中的应用价值,并评估其信度和效度。方法：应用横断面研究方法,选择COPD住院患者200例,对其进行问卷调查。结果：获得有效问卷189份。医院焦虑抑郁量表（HADS）中焦虑、抑郁亚量表得分分别与焦虑自评量表、抑郁自评量表得分呈正相关（P<0.01）;以焦虑自评量表和抑郁自评量表作为诊断“金标准”分别绘制焦虑亚量表和抑郁亚量表的ROC曲线,其曲线下面积分别为0.823（95%CI：0.752~0.881）和0.906（95%CI：0.847~0.948）;医院焦虑抑郁量表总表、焦虑亚量表及抑郁亚量表的内部一致性系数的Cronbach's α分别为0.89, 0.76, 0.83;HADS得分水平与生活质量指数量表呈负相关,证明了其构念效度（P<0.05）。结论：医院焦虑抑郁量表可以可靠、有效地筛查COPD患者的焦虑、抑郁情绪,可以提高临床医务人员对患者不良情绪的筛查效能。     

急诊非器质性呼吸困难患者焦虑抑郁状态分析

目的 探讨急诊非器质性呼吸困难患者焦虑抑郁状态及相关影响因素.方法 连续人选中国医科大学北京顺义区医院急诊科与首都医科大学附属北京朝阳医院急诊科2014年1月1日至2014年5月30日急诊就诊的主诉呼吸困难患者,经过诊疗以后最终诊断为非器质性呼吸困难患者80例,其中68例同意进行心理测评.采用综合医院焦虑抑郁评分量表对68例非器质性呼吸困难患者行心理测评,评价焦虑和抑郁的发生率,对性别、年龄、受教育程度、情绪波动等影响因素进行分析.结果 68例患者中,焦虑患者22例,占32.4％,抑郁患者14例,占20.6％.女性、中学以下学历、就诊前情绪波动以及非本地居民来源者焦虑抑郁发生率更高(P＜0.05).Logistic回归分析结果显示中学以下学历、就诊前情绪波动和非本地居民来源均是发生焦虑、抑郁的主要影响因素.结论 对于急诊非器质性呼吸困难患者,在进行急诊常规诊疗的同时,应重视患者心理因素,必要时应该建议患者求助心理干预.     

掌上超声诊断仪对胸闷、胸痛急诊患者的针对性检查

目的评价掌上超声诊断仪对急诊胸痛、胸闷患者进行超声心动图检查、快捷诊断和初筛的临床价值。 方法选择2014年1至10月中国医学科学院阜外医院收治的271例急诊患者。应用美国GE Vscan型掌上超声诊断仪进行床旁超声心动图检查,主要评估心腔内径、左心室收缩功能、节段性室壁运动异常,心包以及升主动脉等。所有患者均在应用美国GE Vscan型掌上超声诊断仪检查之后,再应用美国GE Vivid i型超声心动图检查仪进行检查。采用χ²检验比较Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查结果差异;采用独立样本t检验比较Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪、高年资医师与低年资医师检查用时差异。 结果掌上超声诊断仪能对全部271例患者进行清晰成像。经Vscan型掌上超声诊断仪扫查确诊,存在节段性室壁运动异常者91例,左心室收缩功能减低者37例,心包积液3例,升主动脉夹层14例;其余患者超声心动图检查结果未提示存在室壁运动异常或收缩功能异常。Vscan型掌上超声诊断仪在评价节段性室壁运动异常及左心室收缩功能异常各漏诊1例,但Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查结果差异无统计学意义（χ²=0.03,P>0.05）。每个患者的检查时间为1~5 min,Vscan型掌上超声诊断仪与Vivid i型超声心动图检查仪检查用时差异也无统计学意义（t=-1.478,P>0.05）。应用Vscan型掌上超声诊断仪检查时,高年资医师比低年资医师检查用时短,且差异有统计学意义[（2.6±1.4）min vs （3.5±1.8）min,t=-2.41,P<0.05]。 结论对于以胸闷、胸痛等为主诉就诊的急诊患者,其临床诊断不明确且体格检查等结果为阴性时,掌上超声诊断仪能够有针对性的快速、准确评价心脏解剖结构、功能以及血流动力学状态,从而指导有效治疗,避免漏诊,具有重要的临床应用价值。