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Subsequently, the patients underwent spirometry and six-minute walk tests 6MWTs , with determination of the six-minute walk distance 6MWD , as well as initial and final SpO2. Keywords: Pulmonary disease, chronic obstructive; Spirometry; Dyspnea; Exercise tolerance. It is clinically characterized by cough, expectoration, wheezing, dyspnea, and exercise intolerance. Dyspnea is a symptom associated with exercise performance and, therefore, quality of life. One of the major goals of COPD treatment is a reduction in dyspnea.
The severity of the disease can be determined by the intensity of dyspnea. Inspiratory capacity is related to lung hyperinflation, which is a basic mechanism of dyspnea in COPD, and therefore correlates with dyspnea. Each of these instruments has its strong points and weak points. The exclusion criteria were as follows: presenting with dyspnea due to any cause other than COPD; using supplemental oxygen, since these patients have difficulty in performing the 6MWT; being unable to perform the 6MWT; being unable to answer the dyspnea questionnaires and scales; being unable to perform the pulmonary function tests; presenting with exacerbation in the last three months; and presenting with radiological abnormalities indicative of other conditions.
A total of 29 patients were excluded for various reasons. When patients returned, they underwent the following: 1 Formoterol inhalation-The recommended dose of formoterol was inhaled in the presence of the researcher.
Prebronchodilator tests were not performed then. An anterograde multivariate regression model was applied in order to determine which dyspnea scales and functional parameters correlated better with the 6MWD. The 6MWD values were expressed in absolute values, since several of the predicted values tested presented residuals that correlated with the anthropometric data. The two patients who presented with grade 0 dyspnea as assessed by the mMRC scale had reported dyspnea before the treatment given during the study.
In 12 patients, there was a significant variation in postbronchodilator FVC. The general and functional data of the patients are shown in Table 1. The measurements obtained with the dyspnea scales and questionnaires, as well as those derived from the 6MWT, are shown in Table 2. The correlation matrix between the BODE index, the dyspnea scale scores, and the dyspnea questionnaire scores is shown in Table 3. The correlation coefficients rs between the various measurements of dyspnea ranged from 0.
Weaker but significant correlations were observed among the scores on the remaining dyspnea scales. Inspiratory capacity, expressed in absolute values, did not correlate with any of the dyspnea scales evaluated. The same occurred when inspiratory capacity was expressed as a percentage of the predicted value data not shown. The anthropometric data age and height correlated with the 6MWD. These data were included, together with the various dyspnea scales, in an anterograde multivariate regression model in order to determine their effect on the 6MWD.
The final model selected three variables. The first variable that was selected was the BDI, with a coefficient of determination of 0. Other dyspnea scales were not selected. A similar procedure was used in order to correlate the 6MWD with the anthropometric variables, the functional variables in absolute values , and the post-6MWT SpO2.
Only inspiratory capacity was selected by the model, with a coefficient of determination of 0. Discussion The results of the present study indicate that the evaluation of symptomatic patients with COPD should take into account multiple variables, which, although interrelated, express different aspects of the disease. Cases such as these should not be excluded from COPD studies.
Dyspnea is a sensation of respiratory discomfort and is therefore a symptom. The evaluation of the degree of dyspnea provides an independent dimension that is not provided by pulmonary function tests or by measuring dyspnea in an exercise laboratory. The degree of dyspnea influences and predicts health-related quality of life, as well as survival, more broadly than do physiological measurements.
In patients with COPD, dyspnea can occur due to dynamic hyperinflation, neuromechanical dissociation, gas exchange abnormalities, and inspiratory muscle weakness, as well as to cognitive and psychological influences. None of the instruments that are currently available to evaluate dyspnea address all aspects of this symptom. There are unidimensional scales, such as the VAS and the Borg scale, which take into account only one aspect of dyspnea, activity-based unidimensional scales the mMRC scale and the OCD , and indirect, multidimensional scales, such as the BDI and the SOBQ, which are also activity-based but address various other aspects of dyspnea.
The dyspnea scales are validated i. The various dyspnea scales were developed in order to quantify limitations in the activities of daily living due to dyspnea, and interrelations among the scales are therefore expected. These findings are not surprising. The Borg scale and the VAS are useful for measuring dyspnea after a certain task, such as an exercise test.
These instruments are useful in measuring dyspnea at a given time point. However, they play a limited role in longitudinal measurements. The MRC scale has been used for decades.
Subsequently, the ATS published a revised version, designated the mMRC scale, in which dyspnea grades range from 0 to 4. Because it evaluates only the dyspnea that is related to specific activities, the scale does not allow a multidimensional evaluation of dyspnea.
In addition, the mMRC scale does not readily detect changes in the degree of dyspnea after a therapeutic intervention. One group of authors developed a dyspnea scale divided into two parts: baseline dyspnea the BDI and transition dyspnea. The scale is divided into three categories: functional impairment; magnitude of task; and magnitude of effort. The category "functional impairment" evaluates whether dyspnea has resulted in limitations or incapacity related to activities of daily living or work.
Similarly to the mMRC scale, the category "magnitude of task" evaluates the types of tasks that provoke dyspnea. The category "magnitude of effort" evaluates to what degree patients can exert themselves without experiencing dyspnea, including whether they must frequently interrupt a habitual activity that involves repeated effort. The Transition Dyspnea Index ranges from 0 severe to 4 no impairment in each category, and the total score therefore ranges from 0 to 12 points.
Three additional questions, also on a 6-point scale limitations in daily living due to dyspnea, fear of becoming ill during excessive effort, and fear of dyspnea , are included, totaling 24 items.
The total score ranges from 0 to To our knowledge, the present study is the first to use the SOBQ in Brazil, and the correlations we found between this questionnaire and the remaining dyspnea scales were similar to those reported in a study conducted in the United States, 10 suggesting that the SOBQ is valid for use in Brazil. In the aforementioned study, 10 patients with COPD and airflow obstruction ranging from mild to severe were evaluated.
The results showed that, of the various dyspnea scales evaluated, the SOBQ and the BDI presented the highest levels of reliability and validity. In the present study, there was a strong correlation between these two instruments, and both showed better correlations with FEV1, SpO2, and 6MWD than did the remaining scales. Inspiratory capacity at rest in absolute values did not correlate with any of the dyspnea scale scores. In COPD patients, inspiratory capacity decreases during exertion, such as that occurring during walk tests, 25 even in patients with mild obstruction.
In another study conducted in Brazil, 27 inspiratory capacity was the best predictor of 6MWD. In a review of the application of dyspnea and quality of life scales in COPD, 29 it was concluded that a unidimensional scale can be used if applied in conjunction with specific quality of life scales.
Alternatively, a multidimensional scale, which correlates better with quality of life, can be used. The BDI can be used for that purpose. The advantage of this questionnaire is that it evaluates the emotional aspect of dyspnea, which the other instruments do not address.
The results of the present study underscore the fact that the correlations between functional parameters and dyspnea are weak. In addition, we can conclude that multidimensional instruments are required in order to quantify dyspnea during the monitoring of outpatients with COPD and chronic dyspnea.
The use of such instruments can guide decisions regarding the treatment of these patients and thereby improve the prognosis. Acknowledgments We would like to thank William M. Vollmer, PhD, director of the Methods in Epidemiologic Clinical and Operations Research course, for his invaluable guidance throughout the development of this study.
We would also like to thank Iolanda Fernandes Mackeldey, nursing assistant and pulmonary function test technician, for her aid in carrying out the tests.
References 1. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - update.
Can Respir J. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc. J Bras Pneumol. Reproducibility of visual analog scale measurements of dyspnea in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. Ferris BG. Dyspnoea, disability, and distance walked: comparison of estimates of exercise performance in respiratory disease. Br Med J.
The measurement of dyspnea. Contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Reliability and validity of dyspnea measures in patients with obstructive lung disease.
Int J Behav Med. Ries AL. Impact of chronic obstructive pulmonary disease on quality of life: the role of dyspnea. Am J Med. Dyspnea scales in the assessment of illiterate patients with chronic obstructive pulmonary disease. Am J Med Sci. Discriminative properties and validity of a health status questionnaire in obstructive airway disease patients: the Airway Questionnaire 20 [Article in Spanish].
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