Search

Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.

Throughout the current pandemic, much has been written on the relationship between hypoxemia and the presence of respiratory symptoms in acute COVID-19 lung disease. Now that we are faced with a large population of patients suffering from the sequelae of acute COVID-19 infection whom we hope to

INTRODUCTION: Dyspnea is common and distressing in patients with acute critical illness who require mechanical ventilation (MV), and is often a presenting symptom for COVID-19. However, little is known about the long-term persistence of dyspnea or its impact on patients recovering from mechanical ventilation. This study sought to evaluate early and persistent dyspnea, and its emotional impact, among survivors of respiratory failure due to COVID-19. METHODS: We conducted a prospective observational cohort study at Beth Israel Deaconess Medical Center. We identified ICU survivors who underwent at least 48 hours of MV for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. We assessed the presence and severity of dyspnea throughout their illness (ICU, hospital floor, hospital discharge, 6 months post-discharge) using components of the Multidimensional Dyspnea Profile (MDP), a validated instrument. Additionally, we asked patients with persistent dyspnea at the time of follow up whether dyspnea triggered specific emotional responses, using the MDP. Data are means + standard deviation or number (percent). RESULTS: Forty of 43 patients contacted by telephone completed interviews and 3 declined. Twenty-three patients (58%) were male, 7 (18%) had COPD, 9 (22%) had obstructive sleep apnea, and 11 (28%) had active tobacco use. The duration of invasive MV was 14+7.1 days and hospital length of stay was 24.7+9.6 days. Six-month post-discharge data revealed 25 patients (62.5%) with any dyspnea, and 10 (25%) with moderate to severe dyspnea (10-point severity scale score > 4). Among patients with persistent dyspnea at 6 months, the majority reported fear (60%), anxiety (57.5%), or frustration (52.5%). Depression was the most common severe emotional response accompanying dyspnea (10-point severity scale score of 7-10), reported by 9 patients (22.5%). CONCLUSIONS: Six months after COVID-19-associated respiratory failure, dyspnea was persistent in the majority of patients and commonly associated with negative emotions. Fear and anxiety were most commonly reported. Prior to COVID-19, long-term dyspnea had been described in up to 40% of patients after respiratory failure, though data are limited. Thus dyspnea appears as, or more, common after COVID-19. In addition to the typical components of post-intensive care syndrome (PICS), dyspnea and the negative emotional states it evokes may impair quality-of-life for COVID-19 survivors and should be specifically assessed during post-hospital care visits.

A Woman with Dyspnea on Exertion and Abnormal Findings on Chest Imaging A 70-year-old woman was evaluated because of increasing dyspnea on exertion and abnormal findings on chest imaging. Eleven ye...

Covid-19 — A Reminder to Reason Faced with the Covid-19 pandemic, clinicians feel compelled to do something for their patients. But we need to retain a healthy skepticism and remember the principle...

As many as one in 10 patients experience dyspnoea at hospital admission but the relationship between dyspnoea and patient outcomes is unknown. We sought to determine whether dyspnoea on admission predicts outcomes.We conducted a retrospective cohort study in a single, academic medical centre. We analysed 67 362 consecutive hospital admissions with available data on dyspnoea, pain and outcomes. As part of the Initial Patient Assessment by nurses, patients rated “breathing discomfort” using a 0 to 10 scale (10=“unbearable”). Patients reported dyspnoea at the time of admission and recalled dyspnoea experienced in the 24 h prior to admission. Outcomes included in-hospital mortality, 2-year mortality, length of stay, need for rapid response system activation, transfer to the intensive care unit, discharge to extended care, and 7- and 30-day all-cause readmission to the same institution.Patients who reported any dyspnoea were at an increased risk of death during that hospital stay; the greater the dyspnoea, the greater the risk of death (dyspnoea 0: 0.8% in-hospital mortality; dyspnoea 1–3: 2.5% in-hospital mortality; dyspnoea ≥4: 3.7% in-hospital mortality; pWe found that dyspnoea of any rating was associated with an increased risk of death. Dyspnoea ratings can be rapidly collected by nursing staff, which may allow for better monitoring or interventions that could reduce mortality and morbidity.

In high-acuity settings such as intensive care units (ICUs), the quality of communication with patients' families is a particularly important component of care. Evidence shows that ICU communication is often inadequate and can negatively impact family outcomes.To assess the impact of a communication training program on resident skills in communicating with families in an ICU and on family outcomes.We conducted a prospective, single-site educational intervention study. The intervention featured a weekly required communication training program (4 h total) during the ICU rotation, which included interactive discussion, and role play with immediate feedback from simulated family members. All internal medicine residents on ICU rotation between July 2012 and July 2014 were invited to participate in the study. Family members who had a meeting with an enrolled resident were approached for a survey or interview. The primary outcome was family ratings of how well residents met their informational and emotional needs.The response rate for the resident baseline survey was 93% (n = 149 of 160), and it was 90% at postcourse and 84% at 3-month follow-up. Of 303 family members approached, 237 were enrolled. Enrolled family members who had a confirmed meeting with a resident were eligible to complete a survey or interview. The completion rate was 86% (n = 82 of 95). Family members were more likely to describe residents as having "fully met" (average rating of 10/10 on 0-10 scale) their informational and emotional needs when the resident had completed two or three course sessions (84% of family members said conversation with these residents "fully met" their needs), as compared with residents who had taken one session or no sessions (25% of family members said needs were "fully met") (P0.0001). Residents described improvements across all domains. All differences are statistically significant, most with large effect sizes.At our institution, an on-site communication training program designed for integration into medical residency programs was associated with strongly positive family member outcomes and significant improvements in residents' perceived skills. This intervention may serve to prepare residents for optimal communications with patients and family members in ICUs and elsewhere.

In December 2013, the U.S. Preventive Services Task Force recommended screening for lung cancer with low-dose computed tomography (LDCT) for selected current and former smokers. The Task Force based the recommendation primarily on the results of the NLST (National Lung Screening Trial). In this trial, patients randomly assigned to LDCT screening for 3 years had lower rates of both lung cancer-specific mortality and all-cause mortality (relative risk reduction, 6.7% [95% CI, 1.2% to 13.6%]; absolute risk reduction, 0.46% [CI, 0% to 0.9%]). Clinicians and health systems confront questions and challenges as they begin to implement lung cancer screening. This paper summarizes a conference during which an internist and a radiologist discuss the application of the Task Force recommendation to an individual patient.

The initiation of a breath is the consequence of the interaction of a complex set of neural inputs to the respiratory centers of the brain and the mechanical properties of the ventilatory pump. Automatic and volitional elements must be considered, as well as behavioral effects resulting from symptoms and psychological factors. A range of pathological conditions may alter different pieces of the respiratory system resulting in changes in respiratory pattern and, in some cases, gas exchange. This chapter will outline the physiology of the key neuromechanical components of the respiratory system responsible for initiation of the breath and review the tests that may be used to assess the system.

While the use of transthoracic echocardiography (TTE) in the ICU is rapidly expanding, the contribution of TTE to altering patient outcomes among ICU patients with sepsis has not been examined. This study was designed to examine the association of TTE with 28-day mortality specifically in that population. The MIMIC-III database was employed to identify patients with sepsis who had and had not received TTE. The statistical approaches utilized included multivariate regression, propensity score analysis, doubly robust estimation, the gradient boosted model, and an inverse probability-weighting model to ensure the robustness of our findings. Significant benefit in terms of 28-day mortality was observed among the TTE patients compared to the control (no TTE) group (odds ratio = 0.78, 95% CI 0.68–0.90, p

Context.—There are few published examples of pathology instruction during the clinical years of medical student training. This lack of exposure to pathology may lead to poor understanding of laboratory testing and the role of pathologists in patient care. Objective.—To design, implement, and evaluate a pathology curriculum integrated into a longitudinal clerkship for third-year medical students. Design.—The curriculum includes an introductory session during the transition week course, pathologist participation in longitudinal student case conferences, and a pathology elective. The curriculum was evaluated by using surveys consisting of both multiple choice and written responses. Results.—A total of 55 students participated in the longitudinal curriculum during the 2009–2010 academic year and 8 students, only one of whom stated a career interest in pathology, participated in the elective. More than 80 pathology topics were discussed and, for the first time, pathologists received teaching awards from the third-year students. All elective students would recommend the elective to colleagues; feedback also suggested an improved understanding of pathology as a profession. At the end of the year, 31% of all students, compared to only 19% in the initial survey, knew that most of an anatomic pathologist's caseload consists of specimens from living patients (P = .13). In addition, elective student interaction with a pathology faculty member directly led to an improvement in test reporting. Conclusions.—A novel longitudinal curriculum allowed for the creative integration of pathology into third-year students' clinical training and led to better student understanding of the role of pathologists in patient care.

Background In adult patients, the consistent use of language to describe dyspnea enhances patient-provider communication and contributes to diagnostic and therapeutic decisions. The objective of this research was to determine whether pediatric patients similarly display consistency in the language used to describe "uncomfortable awareness of breathing." Methods One hundred children between the ages of 8 and 15 years with moderate to severe persistent asthma enrolled in an asthma education research program completed questionnaires regarding descriptors of asthma on each of two occasions. In addition to the breathlessness questionnaires, demographic information, self-reported asthma severity, ED visits, missed school days, anthropometrics, and spirometry were obtained for each participant. Results Children were reliable in their choice of the descriptors that they applied to their breathing discomfort across two occasions, and they selected the same descriptors that were used by adults with asthma in previous studies. Children with greater self-reported asthma severity endorsed more descriptors to characterize breathing discomfort than did children with less severe asthma, but no differences were found among children based on demographic or anthropometric variables. Conclusions Children with moderate to severe persistent asthma are reliable in their choice of descriptors of breathlessness. Knowledge of their experience of symptoms may be helpful clinically in the assessment and management of asthma.

OBJECTIVES: To design, implement, and assess an educational intervention for providers focused on osteoporosis screening and management in older patients with chronic obstructive pulmonary disease or asthma who have been prescribed prolonged courses of oral or high‐dose inhaled corticosteroids or both and are therefore at high risk for bone loss and fractures. DESIGN: One‐group pretest–posttest. SETTING: Academic outpatient pulmonary practice. PARTICIPANTS: Nineteen pulmonary specialists at an academic medical center. INTERVENTION: Educational theory and a needs assessment and attitude survey guided the development of a multicomponent educational intervention. MEASUREMENTS: Change in provider behavior was assessed by auditing the electronic medical records for adherence to osteoporosis management guidelines in high‐risk patients seen by participants at baseline and for 6 months after the educational intervention. Knowledge transfer and changes in attitude were assessed using pre‐ and posttests and surveys. RESULTS: A 19% increase in overall rate of adherence to osteoporosis management guidelines in high‐risk patients was observed: 45% before intervention to 64% after intervention (n=249 patients, P=.003). Postintervention surveys and test scores also showed statistically significant gains from baseline. CONCLUSION: An educational intervention improved adherence to osteoporosis management guidelines of academic pulmonary specialists. The results of this study provide evidence for the positive effect of a multimodal educational program in altering practice behaviors.

The National Lung Screening Trial (NLST) is a randomized multicenter study comparing low-dose helical computed tomography (CT) with chest radiography in the screening of older current and former heavy smokers for early detection of lung cancer, which is the leading cause of cancer-related death in the United States. Five-year survival rates approach 70% with surgical resection of stage IA disease; however, more than 75% of individuals have incurable locally advanced or metastatic disease, the latter having a 5-year survival of less than 5%. It is plausible that treatment should be more effective and the likelihood of death decreased if asymptomatic lung cancer is detected through screening early enough in its preclinical phase. For these reasons, there is intense interest and intuitive appeal in lung cancer screening with low-dose CT. The use of survival as the determinant of screening effectiveness is, however, confounded by the well-described biases of lead time, length, and overdiagnosis. Despite previous attempts, no test has been shown to reduce lung cancer mortality, an endpoint that circumvents screening biases and provides a definitive measure of benefit when assessed in a randomized controlled trial that enables comparison of mortality rates between screened individuals and a control group that does not undergo the screening intervention of interest. The NLST is such a trial. The rationale for and design of the NLST are presented.

Context Dyspnea is an uncomfortable and distressing sensation experienced by hospitalized patients. Objectives There is no large-scale study of the prevalence and intensity of patient-reported dyspnea at the time of admission to the hospital. Methods Between March 2014 and September 2016, we conducted a prospective cohort study among all consecutive hospitalized patients at a single tertiary care center in Boston, MA. During the first 12 hours of admission to medical-surgical and obstetric units, nurses at our institution routinely collect a patient's 1) current level of dyspnea on a 0–10 scale with 10 anchored at "unbearable," 2) worst dyspnea in the past 24 hours before arrival at the hospital on the same 0–10 scale, and 3) activities that were associated with dyspnea before admission. The prevalence of dyspnea was identified, and tests of difference were performed across patient characteristics. Results We analyzed 67,362 patients, 12% of whom were obstetric patients. Fifty percent of patients were admitted to a medical-surgical unit after treatment in the emergency department. Among all noncritically ill inpatients, 16% of patients experienced dyspnea in the 24 hours before the admission. Twenty-three percent of patients admitted through the emergency department reported any dyspnea in the past 24 hours. Eleven percent experienced some current dyspnea when interviewed within 12 hours of admission with 4% of patients experiencing dyspnea that was rated 4 or greater. Dyspnea of 4 or more was present in 43% of patients admitted with respiratory diagnoses and 25% of patients with cardiovascular diagnoses. After multivariable adjustment for severity of illness and patient comorbidities, patients admitted on the weekend or during the overnight nursing shift were more likely to report dyspnea on admission. Conclusion Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.

High-quality research is needed to improve quality of life for people with chronic refractory breathlessness in COPD. The joint American Thoracic Society (ATS)/European Respiratory Society (ERS) statement “An official American Thoracic Society/European Respiratory Society statement: research questions in COPD” by Celli et al. [1] is a timely summary of the current evidence and the questions that arise directly from where that evidence reaches its limits. Such documents are crucial in framing research strategies for researchers and research funders.

Good communication is at the heart of excellent care for patients and families. At the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, we have developed a communication training program for our internal medicine residents. During their intensive care unit (ICU) rotation, residents participate in weekly sessions to learn about key elements for compassionate, effective communication with family members of critically ill patients. The course focuses on teaching skills needed in initial meetings with families of critically ill patients such as answering family members' urgent questions, helping them understand and cope with the patient's illness, and responding to family members' distress, anger, or sadness. Residents are also taught how to sensitively lead family meetings later in the course of care, especially in discussing important decisions about goals of care when cure is unlikely and the patient's comfort and quality of life are paramount. Given the 3-week ICU rotation, the course is designed to be delivered in three parts over 4 hours: 1-hour sessions for the first 2 weeks and a 2-hour simulation session in the third week. Response rate for residents is 98% (n = 137). Residents are 54% male, 69% white, 20% Asian, 4% African American, and 7% other. Prior to training, 97% of residents felt that communication with family members was “very important”; however, few had any other communication training during residency, and many felt underprepared for carrying out important communication tasks. After the course, residents reported statistically significant improvements (p < .0001) in preparation to carry out all 17 surveyed skills, with moderate to high effect sizes (e.g., preparation to lead family meetings, 1-5 scale, 2.5-3.5; understanding of appropriate language to use in family communication, 2.5-3.4, p < .0001). Resident attitudes changed as well: Residents were more likely to agree that they wished they could lead more family meetings (pre vs. post: 15.4% vs. 69.3%), more comfortable talking to family about the possibility of death (30.1% vs. 84.6%), and less likely to agree that they dreaded having to deal with the emotional distress of family members of a patient at the end of life (53.8% vs. 23.1%).

A 24-year-old sailor presented to the emergency department with a seven-day history of shortness of breath, occasional substernal chest pain, increasing abdominal girth, and nausea and vomiting. He reported leg swelling and a weight gain of 14 kg during the preceding three weeks.

There is growing awareness that dyspnoea, like pain, is a multidimensional experience, but measurement instruments have not kept pace. The Multidimensional Dyspnea Profile (MDP) assesses overall breathing discomfort, sensory qualities, and emotional responses in laboratory and clinical settings. Here we provide the MDP, review published evidence regarding its measurement properties and discuss its use and interpretation. The MDP assesses dyspnoea during a specific time or a particular activity (focus period) and is designed to examine individual items that are theoretically aligned with separate mechanisms. In contrast, other multidimensional dyspnoea scales assess recalled recent dyspnoea over a period of days using aggregate scores. Previous psychophysical and psychometric studies using the MDP show that: 1) subjects exposed to different laboratory stimuli could discriminate between air hunger and work/effort sensation, and found air hunger more unpleasant; 2) the MDP immediate unpleasantness scale (A1) was convergent with common dyspnoea scales; 3) in emergency department patients, two domains were distinguished (immediate perception, emotional response); 4) test–retest reliability over hours was high; 5) the instrument responded to opioid treatment of experimental dyspnoea and to clinical improvement; 6) convergent validity with common instruments was good; and 7) items responded differently from one another as predicted for multiple dimensions., The Multidimensional Dyspnea Profile provides a unified, reliable instrument for both clinical and laboratory research http://ow.ly/Ix8ic

Study objectives We tested the hypothesis thatdescriptors of breathlessness represent distinct and separablecognitive constructs, and predicted that the use of descriptors ofbreathlessness by healthy individuals is the same as their use bypatients with cardiopulmonary disease. Design Clusteranalyses obtained in healthy individuals were compared with thoseobtained previously in patients who complained of breathing discomfort. In addition, we used multidimensional scaling (MDS) techniques toanalyze relationships among descriptors in healthy individuals. Setting Public university. Participants The participants were 100 healthy individuals (48 men and 52 women)ranging in age between 18 and 65 years (mean, 27.9 ± 11.7 years). Measurements and results Participants judgedthe dissimilarity among pairs of 15 descriptors of breathlessness thatwere used previously to examine the experience of dyspnea in patientswho complained of breathing discomfort. Cluster analysis solutionsobtained in the healthy individuals were virtually identical to thoseobtained previously in patients. Three dimensions (attributes) ofbreathing discomfort were uncovered with MDS: "Depth and frequency ofbreathing," "Perceived need, or urge, to breathe," and "Difficulty breathing and phase of respiration." The results didnot depend on age, sex, levels of education, or the presence ofuncomfortable awareness of breathing with activities. Conclusions The relations among descriptors ofbreathlessness obtained in healthy individuals support the contentionthat the association of different clusters with different diseasestates reflects distinct and separable cognitive constructs that are not simply dependent on the presence of an underlying pathophysiologyor on a specific disease condition. Our results in healthy individualsalso suggest that distinct qualities of breathlessness relate todifferent physiologic mechanisms underlying respiratorydiscomfort.

Presentation of Case A 61-year-old man was admitted to the hospital because of increasing exertional dyspnea. The patient had been in excellent health until three months earlier, when he began to experience mild exertional dyspnea, with an occasional cough productive of clear sputum. Radiographic studies of the chest performed on two occasions showed abnormalities, and different antibiotics were administered on each occasion without improvement. The dyspnea worsened, and anorexia developed, with a weight loss of 7 kg. Three weeks before admission, pulmonary-function studies were performed at another hospital (Table 1). The patient was referred to this hospital. The patient worked . . .

Dyspnea may be defined as an uncomfortable sensation of breathing. The sense of respiratory effort, chemoreceptor stimulation, mechanical stimuli arising in lung and chest wall receptors, and neuroventilatory dissociation may all contribute to the sensation of dyspnea. Different mechanisms likely give rise to qualitatively different sensations of dyspnea. In most patients, dyspnea is probably due to a combination of mechanisms. For example, in asthma, a heightened sense of effort, neuroventilatory dissociation, and vagal stimuli arising from bronchoconstriction and airway inflammation may all play a role. Patients with different disorders and different mechanisms of dyspnea use different phrases to describe their breathing discomfort. Hence, the language patients use to describe their dyspnea may provide clues to the etiology of their symptoms.

Background Most measures of dyspnea assess a single aspect (intensity or distress) of the symptom. We developed the Multidimensional Dyspnea Profile (MDP) to measure qualities and intensities of the sensory dimension and components of the affective dimension. The MDP is not indexed to a particular activity and can be applied at rest, during exertion, or during clinical care. We report on the development and testing of the MDP in patients with a variety of acute and chronic cardiopulmonary conditions. Methods One hundred fifty-one adults admitted to the ED with breathing symptoms completed the MDP three times in the ED, twice at least 1 h apart (T1, T2), and near discharge from the ED (T3). Measures were repeated in 68 patients twice in a follow-up session 4 to 6 weeks later (T4-T5). The ED sample was 56% men with a mean age of 53 ± 15 years; the follow-up sample was similar. Results Factor analysis resulted in a two-factor solution with a total explained variance of 63%, 74%, and 72% at T1, T2, and T3, respectively. One domain related to primary sensory qualities and immediate unpleasantness, and the second encompassed emotional response. For the two domains, Cronbach α ranged from 0.82 to 0.95, and the intraclass correlation coefficient ranged from 0.91 to 0.98. Repeated-measures analysis was significant for change (T1, T3, T4), showing responsiveness to change in MDP domains with treatment (F[2,66] = 19.67, P > .001). Conclusions These analyses support the reliability, validity, and responsiveness to clinical change of the MDP with two domains in an acute care and follow-up setting.

Background. Despite obesity’s relevance and impact, curricula addressing obesity are underrepresented in clinical medical education. A novel pilot program to begin teaching medical students about care of the obese patient was developed and student attitudes toward obesity and bariatric surgery were assessed. Methods.The authors paired third-year students with obese patients undergoing bariatric surgery. Students established a longitudinal patient relationship, received faculty mentorship, and kept a reflections journal. An attitude assessment survey was administered before and after third year. Reflections were analyzed for common themes. Results. Baseline student responses differed from those previously reported for practicing physicians on many survey statements, including more strongly agreeing with the relationship between obesity and serious medical conditions ( P < .001), the need to educate patients about obesity risks ( P < .001), and willingness to recommend bariatric surgery evaluation ( P = .004). These differences were maintained after clinical clerkships. Reflection themes included recognition of obesity stereotypes, improved estimation of body mass index, and awareness of physicians’ attitudes about obesity. Conclusion. Development and assessment of a novel pilot program to teach third-year medical students about obesity and bariatric surgery suggests a potential impact on student attitudes and understanding of obesity and obesity surgery. Students today may have different attitudes toward obesity than those reflected in prior data for physicians in practice, and programs such as this may help maintain positive attitudes.

Since the first report of bronchoconstriction provoked by ingestion of a meal containing monosodium glutamatc (MSG) in 1981, many studies have been performed to define the role of MSG in asthma. These studies have employed a variety of methodologies, and their results have led to different conclusions. In an effort to resolve these differences I used the Paperchase computerized database system to identify all references in the medical literature (English language) to MSG and asthma between 1966 and November 1991. These citations were reviewed with particular attention to 1) prevalence of MSG-associated asthma, 2) selection of subjects, 3) protocol design. 4) dosing of MSG, and 5) time course of the reaction. A total of 29 cases of alleged MSG provoked asthma appear in the medieal literature. In subjects not selected for a history of food reactions, the incidence of MSG-induced bronchospasm is less than 5%. There is only one report of MSG-induced bronchospasm in a double-blind controlled challenge. The remainder of the cases are anecdotal reports or single-blind challenges performed primarily in patients selected for a prior history of reactions to MSG or other food substances. There is no clear evidence to support the concept of a threshold dose for this reaction. The latency between ingestion of MSG and development of bronchospasm is reported to be between 30 min and 12 h. In vitro data suggest there is no direct effect of MSG on bronchial smooth muscle. While MSG may precipitate bronchospasm in a small group of selected patients, this association remains to be validated in double-blind placebo controlled studies.

The third year of medical school, in which students traditionally receive their first immersion into hospital-based clinical medicine, often results in a degradation of attitudes toward medicine and patient care. The authors present data collected in the 2005-2006 academic year from a pilot program aimed at enhancing this experience, thereby enabling students to resist these negative influences.Thirty-two Harvard Medical School students, who spent their entire principal clinical experience (PCE) at one of three clinical sites (PCE group), completed the Patient-Practitioner Orientation Scale (PPOS), a measure of patient-centered attitudes, at the beginning of the year. They completed the PPOS again at year's end as well as the Community, Curriculum, and Culture (C3) hidden curriculum measure of patient-centered clinical experiences. Their responses on these measures were compared with those of a traditional-rotation control group that moved from site to site.At the beginning of the year, no PPOS differences were found within PCE groups or between PCE and control students. Traditional students' attitudes became significantly less patient-centered at year's end, whereas PCE students' attitudes did not change. PCE students reported more support for their patient-centered behaviors, and, across all students, C3 scores and changes in PPOS scores were significantly correlated.Innovations in clinical education may help inoculate medical students against the degradation of attitudes. Although this research was a test of a small pilot program, the consistent pattern of findings across those clinical sites and educational models studied provides suggestive evidence that the oft-cited negative impacts of the principal clinical year are not inevitable.

Despite mandates from accreditation bodies for programs to ensure procedural competence, standardized measures do not exist to assess residents' skills in performing central venous catheter (CVC) insertion. The objective of the present study was to develop an instrument to assess residents in subclavian (SC) CVC insertion, to set performance standards, and to validate the tool using performance data.In 2007, the authors convened experts to create an assessment tool for CVC insertion using a modified Delphi method. They applied the Angoff method to a second set of experts to determine minimum passing scores (MPSs) for both the borderline trainee and the competent trainee. Two faculty evaluators then used the checklist to assess residents performing CVCs on simulators.The authors created and experts confirmed a 24-item checklist. Using the Angoff method, the MPS required completion of 10 major and 2 minor criteria for a trainee to show borderline proficiency with CVC insertion under supervision. This MPS was correlated with a global rating of 2 on a 5-point scale. The MPS for competence was 17 major and 5 minor criteria. None of the residents deemed competent on a global rating scale achieved the MPS for competence.The authors were able to create and validate a consensus-driven procedural assessment tool with data-driven standards for basic proficiency and competence that faculty can use to assess residents as they perform CVC insertion.

(CHEST 2009; 135:201–209) Editor’s note: In this series, interactive diagrams are an important part of each article and are referred to throughout. You can access these diagrams online at www.chestjournal.org/content/135/1/201.full. Included with the diagrams are “Show Me” videos, animated narrations that walk you through the main points of each diagram. The first time you access the online material, you may be asked to update your Web browser’s Flash Player plugin; this will enable you to view the diagrams as intended. If you are not automatically prompted to update the plugin and you have any problems using the diagrams, you can download the latest version of the Flash Player by visiting http://www.adobe.com/go/getflash.

Introduction: Medical simulation takes advantage of contextual and experiential learning by allowing trainees to practice in realistic environments prior to actual patient care. Although proponents argue that patient simulation can fundamentally enhance both medical education and patient safety, large-scale experience with advanced simulation technologies is limited. To explore expert opinion on the topic, we convened a conference of educational leaders and simulation experts to provide recommendations for how this field should be directed on a broad scale to improve the training of future health professionals. This document summarizes the proceedings of that conference. Methods: We issued a request for applications to all U.S. and Canadian medical schools within the Association of American Medical Colleges (AAMC), seeking a diverse group of institutional teams committed to an in-depth exploration of the topic. Of 33 applications, nine medical schools were selected to participate. Once on site, eight working groups were formed, each comprised of representatives across sites and roles, including deans, clerkship and program directors, content experts, and trainees. We addressed four key topics, which are subsequently summarized for presentation in this report: 1) education (How can medical simulation contribute to the education of trainees?), 2) assessment (What is the role of simulation in evaluating trainees in the context of general competencies?), 3) research (How should we develop a research agenda to evaluate simulation?), and 4) implementation (How should simulation technologies be developed and managed within and across institutions?). Results: Participants in the conference generally agreed that simulation offers a conducive environment for focused reflection and critical thought. Although there was consensus that medical simulation can provide a robust platform for performance assessment, most participants thought that the research basis for high-stakes assessment was still too immature for widespread implementation. Participants generally agreed that sufficiently powered research will require interinstitutional collaboration on uniform curricula and meaningful outcome tools, and that both biomedical and social science research paradigms will need to be applied to the questions at hand. Common barriers to medical simulation include both real and perceived lack of resources, poor understanding among faculty regarding the nature of the tools and techniques, and the inherent complexity of multidisciplinary collaboration. Conclusions: Medical simulation can and should be used to complement current methods of medical education. Educators should make thoughtful choices among simulation modalities to help trainees most effectively achieve learning objectives. Simulation researchers should prioritize the development and validation of clinical performance tools and other defined outcome measures on which meaningful large-scale research can be anchored. Finally, national collaboration should be encouraged and fostered by institutions and funding agencies.

Purpose of review To discuss three emerging areas of research triggering new hypotheses for mechanisms of dyspnea. Recent findings There has been an emphasis on the importance of lung volumes in evaluating symptoms and lung function in patients with chronic obstructive pulmonary disease. Dyspnea intensity seems to more closely correlate with measures of hyperinflation than airflow limitation, highlighting the importance of neuromechanical dissociation in the development of dyspnea. Inhaled furosemide has demonstrated a beneficial effect in laboratory-induced dyspnea, and the sensation of air hunger has been ameliorated by this therapy, possibly via activation of pulmonary stretch receptors. There appear to be distinct affective and sensory components of dyspnea, and the affective dimension may be modifiable, although this has not been fully studied. Summary Dyspnea in chronic obstructive pulmonary disease is clearly related to hyperinflation, and lung volumes are valuable for characterizing disease. It remains unclear whether a limitation in tidal volume due to dynamic hyperinflation is the key factor in exertional dyspnea in this disease. Research of inhaled furosemide demonstrates the importance of afferent sensory input in modifying dyspnea, and deserves further study. The contributions of the affective and sensory components of dyspnea remain unclear, but should be studied further.

Dyspnea frequently accompanies a variety of cardiopulmonary abnormalities. Although dyspnea is often considered a single sensation, alternatively it may encompass multiple sensations that are not well explained by a single physiologic mechanism. To investigate whether breathlessness experienced by patients represents more than one sensation, we studied 53 patients with one of the following seven conditions: pulmonary vascular disease, neuromuscular and chest wall disease, congestive heart failure, pregnancy, interstitial lung disease, asthma, and chronic obstructive pulmonary disease. Patients were asked to choose descriptions of their sensation(s) of breathlessness from a dyspnea questionnaire listing 19 descriptors. Cluster analysis was used to identify natural groupings among the chosen descriptors. We found that patients could distinguish different sensations of breathlessness. In addition, we found an association between certain groups of descriptors and specific conditions producing dyspnea. These findings concur with those in an earlier study in normal volunteers in whom dyspnea was induced by various stimuli. We conclude that different types of dyspnea exist in patients with a variety of cardiopulmonary abnormalities. Furthermore, different mechanisms may mediate these various sensations.

Patients in acute respiratory distress require rapid assessment of the cause of dyspnea. We have observed that many of those patients who are in congestive heart failure (CHF) exhibit rounding of the abdominal cross-section during expiration. We sought to evaluate the diagnostic utility of this breathing pattern in dyspneic patients presenting to an emergency department. Twenty-six subjects with dyspnea due to a variety of conditions were recruited from the emergency department at Beth Israel Deaconess Medical Center. Subjects ranged in age from 21 to 94 years and 81% were female. We measured variation in the anteroposterior and transverse diameters of the rib cage and abdomen using respiratory magnetometers and determined phase of respiration with a pneumotachometer. Investigators blinded to the subjects’ identities and diagnoses interpreted measurements as indicating normal respiratory movement without expiratory abdominal rounding, slight expiratory rounding, or pronounced expiratory rounding. The likely cause of dyspnea was determined from discharge diagnoses in the medical record. Expiratory rounding was observed in 12/14 subjects with CHF and 5/12 subjects without CHF (p = 0.0186), and pronounced expiratory rounding was present in 11/14 patients with CHF and 2/12 patients without CHF (p = 0.0016). Test characteristics for the association of CHF with pronounced expiratory rounding were sensitivity 79%, specificity 83%, and predictive accuracy 81%. In patients with acute respiratory distress, expiratory abdominal rounding suggests CHF as the primary cause of dyspnea; a greater degree of rounding suggests a greater likelihood of CHF. The clinical utility of this diagnostic sign remains to be determined in a prospective study.

Study objectives: To determine whether there is any difference in diagnostic, therapeutic, and outcome efficacy between protocols utilizing daily ( ie , routine) chest radiographs (CXRs) and those utilizing clinically indicated ( ie , nonroutine) CXRs in mechanically ventilated patients. Design: Prospective, randomized, observational study. Setting: A 20-bed medical ICU at a university hospital. Patients: Adult patients who had been receiving mechanical ventilation for > 48 h. Interventions: None. Measurements and results: Ninety-four patients who had been intubated for at least 48 h were randomized to receive either routine or nonroutine CXRs and were observed until extubation or death. The percentage of CXRs with new findings was significantly larger in the nonroutine CXR group (53.1%; 120 CXRs) compared to that in the routine CXR group (33.4%; 98 CXRs; odds ratio [OR], 1.59; 95% confidence interval [CI], 1.16 to 2.18; p=0.004). The number of CXRs with new findings that resulted in interventions was significantly larger in the nonroutine CXR group (26.5%; 60 CXRs) compared to that in the routine CXR group (13.3%; 39 CXRs; OR, 2.0; 95% CI, 1.29 to 3.08; p=0.002). There was no difference in the mean duration of mechanical ventilation (routine CXR arm, 7.93 days; nonroutine CXR arm, 6.76 days; p=0.2606), length of ICU stay (routine CXR arm, 11.93 days; nonroutine CXR arm, 9.55 days; p=0.1936), and total length of hospital stay (routine CXR arm, 19.34 days; nonroutine CXR arm, 16.45 days; p=0.2199) between the two groups. Although patients in the nonroutine arm of the study received fewer CXRs, adverse outcomes ( eg , length of mechanical ventilation, length of hospital stay, length of ICU stay, and mortality) did not increase (p = 0.818). Using the number of CXRs per patient as a surrogate, there was a statistically significant cost savings and decreased radiation exposure in the nonroutine CXR group. Conclusions: For mechanically ventilated patients, a strategy calling for daily routine CXRs compared to CXRs obtained based on clinical indications alone was not associated with reduced ICU or hospital length of stay or with reduced mortality.

Mechanical vibration of the chest wall can reduce dyspnea. It is unclear which sensations of respiratory discomfort are modulated by vibration (work/effort, air hunger, tightness). We performed two experiments to test whether vibration modifies air hunger: Experiment 1-eight adults performed six breath holds and rated their uncomfortable 'urge to breathe.' Vibration was applied separately at four chest-wall and two control sites, using two amplitudes. Breath-hold duration and ratings were unchanged by vibration at any site or amplitude. Experiment 2-nine adults were mechanically ventilated (mean 8.73 L/min) at constant hypercapnia (mean 48 mmHg) to produce mild to moderate ratings of air hunger (mean 37% of scale) with minimal respiratory muscle work. Vibration at 2nd or 3rd intercostal spaces during either inspiration or expiration did not change air hunger compared to triceps vibration. These experiments demonstrated that vibration does not relieve air hunger; we postulate that the effect of vibration is specific to the form of dyspnea.

The cost of graduate medical education in the United States is subsidized by the federal government through direct and indirect Medicare payments. These payments are intended to cover the portion of resident salaries, teaching expenses, and indirect hospital costs associated with the academic mission attributable to the care of Medicare beneficiaries, using a complex allocation formula. However, there are other program expenses associated with medical education that are not reimbursed by Medicare and still significantly affect the competitiveness and quality of the educational programs. Although most educators recognize the amount of extra work and money required to run high-quality training programs, there are few analyses demonstrating the actual amount and effect of these extra expenditures on graduate medical education.1-4 Programs often spend significant amounts on recruitment efforts, including interviews, travel reimbursements, and orientation days. They purchase resource education materials for residents, such as books, simulation training, digital resources, association and membership dues, and in-service examinations to support their education. For scientific meetings and events, they often pay for travel and lodging expenses, program application fees and food; graduation ceremonies, awards, and certificates add to the expenses of running a program. Other items purchased for trainee support include laboratory coats, office supplies, computer hardware and software, parking, meal cards, and pagers. As fiscal pressures intensify for academic medical centers and associated faculty practice plans, it is essential to identify the magnitude and distribution of these “hidden costs” of residency training. As part of a strategic review of education and budgets, the 8 core Accreditation Council for Graduate Medical Education (ACGME) residency programs (comprising 461 trainees) at an academic medical center reported all nonsalary costs of training residents. The programs were asked to identify the costs by category of expenditure (using the 4 categories noted above) and the source of the funding: hospital cost center, physician practice plan, or special funds (eg, philanthropy, grants). The total annual hidden costs for resident education at that institution were $1,865,016. Approximately 70% ($1,315,693) was paid by the physician practice plan; 25% ($462,202) by the hospital; and 5% ($87,121) from special funds. The average annual cost per resident was $4439 (range, $1500 to $9417 among programs). By category, the average annual per resident costs were Educational materials $1423 (32.1%); Trainee support $1299 (29.3%); Meetings and events $1191 (26.8%); and Recruitment $525 (11.8%). See the figure. One limitation of this analysis was that we relied on our program directors to define the costs and the category under which they would best be classified. Departmental budgets were not audited independent of those reports. The figures obtained were from 2006 (as part of a baseline analysis for ongoing institutional efforts to support residency training programs) so may not be accurate for 2012 conditions (they likely underestimate current costs). The figures reported are for a single institution only. While it is probable that similar conditions exist elsewhere, further study is warranted to investigate the effect of these costs on hospitals and academic practices as the cost containment elements of health care reform reduce clinical margins and jeopardize the cross-subsidization of education that has been prevalent for many years. With more than 109 000 ACGME-accredited residents currently in training, even if this analysis is off by an order of magnitude, it still represents a cost of tens of millions of dollars per year in the United States alone.5

Dyspnea is a cardinal symptom of asthma and may arise from several pathophysiological mechanisms, including pulmonary hyperinflation, stimulation of vagal receptors, and, rarely, chemoreceptor stimulation. The language that patients use to describe their breathlessness may provide important clues about the physiology underlying symptoms in a particular patient. Several physiological derangements may contribute to dyspnea in a given individual. The variability in the severity of breathlessness for any given degree of airflow obstruction may relate to differences in the relative importance of these physiological changes and/or to a range of perceptual abilities in asthmatic patients. One hypothesis that is under current investigation is that defective perception of asthma symptoms may lead to undertreatment and the potential for greater morbidity and mortality from asthma.

In a Dutch birth cohort study published in this issue of the Journal, children had an increased risk of bronchial hyperresponsiveness or dyspnea at age 8 years if they had a high body mass index (BMI) at 6 to 7 years of age with or without increased BMI at an earlier age. Taking advantage of the longitudinal nature of their study of 3,756 children, the authors also report the encouraging finding that children who had a high BMI at a young age but whose BMI returned to normal did not have increased risk either of bronchial hyperresponsiveness or dyspnea. As always, extrapolation from an observational study to early-life interventions should be done cautiously. It is not known whether children whose BMI decreases without any known deliberate intervention are the subset of children who might benefit from BMI screening or from weight-reduction programs. Programs for screening and early intervention in obesity abound, but further prospective evaluation of their success in reducing weight and obesity-associated respiratory symptoms is needed. But what does overweight-associated dyspnea signify in the children from this birth cohort, and is dyspnea a symptom of asthma, as the investigators suggest? Mouse model data suggest that obesity can lead to bronchial hyperresponsiveness. Airway narrowing can occur through obesity-associated lung and tidal volume reduction, low-grade systemic inflammation, or obesity-related changes in adipose-derived hormones, including leptin and adiponectin. Nevertheless, studies of adults in which data suggest that asthma might be overdiagnosed in obese adults with dyspnea are accumulating. Misdiagnosis of asthma can result in inappropriate prescription of short-acting bronchodilators or corticosteroids in persons who are short of breath for obesity-related dyspnea that does not represent reversible airway obstruction. In a study of 16,171 participants ( 17 years of age) from the Third National Health and Nutrition Examination Survey, the highest BMI quintile (ie, the most obese participants) was associated with the greatest risk of self-reported asthma, bronchodilator use, and dyspnea with exertion (odds ratio, 2.66; 95% CI, 2.35-3.00). The highest BMI quintile, however, had the lowest risk for significant airflow

Background Laboratory-induced dyspnea (breathing discomfort) in healthy subjects is widely used to study perceptual mechanisms, yet the relationship between laboratory-induced dyspnea in healthy volunteers and spontaneous dyspnea in patients with chronic lung disease is not well established. We compared affective responses to dyspnea 1) in COPD patients vs. healthy volunteers (HV) undergoing the same laboratory stimulus; 2) in COPD during laboratory dyspnea vs. during activities of daily living (ADL). Methods We induced moderate and high dyspnea levels in 13 COPD patients and 12 HV by increasing end-tidal CO2 (PETCO2) during restricted ventilation, evoking air hunger. We used the multidimensional dyspnea profile (MDP) to measure intensity of sensory qualities (e.g., air hunger (AH) and work/effort (W/E)) as well as immediate discomfort (A1) and secondary emotions (A2). Ten of the COPD subjects also completed the MDP outside the laboratory following dyspnea evoked by ADL. Results COPD patients and HV reported similar levels of immediate discomfort relative to sensory intensity. COPD patients and HV reported anxiety and frustration during laboratory-induced dyspnea; variation among individuals far outweighed the small differences between subject groups. COPD patients reported similar intensities of sensory qualities, discomfort, and emotions during ADL vs. during moderate laboratory dyspnea. Patients with COPD described limiting ADL to avoid greater dyspnea. Conclusions In this pilot study, we found no evidence that a history of COPD alters the affective response to laboratory-induced dyspnea, and no difference in affective response between dyspnea evoked by this laboratory model and dyspnea evoked by ADL.