Continuing Education Column Dyspnea Jung Hyun Chang, M.D. Department of Respiratory Medicine Ewha Womans University College of Medicine, Mokdong Hospi

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Dyspnea Jung Hyun Chang, M.D. Department of Respiratory Medicine Ewha Womans University College of Medicine, Mokdong Hospital E mail : hs1017@ewha.ac.kr Abstract Dyspnea is one of the most common respiratory symptoms and is a term to indicate a subjective experience of breathing discomfort. Most patients with dyspnea can be categorized into two groups: respiratory system dyspnea and cardiovascular system dyspnea. The underlying mechanisms encompass variable interactions of physiological, psychological, social, and environmental factors. Among these physiologic mechanisms are most important. Respiratory system dyspnea derives from stimulation of central or peripheral chemoreceptor, stimulation of mechanoreceptor, motor commands of cerebral cortex, afferent mismatch and/or neuromechanical dissociation due to derangements in the central controller, the ventilatory pump, and gas exchanger. Cardiovascular system dyspnea derives from impaired oxygen delivery and oxygen utilization due to cardiac disease, anemia, and deconditioning. The objective scales and standardized measurements for the subjective expression of dyspnea have been commonly used. The proper evaluation and treatment of dyspnea have to be planned taking underlying diseases and accompanying physiologic mechanisms into consideration. Keywords : Dyspnea; Respiratory; Cardiovascular; Physiological; Chemoreceptor 254

Efferent signals Afferent signals Motor cortex Effort() Sensory cortex Chemoreceptors Effort Air hunger Brainstem( ) Upper airway Upper airway Chest tightness Ventilatory muscles (9) 255

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Borg Medical Research Council Rating Intensity of sensation Grade 1 Breathless with strenuous exercise 0 Nothing at all Grade 2 Short of breath when hurrying on the level or walking 0.5 Very, very slight (just noticeable) up a slight hill 1 Very slight Grade 3 Walk slower than people of the same age on the 2 Slight level or stop for breath while walking at own pave 3 Moderate on the level 4 Somewhat severe Grade 4 Stop for breath after walking about 100 yards or 5 Severe after a few minutes on the level 6 Grade 5 Too breathless to leave the house or breathless 7 Very severe when dressing or undressing 8 9 Very, very severe (almost maximal) 10 Maximal 260

Descriptions Grade Degree Not troubled by shortness of breath when hurrying on the level or walking up a slight hill Troubled by shortness of breath when hurrying on the level or walking up a slight hill Walks more slowly than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level Stops for breath after walking about 100 yard or after a few minutes on the level Too breathless to leave the house; breathless on dressing or undressing 0 1 2 3 4 None Mild Moderate Severe Very severe 261

11. American Thoracic Society. Dyspnea. mechanisms, assessment, and management: a consensus statement. Am J Respir Crit Care Med 1999; 159: 321-40 12. Higgins M. Epidemiology of obstructive pulmonary disease. In: Cassaburi R, Petty TL, eds. Principles and practice of pulmonary rehabilitation. Philadelphia: WB Saunders, 1993 13. Moy ML, Woodrow WJ, Sparrow D, Israel E, Schwartzstein RM. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med 2000; 162: 451-5 262

14. Schwartzstein RM, Manning HL, Weiss JW, Weinberger SE. Dyspnea: a sensory experience. Lung 1990; 168: 185-99 15. Hamilton AL, Killian KJ, Summers E, Jones NL. Muscle strength, symptom intensity and exercise capacity in patients with cardiorespiratory disorders. Am J Respir Crit Care Med 1995; 152: 2021-31 16. Fishman AP. Approach to the patient with respiratory symptoms. In: Fishman AP, ed. Fishman's pulmonary diseases and disorders. 3rd ed. New York: McGrawHill, 1998: 366-70 17. Gifl AG, Cahill CA. Psychophysiologic aspects of dyspnea in chronic obstructive pulmonary disease: A pilot study. Heart Lung 1990; 19: 252-7 18. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, McCullough PA, et al. Rapid measurement of Btype natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347: 161-7 19. Schwartzstein RM. Approach to the patient with dyspnea. In: UpToDate. 12(3) ed. UpToDate, 2004 10. Killian KJ, Gandevia SC, Summers E, Campbell EJ. Effect of increased lung volume on perception of breathlessness, effort and tension. J Appl Physiol 1984; 57: 686-91 11. O Donnell DE, Bertley JC, Chau LK, Webb KA. Qualitative aspects of exertional breathlessness in chronic airflow limitation: pathophysiologic mechanisms. Am J Respir Crit Care Med 1997; 155: 109-15 12. Silvestri GA, Mahler D. Evaluation of dyspnea in the elderly patients. Clin Chest Med 1993; 14: 393-404 13. Simon PM, Schwartzstein RM, Weiss JW, Fencl V, Teghtsoonian M, Weinberger SE. Distinguishable types of dyspnea in patients with shortness of breath. Am Rev Respir Dis 1990; 142: 1009-14 14. Paul WJ. Breathlessness. In: Gibson GJ, ed. Respiratory Diseases. 3rd ed. China: Elsevier Science, 2003: 285-90 15. Adams L, Chronos N, Lane R, Guz A. The measurement of breathlessness induced in normal subjects: validity of two scaling techniques. Clin Sci 1985; 69: 7-16 16. Fletcher CM, Elmes PS, Fairbairn AS, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 5147: 257-66 17. McGavin CR, Artvinli M, Naoe H, McHardy GJ. Dyspnea, disability and distance walked: comparison of estimates of exercise performance in respiratory disease. Br Med J 1978; 2: 241-3 18. Mahler D, Rosiello R, Harver A, Lentine T, McGovern JF, Daubenspeck JA. Comparison of clinical dyspnea ratings and psychological measurements of respiratory sensation in obstructive airway disease. Am Rev Respir Dis 1987; 135: 1229-33 19. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF, Wasserman K. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis 1991; 143: 9-18 20. Swinburn CR, Wakefield JM, Jones PW. Relationship between ventilation and breathlessness during exercise in chronic obstructive airway disease is not altered by prevention of hypoxemia. Clin Sci 1984; 67: 515-9 21. Thomas RL, Stoker GL, Ross JC. Efficacy of pursedlips breathing in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1966; 93: 100-6 22. Swinburn CR, Mould H, Stone TN, Corris PA, Gibson GJ. Symptomatic benefit of supplemental oxygen in hypoxemic patients with chronic lung disease. Am Rev Respir Dis 1991; 143: 913-5 23. Light RW, Muro JR, Sato RI, Stanburry DW, Fischer CE. Effects of oral morphine on breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease. Am Rev Respire Dis 1989; 139: 126-33 24. Sibuya M, Yamada M, Kanamaur A, Tanaka K, Suzuki H, Homma I, et al. Effect of chest wall vibration on dyspnea in 263

patients with chronic respiratory disease. Am J Respir Crit Care Med 1994; 149: 1235-40 25. Winning AJ, Hamilton RD, Shea SA, Knoff C, Guz A. The effect of airway anaesthesia on the control of breathing and the sensation of breathlessness in man. Clin Sci 1985; 68: 215-25 26. Schwartzstein RM, Lahive K, Pope A, Weinberger SE, Weiss normal subjects. Am Rev Respir Dis 1987; 136: 58-61 27. Roussos C, Macklem PT. The respiratory muscles. N Engl J Med 1982; 307: 786-97 28. Smoller JW, Pollack MH, Otto MW, Rosenbaum JF, Kradin RL. State of the art: panic anxiety, dyspnea and respiratory disease. Am J Respir Crit Care Med 1996; 154: 6-17 JW. Cold facial stimulation reduces breathlessness induced in 264