How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease

Abstract

Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg’s 0–10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.

Hypoxic and Hyperoxic Breathing as a Complement to Low-Intensity Physical Exercise Programs: A Proof-of-Principle Study

“…The Borg rating of the perceived exertion scale (RPE scale) is a frequently used quantitative measure of perceived exertion during physical activity, useful to assess the subjective intensity of a workout session. In medicine, this is considered a reliable marker for clinical diagnosis of breathlessness and dyspnea, chest pain, angina, and musculo-skeletal pain [31].…”

Evaluation of the Clinical Effectiveness of the Salmeterol/Fluticasone Fixed-Dose Combination Delivered via the Elpenhaler® Device in Greek Patients with Chronic Obstructive Pulmonary Disease and Comorbidities: The AEOLOS Study

“…Notably, the mMRC is an important independent predictor of 1-and 5-year mortality in COPD patients [25] with a study showing mMRC to be a better predictor of death than airway obstruction [26][27][28][29]. For this reason, GOLD 2020 recommends the use of the mMRC for categorizing COPD burden and guiding its management [2,30]. Furthermore, a domain-level analysis of Patient-Reported Outcomes (PRO) measures showed that breathlessness and its impact on patients were the most interpreted reported domains [31].…”

Tests to uncover and assess breathlessness: a proposed framework

“…(3) Standardized instructions and procedures (to optimize repeatability and validity of the performance and/or ratings) (4) Assessment of breathlessness by self-report using a validated scale (as the sensation cannot be accurately inferred from proxies or biomarkers as of yet). Suitable scales may be a Borg 0-10 (CR10) scale, 0-10 NRS, or 0-100 VAS [18]. (5) Reliability and validity for the population and setting of use (6) Acceptable burden, requirements and costs for implementation…”

“…Activity and function is often limited by the level of breathlessness (‘symptom threshold’). An apt illustration is during symptom-limited exercise testing, such as cardiopulmonary exercise testing (CPET) or 6-min walk test, where the level of breathlessness at the end of the test (the tolerated level) is quite similar between people – and cannot even readily distinguish healthy people from those with severe disease [ 12 , 17 , 18 ]. However, the level of exertion (workload or power output) needed to provoke that symptom level differ markedly from health to people with increasing disease severity and deconditioning [ 19 ].…”