Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions

Figures & data

Figure 1 Inter-relationships of dyspnea.

Note: Reprinted from Chest, 147, Mahler DA and O'Donnell DE, Recent advances in dyspnea, 232–241, Copyright (2015), with permission from Elsevier.16
Abbreviations: PaCO₂, partial pressure of carbon dioxide; PaO₂, partial pressure of oxygen; VCO₂, volume of carbon dioxide.

Table 1 Assessment tools for dyspnea

Questionnaire	Overview	Practice considerations
Baseline Dyspnea Index, Transition Dyspnea Index^Citation45–Citation47	Multidimensional scales designed to provide information on the individual components of dyspnea: Functional impairment Magnitude of task Magnitude of effort needed to evoke dyspnea Baseline Dyspnea Index rates the severity of dyspnea at baseline, whereas Transitional Dyspnea Index quantifies changes from baseline	Most commonly used as a research tool in clinical trials Assesses the impact of an intervention Can be interview-based or self-administered
Chronic Respiratory Questionnaire^Citation81	20-item measure Four aspects are examined: dyspnea, fatigue, emotional function, and mastery	Self-administered version available Not a dyspnea-specific measure
Clinical COPD Questionnaire^Citation26,Citation82	10-item measure divided into three domains: symptoms, functional, and mental state Questions focus on symptoms during the past week, including dyspnea symptoms and their impact on physical, daily, and social activities	Recommended by GOLD Most commonly used as a research tool in clinical trials Correlates well with SGRQ Not a dyspnea-specific measure
COPD Assessment Test^Citation26,Citation83	Eight items, three relevant to dyspnea, to measure the impact of COPD on well-being and day-to-day activities Five-point Likert scale determines the level of breathlessness after walking up a hill or one flight of stairs, and assesses the extent of activity limitation at home	Recommended by GOLD to evaluate symptoms, including dyspnea; scoring ≥10 indicates a high level of symptoms (equivalent to SGRQ score ≥25) Not a dyspnea-specific measure
Dyspnea-12^Citation84,Citation85	12-item measure across physical (seven items) and affective (five items) domains Items are scored on a scale of 0 (none), 1 (mild), 2 (moderate), or 3 (severe) Total scores range 0–36, with high scores indicating greater severity	Self-administered Asks patients to reflect on how they are experiencing dyspnea in their daily lives, rather than in response to a specific activity
mMRC breathlessness scale^Citation26,Citation86,Citation87	Five statements that describe almost the entire range of respiratory disability from “none“ (grade 0) to “almost complete incapacity“ (grade 4) The MRC scale does not quantify breathlessness itself but enables a numeric value to be placed on exercise capacity	Recommended by GOLD to evaluate symptoms, including dyspnea. Grade ≥2 signifies a high level of symptoms Self-administered; patients choose a phrase that best describes their condition Widely used in clinical practice
Multidimensional Dyspnea Profile^Citation88	11-item measure that assess dyspnea across a sensory domain and two affective domains (unpleasantness and emotional response) Designed to examine individual items that are thought to be aligned to separate mechanisms	Can be self-administered, with support of HCP or trial investigator
SGRQ^Citation26	50-item measure divided into two parts Scores range from 0 to 100, with higher scores indicating greater limitation; a score of ≥25 is used as a threshold for considering regular treatment of symptoms	Recommended by GOLD Too complex for use in routine practice, but often used in clinical studies Not a dyspnea-specific measure
UCSD SOBQ^Citation89	24-item measure Assesses self-reported shortness of breath while performing various daily activities If the activities listed are not typically performed by the patient, the patient is asked to estimate the degree of shortness of breath that they would anticipate when completing the specified task Three additional items ask about limitations due to shortness of breath, fear of harm from overexertion, and fear of shortness of breath	Self-administered Provides comprehensive assessment of dyspnea, but its length may present a less practical option than other measures for day-to-day clinical use

Abbreviations: GOLD, global initiative for chronic obstructive lung disease; HCP, healthcare professional; mMRC, modified Medical Research Council; MRC, Medical Research Council; SGRQ, St George’s respiratory questionnaire; UCSD SOBQ, University of California, San Diego shortness of breath questionnaire.

Figure 2 Paradigm to optimize control of dyspnea.

Abbreviation: PR, pulmonary rehabilitation.

Table 2 Unmet needs in the management of dyspnea in COPD

Unmet need	Current situation
Measurement of dyspnea with validated tools	Reliance on patients’ self-reporting symptoms Lack of a validated patient-reported outcome measure
Blood markers for assessment and treatment of dyspnea	Although some physiological markers (lung volume, lung hyperinflation measures, diffusion capacity, and oxygen saturation) have been identified, there are no blood markers for dyspnea
Consensus on dyspnea assessment	No universally agreed upon measure of dyspnea
Further studies on the underlying mechanisms of dyspnea	Understanding of neurophysiological mechanisms of dyspnea is incomplete
Multicenter, prospective, randomized controlled studies of interventions for dyspnea	Lack of agreed-upon, standardized measure of dyspnea Lack of evidence base for existing and new dyspnea-relieving therapies
Further studies of the efficacy of self-management strategies and active palliation approaches	Lack of consistent guidance on the best ways to address self-limiting behaviors and optimize end-of-life care

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