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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Introduction: COPD has become more prevalent among women, revealing a specific feminine phenotype. Women experience greater dyspnea and a more impaired quality of life. The main objective of this study was to assess the effect of gender on dyspnea during a pulmonary rehabilitation program (PRP)., Methods: Retrospective study including COPD patients having participated in PRPs. The following data were analyzed according to gender before and after a PRP: dyspnea, quality of life, anxiety and depression, exercise capacity, muscle function (quadriceps and inspiratory muscles)., Results: More than 500 patients (252 men and 252 women) were included. We did not find a significant effect of gender on the evolution of dyspnea, anxiety or depressive disorders, exercise capacity, inspiratory muscle strength, or overall quality of life score. That said, we found a possible effect on the sub-scores of the quality of life questionnaire, and regarding quadriceps strength. All criteria improved during the program in both groups., Conclusions: During a PRP, gender does not impact the evolution of dyspnea. While women may nonetheless benefit to a greater extent in terms of quality of life sub-scores (impact, activities, symptoms) and quadriceps strength, these results still require confirmation., (Copyright © 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Rationale: Diaphragm muscle weakness might underlie persistent exertional dyspnea, despite normal lung and cardiac function in individuals who were previously hospitalized for acute coronavirus disease (COVID-19) illness. Objectives: The authors sought, first, to determine the persistence and pathophysiological nature of diaphragm muscle weakness and its association with exertional dyspnea 2 years after hospitalization for COVID-19 and, second, to investigate the impact of inspiratory muscle training (IMT) on diaphragm and inspiratory muscle weakness and exertional dyspnea in individuals with long COVID. Methods: Approximately 2 years after hospitalization for COVID-19, 30 individuals (11 women, 19 men; median age, 58 years; interquartile range [IQR] = 51-63) underwent comprehensive (invasive) respiratory muscle assessment and evaluation of dyspnea. Eighteen with persistent diaphragm muscle weakness and exertional dyspnea were randomized to 6 weeks of IMT or sham training; assessments were repeated immediately after and 6 weeks after IMT completion. The primary endpoint was change in inspiratory muscle fatiguability immediately after IMT. Measurements and Main Results: At a median of 31 months (IQR = 23-32) after hospitalization, 21 of 30 individuals reported relevant persistent exertional dyspnea. Diaphragm muscle weakness on exertion and reduced diaphragm cortical activation were potentially related to exertional dyspnea. Compared with sham control, IMT improved diaphragm and inspiratory muscle function (sniff transdiaphragmatic pressure, 83 cm H 2 O [IQR = 75-91] vs. 100 cm H 2 O [IQR = 81-113], P  = 0.02), inspiratory muscle fatiguability (time to task failure, 365 s [IQR = 284-701] vs. 983 s [IQR = 551-1,494], P  = 0.05), diaphragm voluntary activation index (79% [IQR = 63-92] vs. 89% [IQR = 75-94], P  = 0.03), and dyspnea (Borg score, 7 [IQR = 5.5-8] vs. 6 [IQR = 4-7], P  = 0.03). Improvements persisted for 6 weeks after IMT completion. Conclusions: To the best of the authors' knowledge, this study is the first to identify a potential treatment for persisting exertional dyspnea in long COVID and provide a possible pathophysiological explanation for the treatment benefit. Clinical trial registered with www.clinicaltrials.gov (NCT04854863, NCT05582642).

Background: COVID patients continue to experience unremitting symptoms that extend far beyond the initial illness. While there is rapid accumulation of data on acute COVID treatment in hospitalized patients, little is known regarding post-COVID management., Objectives: To describe our center's experience treating post-COVID sub-syndromes encountered in Post-COVID Lung Clinic., Methods: We retrospectively reviewed data on 98 post-COVID patients evaluated in our clinic between 07/01/2020-12/31/2022. We encountered three distinct post-COVID subtypes: 1) respiratory complaints associated with increased O2 requirements and abnormal CT findings (post-COVID interstitial lung disease [ILD]), 2) respiratory complaints associated with tachycardia (post-COVID dyspnea-tachycardia syndrome [DTS]). Post-COVID ILD patients (n = 28) received steroids in combination with cell cycle inhibitor (mycophenolate mofetil-MMF). Post-COVID DTS patients (n = 16) were treated with metoprolol. 3) A third, undifferentiated group presented with mild respiratory complaints and normal spirometry (n = 17) and was followed in clinic without initiation of a specific treatment., Results: In treated post-COVID ILD patients, mean oxygen requirements at rest (1.96 ± 1.79 L/NC) decreased to 0.89 ± 1.29 L/NC at 6 months follow-up, p = 0.005. In patients with post-COVID DTS, mean heart rate at rest decreased (98 ± 15 bpm to 79 ± 11 bpm) at 6 months follow-up, p = 0.023. 60 % of patients reported an improvement in exertional dyspnea., Conclusions: Our descriptive study presents a single center outpatient COVID-19 clinic experience. We encountered 3 post-COVID sub-syndromes and describe their treatments: post-COVID interstitial lung disease [ILD] treated with a novel regimen of MMF and steroids, post COVID dyspnea-tachycardia syndrome [DTS] treated with metoprolol, and a third subgroup with mild undifferentiated symptoms without specific treatment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Post COVID-19 syndrome is a frequent disabling outcome, leading to a delay in social reintegration and return to working life., Study Design: This was a prospective observational cohort study. The main objective was to explore the effectiveness of a Spa rehabilitation treatment on the improvement of post COVID-19 dyspnoea and fatigue, also analyzing the relationship between such symptoms. Additionally, it was assessed if different clinical characteristics could predispose patients in experiencing post COVID-19 symptoms or could influence the effectiveness of a Spa intervention., Methods: From July to November 2021, 187 post COVID-19 patients were enrolled in the study. All the patients complained persi-sting dyspnoea, whose impact on daily activities was assessed using the modified Medical Research Council dyspnoea scale. 144 patients (77.0%) reported also fatigue. The Spa treatment was started at least 3 months after COVID-19 acute phase. At the end of the treatment, patients were asked to rate the improvement in the dyspnoea and fatigue sensation. 118 patients also underwent the modified Borg Dyspnoea Scale for severity estimation of Exertion Dyspnoea and the Barthel index for severity estimation of Physical Limitation., Results: 165 out of 187 patients (88.2%) reported an improvement in dyspnoea, while 116 out 144 patients (80.6%) reported an improvement in both dyspnoea and fatigue. On a total of 118 subjects, a clinically significant improvement in the modified Borg Dyspnoea Scale (i.e. Delta Borg equal or more than -2.0 points) was reached by the 50.8% of patients, while a clinically significant improvement in the Barthel index (i.e. Delta Barthel equal or more than +10.0 points) was reached by the 51.7% of them. The 31.4% of patients reached a minimal clinically important improvement in both the modified Borg Dyspnoea Scale and the Barthel index. No risk factors were associated to a clinically impacting dyspnoea at entry, while a BMI>30 Kg/m2 was the main risk factor for chronic fatigue. Presence of respiratory comorbidities, obesity and severe acute COVID-19 (phenotype 4) configured risk factors for the lack of improvement of dyspnoea after the treatment, while no risk factors were associated to a lack of improvement for fatigue. Older age, obesity and comorbidities seemed to make more difficult to reach a clinically meaningful improvement in the modified Borg Dyspnoea Scale and the Barthel index after treatment. Female gender may imply more physical limitation at entry, while male patients seem to show less improvement in the Barthel index after treatment., Conclusions: Dyspnoea and fatigue were confirmed to be important post COVID-19 symptoms even in younger subjects of wor-king age and subjects with absent or modest pulmonary alterations at distance from acute COVID-19. A Spa health resort seems to be an effective "low-intensity" setting for a rehabilitation program of such patients. There is a strong relationship in terms of improvement between dyspnoea and fatigue, even if risk factors for their occurrence appear to be different. The improvement in exertion dyspnoea and physical limitation seemed to be less mutually related, probably due to a greater complexity in the asses-sment questionnaires. Some risk factors may predict a lack of improvement in symptoms after treatment.

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease that affects exocrine glands, mainly the salivary and lacrimal glands, leading to the development of sicca symptoms. Patients with pSS may also present with extraglandular manifestations, including lung involvement, estimated to occur in 9-24% of cases. Shrinking lung syndrome (SLS) is an uncommon respiratory complication primarily associated with systemic lupus erythematosus, with a prevalence of approximately 1% in these patients. It typically manifests as dyspnea, pleuritic chest pain, lung volume reduction, and a restrictive pattern on respiratory function tests. Cases reporting SLS with other connective tissue diseases, including pSS, are even rarer. Herein, we describe a case of a 57-year-old woman with a 10-year history of pSS who presented with dyspnea and pleuritic chest pain. After evaluation, the patient was diagnosed with SLS based on clinical, radiologic, laboratorial, and electrophysiologic characteristics. In addition, we identified and analyzed previously published cases of SLS in pSS. Treatment includes corticosteroids, immunosuppressants, and respiratory muscle training. This study highlights the importance of considering SLS in the differential diagnosis of patients with pSS and respiratory symptoms., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: Disclosures Dr Welsh and Dr Schuldt have no conflicts of interest to report.

Objective: The aim of the study was to compare the effectiveness of a telerehabilitation exercise program versus "wait-and-see" on physical exertion, quality of life, dyspnea severity, heart rate, and oxygen saturation in patients with post-COVID fatigue and dyspnea., Design: Sixty-four patients were enrolled in this randomized clinical trial. A telerehabilitation program based on patient education, physical activity, airway clearing, and breathing exercise interventions was conducted. Self-perceived physical exertion during daily living activities, dyspnea severity, health-related quality of life and physiological outcomes, and the 6-min walking test were assessed at baseline, after the program and at 1- and 3-mo follow-up periods., Results: The experimental group experienced greater improvements in self-perceived physical exertion during daily living activities, dyspnea severity, health-related quality of life, and 6-min walking test (all, P < 0.001). In addition, patients undergoing the telerehabilitation program reported lower exertion scores at rest and after the 6-min walking test (both, P < 0.001). Between-group oxygen saturation differences were found at rest ( P < 0.001), but not after the 6-min walking test ( P = 0.024). Finally, significant between-group differences were found for heart rate after the 6-min walking test ( P < 0.001)., Conclusions: Although both groups showed a significant improvement after 3 mos of follow-up, the group receiving the telerehabilitation program described a greater improvement compared with the group receiving no intervention., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Long COVID is defined as persistency of symptoms, such as exertional dyspnea, twelve weeks after recovery from SARS-CoV-2 infection., Objectives: To investigate ventilatory efficiency by the use of cardiopulmonary exercise testing (CPET) in patients with exertional dyspnea despite normal basal spirometry after 18 (T 18 ) and 36 months (T 36 ) from COVID-19 pneumonia., Methods: One hundred patients with moderate-critical COVID-19 were prospectively enrolled in our Long COVID program. Medical history, physical examination and lung high-resolution computed tomography (HRCT) were obtained at hospitalization (T 0 ), 3 (T 3 ) and 15 months (T 15 ). All HRCTs were revised using a semi-quantitative CT severity score (CSS). Pulmonary function tests were obtained at T 3 and T 15 . CPET was performed in a subset of patients with residual dyspnea (mMRC ≥ 1), at T 18 and at T 36 ., Results: Remarkably, at CPET, ventilatory efficiency was reduced both at T 18 (V' E /V'CO 2 slope = 31.4±3.9 SD) and T 36 (V' E /V'CO 2 slope = 31.28±3.70 SD). Furthermore, we identified positive correlations between V' E /V'CO 2 slope at T 18 and T 36 and both percentage of involvement and CSS at HRCT at T 0 , T 3 and T 15 . Also, negative linear correlations were found between V' E /V'CO 2 slope at T 18 and T 36 and DL CO at T 3 and T 15 ., Conclusions: At eighteen months from COVID-19 pneumonia, 20 % of subjects still complains of exertional dyspnea. At CPET this may be explained by persistently reduced ventilatory efficiency, possibly related to the degree of lung parenchymal involvement in the acute phase of infection, likely reflecting a damage in the pulmonary circulation., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Field tests are commonly used as complements of cardiopulmonary exercise test (CPET) to evaluate the functional exercise capacity. The aims of this study were to validate the one-minute sit-to-stand test (STST) in congenital heart disease (CHD) children and to evaluate the possibility of predicting the peakVO 2 using the STST in this paediatric population., Methods: Children (8- to 18-year-old) followed for a CHD and performing CPET were recruited prospectively. Concomitantly, they performed STST. The heart rate (HR), oxygen saturation (SpO 2 ), muscular fatigue and dyspnoea were recorded before (t0), immediately after (t1) and 1min after the end of the STST (t2)., Results: We observed a poor but significant correlation between the STST and the peakVO 2 (r=0.306; p=0.013). A significant difference between girls and boys were observed for peakVO 2 (p<0.001), HR t0 (p=0.030), HR t1 (p=0.002) and HR t2 (p<0.001). The proposed model of prediction, including the number of STST, weight, height and age explains 37% of the predicted peakVO 2 variance., Conclusion: The STST can provide relevant data on physical capacity in children with CHD. When CPET cannot be performed, we therefore propose an alternative equation using the STST as a surrogate of peakVO 2 in CHD children., (Copyright © 2024 SEPAR. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Manual breathing assist technique (MBAT) is a common physical therapy technique used to facilitate airway clearance and improve ventilation and oxygenation. The effects during and immediately after intervention in individuals with chronic obstructive pulmonary disease (COPD) are unknown. This study aimed to investigate the acute effects and potential mechanisms of MBAT on lung volume, dyspnea, and oxygenation in individuals with COPD., Methods: This non-randomized quasi-experimental pre-test/post-test study included participants from pulmonary rehabilitation programs at Tagami Hospital (COPD group) and a community exercise program (Healthy group). During a single session, MBAT was applied during the expiration of every breath for 10 minutes. Dyspnea and lung volumes (tidal volume; VT, inspiratory capacity; IC, inspiratory reserved capacity; IRV, expiratory reserve capacity; ERV) were collected at baseline and after MBAT. Pulse oximetry (SpO2), skeletal muscle oxygenation (SmO2), and oxy- and deoxy-hemoglobin (O2Hb and HHb) using near-infrared spectroscopy (NIRS) were collected at baseline, during, and after MBAT. Between-group comparisons were conducted using the Mann-Whitney U-test and chi-square analyses. Within-group changes before and after MBAT were analyzed using the Wilcoxon signed-rank test. The Kruskal-Wallis test was used to detect differences in NIRS variables in each phase and over time., Results: Thirty participants with COPD, matched for age and sex, were included, with 15 individuals per group. The difference scores of VT, IRV, and IC were significantly higher in the Healthy group than in the COPD group, but improvements in dyspnea and SpO2 were significantly higher in the COPD group. Compared to baseline, ERV decreased significantly in both groups, with dyspnea and SpO2 improving significantly only in the COPD group. Inspiratory accessory muscle ΔO2Hb and ΔHHb were significantly higher and lower (respectively) during MBAT in the COPD group compared to the Healthy group. Additionally, only the COPD group had increased SmO2 during and after MBAT compared to baseline., Conclusions: MBAT in patients with COPD had acute physiological effects in reducing dyspnea by facilitating expiration and decreasing the recruitment of accessory respiratory muscles. MBAT may help individuals with COPD reduce dyspnea before exercise therapy in a pulmonary rehabilitation program., Competing Interests: This work was conducted in accordance with ethical standards. The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: When the work load of the respiratory muscles increases and/or their capacity decreases in individuals with COPD, respiratory muscle activation increases to maintain gas exchange and respiratory mechanics, and perception of dyspnea occurs. The present study aimed to compare diaphragm and accessory respiratory muscle activation during normal breathing, pursed-lip breathing, and breathing control in different dyspnea relief positions, supine and side lying., Methods: A cross-sectional study design was used. Sixteen individuals with COPD age between 40-75 y were included. Pulmonary function was evaluated by spirometry, muscle activation by surface electromyography, and dyspnea by the modified Borg scale. Muscle activation was measured in the diaphragm, scalene, sternocleidomastoid, and parasternal muscles. The evaluation was made in the dyspnea relief positions (sitting leaning forward, sitting leaning forward at a table, leaning forward with back against a wall, standing leaning forward, and high lying), seated erect, supine, and side lying., Results: There were significant differences between the 8 positions ( P < .001). There was no significant difference in muscle activation between sitting leaning forward and sitting leaning forward at a table position with analyzing post hoc test results ( P > .99 for each muscle). However, muscle activation was lower in these 2 positions than in the other positions ( P < .001 for each muscle). Muscle activation was greater in the supine position than in the other positions ( P < .001 for each muscle). No difference was observed in muscle activation between the seated erect, leaning forward with back against a wall, standing leaning forward, high-lying, or side-lying positions ( P > .05 for each muscle with a minimum P value of .09)., Conclusions: The use of sitting leaning forward and sitting leaning forward at a table positions together with breathing control may help people with COPD to achieve more effective dyspnea relief and greater energy efficiency., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Objective: To investigate whether an early comprehensive pulmonary rehabilitation intervention initiated during hospital admission is safe and effective for patients with acute exacerbation of chronic obstructive pulmonary disease., Design: Prospective randomized controlled study., Subjects/patients: Patients with acute exacerbation of chronic obstructive pulmonary disease., Methods: In total, 108 patients were randomized to the early comprehensive pulmonary rehabilitation and usual care groups within 48 hours. The 6-min walking distance, quality of life, breathlessness, and inspiratory muscle strength were measured on admission and discharge. Any adverse events of pulmonary rehabilitation were recorded., Results: On discharge, the patients in the early comprehensive pulmonary rehabilitation group had a more significant improvement in the 6-min walking distance (47.5 vs 23.0, p = 0.04). There was no significant difference in quality of life and breathlessness between the 2 groups. In the early comprehensive pulmonary rehabilitation group, inspiratory muscle strength and peak inspiratory flow were significantly improved, and the changes were much more pronounced than in the usual care group. There were no adverse events., Conclusion: Early comprehensive pulmonary rehabilitation is safe and effective for hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease, and should be performed during the early stage of hospitalization.

Competing Interests: Conflict of interest: none declared.

Fibrotic hypersensitivity pneumonitis (HP) has a poor prognosis when no antigen is identified, which occurs in many cases. We present a case of HP due to foam exposure in bedding, an unrecognised cause of HP. A woman was referred for dyspnoea and cough. High-resolution chest computed tomography (HRCT) showed a three-density pattern with gas trapping. Pulmonary function tests (PFTs) revealed restriction and reduced diffusing capacity. Bronchoalveolar lavage showed lymphocytosis (43%) and lung cryobiopsy showed fibrosis, lymphocytic infiltration and multinucleated giant cells. She had foam in mattress and pillows but no other exposures. Her symptoms, PFTs, and imaging improved after avoiding foam in her bedding. After re-exposure to a foam pillow, her symptoms, PFTs, and HRCT worsened. Microbiological analysis of the foam pillow reported Penicillium spp , known to cause HP. Foam exposure is a novel cause of HP, and foam avoidance can prevent disease progression and death., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A 58-year-old man was admitted with a typical presentation of acute left heart failure. However, the patient showed a partial response to the anti-heart failure therapy. Following admission, a continuous fever was monitored, and a CT scan revealed that multiple opacities on bilateral lungs had progressed. Bronchoscopy was performed, and Coxiella burnetii was detected by Metagenomic next-generation sequencing (mNGS) in bronchoalveolar lavage (BALF), and transbronchial lung biopsy showed organizing pneumonia. Considering that the patient had a history of rabbit breeding and delivery, with some newborn rabbits dying before he became ill, organizing pneumonia secondary to Q fever pneumonia was diagnosed. Anti-Q fever treatment was initiated and the patient's temperature returned to normal. Glucocorticoid was administered after adequate treatment for Q fever. The patient's symptom of dyspnea relieved soon and opacities on CT scan were absorbed remarkably. The final diagnosis was organizing pneumonia secondary to Q fever pneumonia accompanied with left heart failure.

Introduction: Dyspnea is a common and distressing symptom in patients with advanced malignant and non-malignant diseases. It is a subjective experience that can only be described by the patients themselves and can be associated with a massive reduction in quality of life, including social isolation and wish to hasten death. Often there is an affective component such as anxiety or panic. Objective parameters do not necessarily correlate with the subjective experience. Health professionals often underestimate and inadequately treat the burden of dyspnea. The introduction of the concept of chronic breathlessness syndrome or acute-on-chronic-breathlessness aims to illustrate the nature of the condition and facilitate the identification and access to appropriate treatment. The management of dyspnea is complex, and for effective treatment, a combination of general, non-pharmacological, and pharmacological measures is usually advisable. Opioids should be offered to patients with incurable cancer and refractory dyspnea for symptom relief. They can be supplemented with benzodiazepines in cases of concomitant anxiety. The administration of oxygen is only indicated in cases of hypoxemia. Key measures include education, self-management skills acquisition and advance care planning for emergency situations., Competing Interests: Die Autorin hat keine Interessenkonflikte im Zusammenhang mit diesem Artikel deklariert., (© 2024 Aerzteverlag medinfo AG.)

Case Presentation: A 62-year-old woman came to our hospital with worsening cough and dyspnea over the preceding week, during which time she had been treated with azithromycin and prednisone for suspected pneumonia. She had no fever, chills, or sweats, but her cough had become productive of clear to blood-tinged phlegm during the interval. Medical history was significant for insulin-dependent diabetes mellitus and OSA. She had quit smoking 44 years earlier and had no history of lung disease. She was a bank teller residing in southeastern Minnesota and described no relevant inhalational or environmental exposures, drug use, aspiration, or travels preceding her illness., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

This is a self report. It is age related because I am 96 years old; about 5 years ago I was asymptomatic in this respect. I describe the difficulties to think to have to take a breath without getting evidence of hypoxia such as flashes of light and other evidence of hypoxia such as loss of muscle tone. The problem I have is loss of autonomic function which normally controls breathing without the need to think to take a breath., (© 2024. Springer-Verlag GmbH Germany.)

Dyspnea is the most common and activity-limiting symptom for those with chronic obstructive pulmonary disease (COPD). Treatment is complex, palliative care (PC) dyspnea relief interventions are poorly understood, and PC remains underutilized in COPD despite national guidelines and recommendations. The purpose of this rapid review was to explore the concept of dyspnea and role of PC through the lens of providers, caregivers, and patients with COPD. A systematic approach for synthesis was used to identify 13 articles published between January 2018 and October 2023. Team members compared data via visualization and theme clustering to identify key conclusions describing operationalization of dyspnea, management, and PC implications. Dyspnea operationalization was challenging, with inconsistent measurement and terminology. Dyspnea was a significant burden in COPD and contributed to complexity of treatment. Opioids were used most often to treat dyspnea, but provider perspectives and biases can influence treatment decisions and perceptions of opioid therapy by the patient and caregiver. Evidence-based clinical practice guidelines and policies are needed to clarify the use of opioid therapy for dyspnea management to reduce stigmatization and barriers to treatment. Provider education should emphasize a multipronged approach to treatment of dyspnea in COPD with integration of PC early in the care continuum., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 by The Hospice and Palliative Nurses Association. All rights reserved.)

Objective: Bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS) are causes of bilateral vocal fold immobility (BVFI) and may cause shortness of breath, stridor, and need for surgical intervention. Although increased body mass index (BMI) is associated with restrictive breathing patterns in patients with normal upper airways, it is unclear how BMI impacts dyspnea and need for surgical intervention in BVFI patients., Study Design: Retrospective cohort study., Setting: Three tertiary academic centers in the United States., Methods: Demographics, BMI, Dyspnea Index (DI), etiology, presence of tracheostomy and surgical intervention (dilation, tracheostomy, cordotomy, arytenoidectomy, open reconstruction) were collected. Primary outcomes included dyspnea measured by DI and need for surgery to improve airway. Linear regressions were performed to assess continuous outcomes. Mann-Whitney U-test was utilized to assess categorical outcomes., Results: Among 121 patients, 52 presented with BVFP and 69 with PGS. Previous neck surgery was the most common cause of BVFI (40.2%). 44.3% of patients received a tracheostomy. Through multivariate linear regression, increased BMI was significantly associated with increased DI in the entire cohort (β = .43, P = .016). Increased BMI was also associated with need for any surgical intervention (odds ratio [OR] = 1.07, 95% confidence interval [CI] = [1.01-1.13]) in the overall cohort. When stratifying our data, BMI was only significantly associated with DI in BVFP (β = .496) and need for surgical intervention in PGS (OR = 1.11, 95% CI = [1.01-1.21]), although a positive trend was seen in all analyses., Conclusion: Increased BMI may correlate with worsening dyspnea symptoms and need for surgical intervention in patients with BVFI. Weight-loss-related counseling may benefit symptom management., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Aim: This study aims to explore the duration and influencing factors of care-seeking delay among patients with heart failure (HF) in China., Methods and Results: A convergent mixed method containing a cross-sectional study and two parts of qualitative studies was designed, following the STROBE and COREQ guidelines. Convenience sampling was applied to recruit patients with HF from two general hospitals from December 2021 to December 2022. Purposive sampling was used to enrol healthcare professionals from two general hospitals and two community hospitals from June to November 2022. Among the 258 patients with HF in the cross-sectional study, the median duration of care-seeking delay was 7.5 days. The result integration indicated that the delay duration was influenced by the dyspnoea symptom burden, the oedema symptom burden, and the depression status. The lower dyspnoea symptom burden, the higher oedema symptom burden, and the higher depression score were related to the prolonged care-seeking delay duration. The duration was also affected by the COVID-19 pandemic, level of support from medical system, and the symptom management abilities of the caregivers. The COVID-19 pandemic, low level of support from medical system, and limited symptom management abilities of caregivers were related to the prolonged care-seeking delay duration., Conclusions: Care-seeking delay among patients with HF needs attention in China. The duration of care-seeking delay of patients with HF was influenced by the dyspnoea symptom burden, the oedema symptom burden, and depression status, as well as the COVID-19 pandemic, level of support from medical system, and the symptom management abilities of the caregivers., (© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Context: Dyspnea, a prevalent and debilitating symptom in patients with advanced lung cancer, negatively affects symptom burden and prognosis. Physical activity has emerged as a promising non-pharmacological intervention for managing dyspnea., Objectives: This study compared the effectiveness of two widely-recognized physical activity modalities, namely Tai Chi (TC) and aerobic exercise (AE) for treating dyspnea in patients with advanced lung cancer., Methods: Patients with advanced lung cancer (n=226) were randomized into TC, AE, or control groups. There was no baseline dyspnea requirement for patients. The AE group received two 60-minute supervised sessions and home-based exercises per month, the TC group received 60-minute sessions twice weekly, and the control group received exercise guidelines for 16 weeks. The primary outcome (sleep quality) of the study has been previously reported. In this secondary analysis, we focused on dyspnea outcomes, including overall and lung cancer-specific dyspnea. Assessments were conducted at baseline (T0), 16 weeks (T1), and one year (T2)., Results: Compared to the control group, TC significantly improved overall dyspnea at T1 (between-group difference, -8.69; P=0.03) and T2 (between-group difference, -11.45; P=0.01), but not AE. Both AE (between-group difference, -11.04; P=0.01) and TC (between-group difference, -14.19; P<0.001) significantly alleviated lung cancer-specific dyspnea at T2 compared with the control group., Conclusion: Both TC and AE alleviate dyspnea severity in patients with advanced lung cancer, and continuous exercise can yield substantial improvements. Due to its multi-component nature, Tai Chi has a greater effect on dyspnea., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Dyspnea, or breathlessness, is an important symptom in amyotrophic lateral sclerosis/motor neuron disease (ALS/MND). We examined the measurement properties of the Dyspnea-12., Methods: Rasch analysis enabled conversion of raw Dyspnea-12 scores to interval level metric equivalents. Converted data were used to perform trajectory modeling; those following different trajectories were compared for demographic, clinical, symptom, and functioning characteristics. Logistic regression examined differences between distinct trajectories., Results: In 1022 people, at baseline, mean metric Dyspnea-12 was 7.6 (SD 9.3). 49.8% had dyspnea, severe in 12.6%. Trajectory analysis over 28 months revealed three breathlessness trajectories: group 1 reported none at baseline/follow-up (42.7%); group 2 significantly increased over time (9.4%); group 3 had a much higher level at baseline which rose over follow-up (47.9%). Group 3 had worse outcomes on all symptoms, functioning and quality of life; compared to group 1, their odds of: respiratory onset sixfold greater; King's stage ≥3 2.9 greater; increased odds of being bothered by choking, head drop, fasciculations, and muscle cramps; fatigue and anxiety also elevated ( p  < .01)., Conclusion: Dyspnea is a cardinal symptom in ALS/MND and can be quickly measured using the Dyspnea-12. Raw scores can easily be converted to interval level measurement, for valid change scores and trajectory modeling. Dyspnea trajectories reveal different patterns, showing that clinical services must provide monitoring which is customized to individual patient need. Almost half of this large population had worsening dyspnea, confirming the importance of respiratory monitoring and interventions being integrated into routine ALS care.

A 69-year-old man who underwent a liver transplant in 2014 due to hepatitis C virus hepatopathy was evaluated for dyspnea on exertion and chest pain.

We describe a rare occurrence of unilateral vocal fold paralysis associated with a cervical osteophyte abutting the course of the recurrent laryngeal nerve. Trans-nasal laryngoscopy is vital in diagnosing vocal fold paralysis, but often does not provide insight into etiology. This case highlights the importance of radiographic imaging in newly diagnosed vocal fold paralysis, and underscores the principle that a diagnosis is not idiopathic until all sources have been ruled out., Competing Interests: Declaration of Conflicting InterestsThe authors declare that there are no conflicts of interest.

Background: Pulmonary rehabilitation (PR) is an effective treatment method for chronic obstructive pulmonary disease (COPD). However, individuals with chronic diseases that require lifelong treatment and experience exacerbations need motivational methods., Objectives: The aim of this study was to examine the effects of virtual reality on symptoms, daily living activity, functional capacity, anxiety and depression levels in COPD exacerbation., Methods: Fifty patients hospitalized for COPD exacerbation were included in the study. They were randomly assigned to two groups. Twenty-five patients participated in a traditional PR (once-daily until discharge), including pedaling exercises. The second/25 patients followed the same protocol but experienced cycling simulation in the forest via virtual reality (VR + PR). All patients were evaluated using 1-minute/Sit-to-Stand test (STST), modified-Medical Research Council (mMRC) scale, COPD Assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), and London Chest Activities of Daily Living (LCADL) before and after the treatment., Results: The STST showed an increase in both groups post-treatment, notably higher in the VR + PR (p = 0.037). Dyspnea levels and CAT scores decreased in all patients, but the decrease was greater in the PR + VR group for both parameters (p = 0.062, p = 0.003; respectively). Both groups experienced a reduction in the HADS scores compared to the pre-treatment, with a more significant decrease in depression and the total score in the VR + PR (p < 0.05). LCADL's sub-parameters and total score, excluding household, decreased in both groups after treatment (p < 0.05). The improvement was more substantial in the VR + PR., Conclusions: Virtual reality provides benefits in the management of COPD exacerbations and can be used safely., Clinical Trial Registiration: Registered at clinicaltrials.gov, registration ID: NCT05687396, URL: www., Clinicaltrials: gov., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To establish the effects of pulmonary rehabilitation (PR) in patients with persistent symptoms after COVID-19 infection. In addition, to compare the modalities of PR services (face-to-face and telerehabilitation) and the duration of PR in weeks (4-8 weeks and >8 weeks)., Data Sources: PubMed/MEDLINE, Embase (Elsevier), Central/Cochrane Library, SciELO Citation Index (Web of Science), and CINAHL., Study Selection: Studies determining the effects of PR in patients with post-COVID-19 syndrome were included and grouped according to PR delivery modality., Data Extraction: Data extraction and quality assessment were independently performed by 2 reviewers. The methodological quality was assessed using the Cochrane Risk of Bias Tool 1 (RoB-1)., Data Synthesis: The literature search retrieved 1406 articles, of which 7 studies explored the effects of PR on patients with post-COVID-19 syndrome, with 188 patients randomized to PR. The mean age of participants was 50 years and 49% were women. Meta-analysis showed an increase in exercise capacity with PR compared with control (6-minute walking test: mean difference: 60.56 m, 95% confidence interval: 40.75-80.36), a reduction in fatigue (Fatigue Severity Scale: -0.90, -1.49 to -0.31) but no change in dyspnea (-0.57, -1.32 to 0.17) and muscle strength (3.03, -1.89 to 7.96). There were no differences between telerehabilitation and face-to-face PR regarding effects on peripheral muscle strength (P=.42), dyspnea (P=.83), and fatigue (P=.34). There were no differences between programs 4-8 weeks and >8 weeks regarding exercise capacity (P=.83), peripheral muscle strength (P=.42), and dyspnea (P=.76)., Conclusions: PR improves exercise capacity and reduces fatigue in patients with post-COVID-19 syndrome. Duration of PR (4-8 weeks vs > 8 weeks) or PR modality (telerehabilitation vs face-to-face) did not affect outcomes but data were limited and based on subgroup analysis. Further evidence is required to determine the optimal delivery mode and duration of PR for post-COVID-19 syndrome., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The six-minute walk test (6MWT) is widely used to assess functional capacity and prognosis in patients with idiopathic pulmonary fibrosis (IPF). However, studies on oxygen saturation recovery after the 6MWT in patients with IPF are rare. In our study, we investigated the relationship between oxygen saturation recovery time and dyspnea, fatigue, quality of life, prognostic markers and pulmonary hypertension (PH)., Methods: In this cross-sectional study, IPF patients diagnosed according to current guidelines and followed up in our Interstitial Lung Disease Outpatient Clinic between 2021 and 2022 were included. Demographics, data from spirometry, diffusion capacity measurement, arterial blood gas analysis, transthoracic echocardiography and the 6MWT were recorded. The oxygen saturation recovery time, distance saturation product (DSP), gender-age-physiology (GAP) index and composite physiological index (CPI) scores were calculated. Dyspnea severity was assessed by the modified Medical Research Council (mMRC) and Dyspnoea-12 (D-12) scales, fatigue severity by the Multidimensional Fatigue Inventory (MFI-20) and quality of life by the St George's Respiratory Questionnaire (SGRQ)., Results: Fifty IPF patients (34 men, 16 women, age: 66.8 ± 7.3 years) were included in the study. The mean FVC was 77.8 ± 19.3%, the DLCO was 52.9 ± 17.1%, the 6-minute walk distance (6MWD) was 385.7 ± 90.6 m, the GAP index was 3.5 ± 1.5, and the CPI was 43.7 ± 14.1. Oxygen saturation after the 6MWT reached pretest values at an average of 135.6 ± 73.5 s. The oxygen saturation recovery time was longer in patients with higher GAP index scores (Rs = 0.870, p < 0.001), CPI scores (Rs = 0.906, p < 0.001), desaturation (Rs = 0.801, p < 0.001), FVC%/DLCO% (Rs = 0.432, p = 0.002), sPAP (Rs = 0.492, p = 0.001), TRV (Rs = 0.504, p = 0.001), mMRC (Rs = 0.913, p < 0.001), MFI-20 (Rs = 0.944, p < 0.001), D-12 scale (Rs = 0.915, p < 0.001) and SGRQ scores (Rs = 0.927, p < 0.001); lower FVC (%) (Rs=-0.627, p < 0.001), DLCO (%) (Rs=-0.892, p < 0.001), PaO 2 (Rs=-0.779, p < 0.001), DSP (Rs=-0.835, p < 0.001), and 6MWD (Rs=-0.763, p < 0.001). A total of twenty patients (40%) exhibited an increased risk of PH. According to our multiple regression analysis, oxygen saturation recovery time was independently associated with the GAP index (p = 0.036), the lowest oxygen saturation occurring during the 6MWT (p = 0.011) and the SGRQ score (p < 0.001)., Conclusions: Our results showed that oxygen saturation recovery time is associated with dyspnea, fatigue, quality of life, increased risk of PH and prognostic markers in IPF. Therefore, we recommend continuous measurement of oxygen saturation after 6MWT until pretest values are reached., (© 2024. The Author(s).)

New coronavirus infection may lead to long-term consequences, particularly to post-COVID syndrome, one of the most common manifestations of which is dyspnea. Post-COVID-19 shortness of breath may persist from one to several months and even years that results in low quality of life of patients. The review highlights possible risk factors and causes of dyspnea in post-COVID period such as lung damage, cardiovascular pathology, hyperventilation syndrome, dysfunction of the autonomic nervous system, detraining, anemia, etc. The authors present data about COVID-19-associated causes of dyspnea and severity of acute COVID-19. The review emphasizes the importance of a multidisciplinary approach to the diagnosis and treatment of patients with shortness of breath in post-COVID-19 period.

Background: The role of obesity on dyspnea in chronic obstructive pulmonary disease (COPD) patients remains unclear. We aimed to provide an assessment of dyspnea in COPD patients according to their Body Mass Index (BMI) and to investigate the impact of obesity on dyspnea according to COPD severity., Methods: One hundred and twenty seven COPD patients with BMI ≥ 18.5 kg/m² (63% male, median (interquartile range) post bronchodilator forced expiratory volume of 1 second (post BD FEV 1 ) at 51 (34-66) % pred) were consecutively included. Dyspnea was assessed by mMRC (Modified medical research council) scale. Lung function tests were recorded, and emphysema was quantified on CT-scan (computed tomography-scan)., Results: Twenty-five percent of the patients were obese (BMI ≥ 30kg/m²), 66% of patients experienced disabling dyspnea (mMRC ≥ 2). mMRC scores did not differ depending on BMI categories (2 (1-3) for normal weight, 2 (1-3) 1 for overweight and 2 (1-3) for obese patients; p = 0.71). Increased mMRC scores (0-1 versus 2-3 versus 4) were associated with decreased post BD-FEV 1 (p < 0.01), higher static lung hyperinflation (inspiratory capacity/total lung capacity (IC/TLC), p < 0.01), reduced DLCO (p < 0.01) and higher emphysema scores (p < 0.01). Obese patients had reduced static lung hyperinflation (IC/TLC p < 0.01) and lower emphysema scores (p < 0.01) than non-obese patients. mMRC score increased with GOLD grades (1-2 versus 3-4) in non-obese patients but not in obese patients, in association with a trend towards reduced static lung hyperinflation and lower emphysema scores., Conclusion: By contrast with non-obese patients, dyspnea did not increase with spirometric GOLD grades in obese patients. This might be explained by a reduced lung hyperinflation related to the mechanical effects of obesity and a less severe emphysema in severe COPD patients with obesity., Competing Interests: GD reports personal fees from Chiesi, GSK and AstraZeneca outside the submitted work. SD reports personal fees from Boehringer Ingelheim and Sanofi-Aventis outside the submitted work. J.M. Perotin reports lecture honoraria from AstraZeneca and support for attending meetings from AstraZeneca and Chiesi; outside the submitted work. The authors report no other conflicts of interest in this work., (© 2024 Dupuis et al.)

This case report presents the diagnostic journey of a man in his mid-70s who experienced shortness of breath, cough, recurrent episodes of fever, weight loss, pruritic erythroderma, uveitis and macrocytic anaemia. The initial diagnosis of cryptogenic organising pneumonia was made based on antibiotic refractory infiltrates seen in the lung CT scan. The patient initially responded favourably to immunosuppression but experienced a recurrence of symptoms when the corticosteroid dose was tapered. Despite ongoing systemic inflammation and refractory symptoms, it took nearly a year to establish the diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic) syndrome. This case highlights the challenges in diagnosing and managing VEXAS syndrome due to its recent discovery and limited awareness in the medical community, as well as the need to consider this syndrome as a rare differential diagnosis of therapy-refractory pulmonary infiltrates., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Disability, resulting from altered interactions between individuals and their environment, is a worldwide issue causing inequities and suffering. Many diseases associated with breathlessness cause disability but the relationship between disability and the severity of breathlessness itself is unknown.This study evaluated associations between disability using the WHO's Disability Assessment Schedule (WHODAS) 2.0 and levels of long-term breathlessness limiting exertion ., Methods: This population-based, cross-sectional online survey (n=10 033) reflected the most recent national census (2016) by age, sex, state/territory of residence and rurality. Assessments included self-reported disability (WHODAS 2.0 12-item (range 12 (no disability) to 60 (most severe disability)) assessed in 6 domains) and long-term breathlessness limiting exertion (modified Medical Research Council (mMRC) breathlessness scale; 0-4 (4-most severe)). Days in the last month affected by breathlessness were reported., Results: Of respondents (52% women; mean age 45), mean total disability score was 20.9 (SD 9.5). 42% (n=4245) had mMRC >0 (mMRC1 31% (n=3139); mMRC2 8% (n=806); mMRC3,4 3% (n=300)). Every level of long-term breathlessness limiting exertion was associated with greater levels of disability (total p <0.001; each domain p <0.001). The most compromised domains were Mobility and Participation .In the last 30 days, people with severe breathlessness (mMRC 3-4): experienced disability (20 days); reduced activities/work (10 days); and completely forwent activities (another 5 days)., Conclusions: Disability should be in the definition of persistent breathlessness as it is systematically associated with long-term breathlessness limiting exertion in a grade-dependent, multidimensional manner. Disability should be assessed in people with long-term breathlessness to optimise their social well-being and health., Competing Interests: Competing interests: DC is an unpaid member of an advisory board for Helsinn Pharmaceuticals and Specialist Therapeutics, and has consulted to, and received intellectual property payments from Mayne Pharma. The other authors report no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Airway occlusion pressure at 100 ms (P0.1) reflects central respiratory drive. Objectives: We aimed to assess factors associated with P0.1 and whether an abnormally low or high P0.1 value is associated with higher mortality and longer duration of mechanical ventilation (MV). Methods: We performed a secondary analysis of a prospective cohort study conducted in 10 ICUs in France to evaluate dyspnea in communicative MV patients. In patients intubated for more than 24 hours, P0.1 was measured with dyspnea as soon as patients could communicate and the next day. Measurements and Main Results: Among 260 patients assessed after a median time of ventilation of 4 days, P0.1 was 1.9 (1-3.5) cm H 2 O at enrollment, 24% had P0.1 values >3.5 cm H 2 O, 37% had P0.1 values between 1.5 and 3.5 cm H 2 O, and 39% had P0.1 values <1.5 cm H 2 O. In multivariable linear regression, independent factors associated with P0.1 were the presence of dyspnea ( P  = 0.037), respiratory rate ( P  < 0.001), and Pa O 2 ( P  = 0.008). Ninety-day mortality was 33% in patients with P0.1 > 3.5 cm H 2 O versus 19% in those with P0.1 between 1.5 and 3.5 cm H 2 O and 17% in those with P0.1 < 1.5 cm H 2 O ( P  = 0.046). After adjustment for the main risk factors, P0.1 was associated with 90-day mortality (hazard ratio per 1 cm H 2 O, 1.19 [95% confidence interval, 1.04-1.37]; P  = 0.011). P0.1 was also independently associated with a longer duration of MV (hazard ratio per 1 cm H 2 O, 1.10 [95% confidence interval, 1.02-1.19]; P  = 0.016). Conclusions: In patients receiving invasive MV, abnormally high P0.1 values may suggest dyspnea and are associated with higher mortality and prolonged duration of MV.

Background: Zinc fever is well described in medical literature, particularly in workers after handling zinc-containing materials at high temperatures e.g., in the welding of hot-dip galvanized steel sheets. It is not known whether zinc fever also occurs at low temperatures., Case Presentation: We present the case of a 33-year-old Caucasian atopic painter and varnisher with work-related dyspnea, sweating, as well as multiple occurrences of fever. He was sent to Institute for Prevention and Occupational medicine of the German Social Accident Insurance, Institute of the Ruhr-Universität Bochum (IPA) for the evaluation of isocyanate asthma, but an inhalative challenge with hexamethylene diisocyanate was negative. Since symptoms were closely related to the use of zinc coatings at room temperature without adequate protective measures, the diagnosis of zinc fever was made. After exposure cessation the worker immediately became symptom-free. The work as painter and varnisher may be associated with various exposures to hazardous substances. Besides solvents, epoxy compounds and isocyanates, which can cause obstructive respiratory diseases; additionally, zinc-containing agents should be considered as health hazards., Conclusions: This case demonstrates that zinc fever may occur also after application of zinc coatings by spray painting at low temperatures., (© 2024. The Author(s).)

Background: Swallowing is a complex process that requires the coordination of muscles in the mouth, pharynx, larynx, and esophagus. Dysphagia occurs when a person has difficulty swallowing. In the case of subjects with respiratory diseases, the presence of oropharyngeal dysphagia potentially increases lung disease exacerbations, which can lead to a rapid decline in lung function. This study aimed to analyze the swallowing of patients with idiopathic pulmonary fibrosis (IPF)., Methods: Patients with IPF were evaluated using the Eating Assessment Tool (EAT-10), tongue pressure, the Timed Water Swallow Test (TWST), and the Test of Mastication and Swallowing Solids (TOMASS). The findings were related to dyspnea severity assessed by the modified Medical Research Counsil (mMRC) score; the nutritional status screened with Mini Nutritional Assessment (MNA) tool; and pulmonary function tests, specifically spirometry and measurement of the diffusing capacity for carbon monoxide (DLCO), the maximal inspiratory pressure (PImax), and the maximal expiratory pressure (PEmax)., Results: The sample consisted of 34 individuals with IPF. Those who exhibited swallowing modifications scored lower on the MNA than those who did not (9.6 ± 0.76 vs. 11.64 ± 0.41 points; mean difference 1.98 ± 0.81 points; p = 0.02). They also showed poorer lung function when considering the predicted force vital capacity (FVC; 81.5% ± 4.61% vs. 61.87% ± 8.48%; mean difference 19.63% ± 9.02%; p = 0.03). The speed of liquid swallowing was altered in 31of 34 of the evaluated subjects (91.1%). The number of liquid swallows correlated significantly with the forced expiratory volume in 1 s (FEV1)/FVC ratio (r = 0.3; p = 0.02). Solid eating and swallowing assessed with the TOMASS score correlated with lung function. The number of chewing cycles correlated negatively with PImax% predicted (r = -0.4; p = 0.0008) and PEmax% predicted (r = -0.3; p = 0.02). FVC% predicted correlated with increased solid swallowing time (r = -0.3; p = 0.02; power = 0.6). Swallowing solids was also impacted by dyspnea., Conclusion: Patients with mild-to-moderate IPF can present feeding adaptations, which can be related to the nutritional status, lung function, and the severity of dyspnea., (© 2024. The Author(s).)