Issues in pulmonary nursingDescriptors of dyspnea by patients with chronic obstructive pulmonary disease versus congestive heart failure
Introduction
Dyspnea, or breathlessness, is the most common symptom reported by patients with chronic obstructive pulmonary disease (COPD)1 and congestive heart failure (CHF)1, 2, 3 seeking medical help. Patients with COPD and CHF are reported to use unique terms when describing breathlessness.4, 5, 6 It has been proposed that these terms are sufficiently unique to be used to diagnose various abnormalities and patient response to treatment.6 These same studies however, have been inconsistent in identifying the terms patients use within various diagnostic categories. Before adopting the notion of unique terms among diagnostic groups, greater clarity about the terms patients use to communicate their breathlessness is required. We therefore studied the differences in both the reported and the volunteered terms patients use to describe dyspnea in 2 diagnostic groups: COPD and CHF patients. We anticipated that the selection of terms from the standardized list4 would be similar to those reported in the literature. Furthermore, we anticipated that the terms volunteered (without benefit of prompting from a list) by patients would be similar to this standardized list.
Dyspnea, breathlessness, and shortness of breath are interchangeable terms used by health care providers to describe reports by patients of breathing discomfort. Patients, however, may not understand or even use these terms to describe their breathing discomfort. For example, though dyspnea may be a common term used by health care providers to describe the breathing distress of patients, rarely do patients use this term. Yet, health care providers often make clinical judgments about the decline or improvement in the patient's condition on the basis of patient reports of symptoms.7 During the past decade, attempts have been made to understand the differences in specific terms patients use to describe their breathing discomfort.1, 4, 5, 6, 8, 9 Given the differences in pathophysiology of conditions producing dyspnea, one would anticipate that descriptors of dyspnea would also differ. In fact, subjects with various disease states such as cardiopulmonary, vascular, neurological, etc., have been reported to use different terms to describe their breathing discomfort. Terms with similar meanings, grouped into clusters (Table 1), have been reported as unique to various pathophysiologic conditions.4
Unique terms have been identified for diagnostic categories among studies, however there is inconsistency in these unique terms between these studies (Table 2). Terms patients use to describe breathlessness may be influenced by many factors: severity of disease,9 race or ethnicity,10 culture, gender,11 emotions,11 level of comprehension, geographic differences in terms used, terms patients learn from interacting with health care providers, local terminology and patient recall. However, recent evidence12, 13 suggests that patient recall is for the most part accurate in COPD patients.
In addition, the frequency and intensity of dyspnea in COPD and CHF subjects has not been fully described. There are no known reports of the differences in frequency of dyspnea between these groups. Improved understanding of dyspnea experienced in COPD and CHF and the language used by patients with these conditions could allow clinicians to intervene quickly to potentially modify the physiologic conditions precipitating the symptoms. Thus, a better understanding of the language used by COPD and CHF patients may provide additional guidance for clinicians in the timely treatment of these conditions.
The purposes of this study were to determine if differences existed between reports of dyspnea in stable COPD and CHF patients in: (1) terms selected (endorsed) from a standard list of terms to describe breathing discomfort; (2) terms patients use (volunteer) to describe breathing discomfort; and (3) frequency and intensity of dyspnea in COPD and CHF patients.
Section snippets
Study site and population
The study took place at a medical center in the Southwest. Subjects attending the subspecialty clinics for COPD and CHF were approached on the day of their outpatient visit. All data was collected from the patient and by the same investigator (AC) in a quiet area of the clinic. Subjects were told this was a study to understand words patients use to describe their breathing discomfort. The majority of subjects were interviewed after seeing the clinician. The purpose of the study and the consent
Results
Seventy-three subjects were evaluated for participation in the study. Sixty subjects met the inclusion criteria, 30 with an established diagnosis of COPD and 30 with CHF. Subjects were all males and predominantly white (83%). The COPD subjects were significantly older (68 vs 61.1 years of age, P < .01) than CHF subjects (Table 3). Ninety-seven percent of COPD and 80% of CHF subjects reported having a history of smoking. Of those with COPD who smoked, all had quit, whereas 17% of the CHF
Discussion
Our findings are consistent with the reports of others in that there were both differences and similarities in terms used by COPD and CHF subjects in describing breathlessness. Our findings, however, do not necessarily support the uniqueness of terms among the COPD and CHF populations. In this study, the only term unique to these 2 groups was from the exhalation cluster. COPD subjects endorsed terms from the exhalation cluster more frequently than CHF subjects. This cluster has been previously
Summary
We found that stable COPD and CHF patients recognize a variety of terms that they feel describe their breathing distress. There was, however, only one term (my breath does not go out all the way) from the exhalation cluster that was unique to either diagnosis (COPD). When patients were asked to volunteer terms, both groups identified a variety of terms that they felt best described their breathing when it is uncomfortable. Few of these terms were identified in the standard list of descriptors.
Acknowledgements
The authors wish to thank the following persons for their assistance in the development of the manuscript: J Anholm, MD, E Bossert, RN, PhD, M Burns, RN, PhD, K Busby, MD, R Crowell, MD, F De La Cruz, LA Hawkins, RN, NP, PM Meek, RN, PhD, Kristi Morrow, M Parshall, RN, PhD, NL Specht, MD, and L Van Cleve, RN, PhD.
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2011, Current Opinion in PharmacologyCitation Excerpt :Specifically, a single descriptor of dyspnea was less accurate in stratifying individuals with or without COPD [15]. In addition, when comparing dyspnea descriptors it was found that many of the terms identified by CHF patients were shared by COPD patients except for one; patients with COPD selected the phrase “my breath does not go out all the way” more frequently than did CHF patients [15]. This may reflect that COPD patients tend to have greater derangements in pulmonary mechanics than do CHF patients and the contributing factors are different between the two diseases.