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Background: Chronic obstructive pulmonary disease (COPD) is a complex, chronic condition. Patients commonly have limited access to face-to-face support due to decreased mobility, symptom b...

ObjectivesBreathlessness ‘crises’ in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED ‘near misses’ where they considered going to the ED but successfully self-managed instead.Design and methodsA qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen’s Transactional Model of Stress and Coping informed interpretive themes.ResultsInterviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services.ConclusionsIn addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients’ generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

Context People with chronic obstructive pulmonary disease experience dyspnea with activities despite optimal medical management. Objectives The purpose of this study was to test the efficacy of two 12-month dyspnea self-management programs (DSMPs), Internet-based (eDSMP) and face-to-face (fDSMP), compared with a general health education (GHE) control on the primary outcome of dyspnea with activities. Methods Participants with chronic obstructive pulmonary disease were randomized to eDSMP (n=43), fDSMP (n=41), or GHE (n=41). The content of the DSMPs were similar and focused on education, skills training, and coaching on dyspnea self-management strategies, including exercise, and only differed in the delivery mode. Dyspnea with activities was measured with the Chronic Respiratory Questionnaire at three, six, and 12 months. Secondary outcomes included exercise behavior and performance, health-related quality of life, self-efficacy for dyspnea management, and perception of support for exercise. The study was registered at Clinicaltrials.gov (NCT00461162). Results There were no differences in dyspnea with activities across groups over 12 months (P=0.48). With the exception of arm endurance (P=0.04), exercise behavior, performance, and health-related quality of life did not differ across groups (P>0.05). Self-efficacy for managing dyspnea improved for the DSMPs compared with GHE (P=0.06). DSMP participants perceived high levels of support for initiating and maintaining an exercise program. Conclusion The DSMPs did not significantly reduce dyspnea with activities compared with attention control. However, the high participant satisfaction with the DSMPs combined with positive changes in other outcomes, including self-efficacy for managing dyspnea and exercise behavior, highlight the need for additional testing of individually tailored technology-enabled interventions to optimize patient engagement and improve clinically relevant outcomes.

Purpose: Patients with lung disease develop coping strategies to relieve dyspnea. The coping strategies of Korean immigrants, however, are poorly understood. The purpose of this study was to describe the strategies that Korean immigrants with asthma or chronic obstructive pulmonary disease (COPD) use to cope with dyspnea and to compare similarities and differences in coping strategies between the two conditions. Design: Outpatients with asthma ( n = 25) or COPD ( n = 48) participated in a cross-sectional descriptive study. Method: Open-ended questions and a structured instrument were used to describe coping strategies for dyspnea. Descriptive and inferential statistics were used to analyze the data. Results: The most prevalent strategy was “I keep still or rest.” Korean immigrants also used traditional therapies to manage dyspnea. Conclusions: Although the coping strategies of Korean immigrants were similar to those of other ethnic groups, they incorporated elements of Asian medical practice and herbs. This finding enables health care providers to better understand Korean immigrants’ efforts to overcome dyspnea and to guide their patients’ approach to coping.

BACKGROUND Current evidence shows that an open visitation policy can benefit patients and families during intensive care unit (ICU) stays. Therefore, an unrestricted visitation policy in the ICU has been proposed as part of patient-centered care. PURPOSE The purpose of this secondary analysis is to explore the likelihood of an ICU with a clinical nurse specialist (CNS) having an open visitation policy when compared with an ICU without a CNS. DESIGN This is a secondary analysis of a survey conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States. METHODS χ Analysis was performed comparing the presence of CNS in the ICU with visitation policies, with P < 0.05 considered statistically significant. RESULTS There were data from 347 hospitals used in the analysis, with 47 hospitals (13.5%) having open visitation policies. There were 108 hospitals (31%) that had a CNS present in the ICU; 14 of the hospitals (13%) had open visitation policies. No significant correlation was found between a CNS being present in the ICU and open visitation policy (odds ratio, 0.93; P = .83), regardless of hospital geographic regions. CONCLUSIONS Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as a change agent in the hospital system, liberalization of visitation in the ICU is an area that could benefit from CNS advocacy.

Background and objective: Little is known about depression in interstitial lung disease (ILD). The aim of this study was to determine the prevalence of depression, characterize the association of depression with clinical variables and describe the natural history of depression in patients with ILD. Methods: In this prospective cohort study, clinical variables were recorded at baseline and 6 months. Depression was measured with the Centre for Epidemiologic Studies Depression scale. Depression prevalence was determined using the established threshold of >15 points. Multivariate linear regression was used to determine the baseline features that independently correlated with baseline depression score and that predicted depression severity at follow-up. Results: Fifty-two subjects were enrolled, and 45 returned for follow-up (three deaths, one lung transplant). Prevalence of depression was 21% at baseline. Independent predictors of depressive symptoms at baseline included dyspnoea severity, pain severity, sleep quality and forced vital capacity (R2 0.67). The odds of clinically meaningful depression at follow-up were 34-fold higher for subjects who had clinically meaningful depression at baseline compared with those who were not (95% confidence interval 3.5–422, P

Introduction Prospectively assessing factors that influence triage nurse assignment of patients to the higher risk level 2 compared to the lower risk level 3 has not previously been explored within the 5-level Emergency Severity Index (ESI) triage system. Considering the large amount of information available about the patient, less experienced triage nurses often struggle in deciding what patient information is truly relevant when assessing if a high-risk situation exists. The primary aim of this study was to identify specific factors used by triage nurses to differentiate level 2 patients from level 3 patients. Methods A convenience sample of triage nurses was recruited from 2 ED sites. If at the completion of the nurse-patient triage interaction the nurse assigned the patient to either level 2 or level 3, the triage nurse then completed a questionnaire related to factors that influenced patient assignment. Results Overall, 18 triage nurses participated in the study with a total of 334 nurse-patient triage interactions collected. Patient age, vital signs, and need for a timely intervention were found to be significant factors that influenced patient assignment to level 2 while expected number of resources influenced patient assignment to level 3. Discussion Utilizing experienced triage nurses on average, this study identified specific, objective factors that, combined with factors already delineated in the ESI Version 4 Implementation Manual, have useful implications for less experienced triage nurses by providing a more comprehensive and relevant foundation for data gathering and decision making.

The primary purpose of this secondary analysis was to determine whether 103 participants with chronic obstructive pulmonary disease rated the affective dimension of dyspnea (dyspnea-related anxiety and dyspnea-related distress) separately from the sensory dimension (intensity) during baseline exercise testing conducted as part of a randomized clinical trial. A secondary purpose was to determine if dyspnea-related anxiety and distress were rated distinctly different from other measurements of anxiety. At the end of a 6-minute walk and an incremental treadmill test, participant ratings of the magnitude of dyspnea-related anxiety and distress on the Modified Borg Scale were significantly different from their ratings of the intensity of dyspnea. Dyspnea-related anxiety and distress also appeared to be concepts independent from measures of state anxiety, negative affect, and anxiety before a treadmill test.

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.

Objective To describe levels of anxiety and self‐efficacy for childbirth in nulliparous women during the late third trimester and to identify relationships among those variables, prehospitalization labor pain, management strategies, and hospital admission status. Design A longitudinal, descriptive study. Participants Thirty‐five English‐speaking nulliparous women, 18 to 40 years of age, more than or equal to 38 week’s gestation, with uncomplicated pregnancies. All participants had a significant other (husband or partner) and attended childbirth education programs. Main Outcome Measures Spielberger Trait Anxiety Inventory, Prenatal Self‐Evaluation Questionnaire, Childbirth Self‐Efficacy Inventory, McGill Pain Questionnaire‐Short Form, postpartum interviews, and medical records review. Results Prenatal anxiety was significantly related to self‐efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor, and admitting cervical dilation. The number of management strategies used was related to pain scores during labor before hospital admission. Women who spent longer periods of time at home in labor arrived at the hospital with a greater cervical dilation. Conclusions Antenatal characteristics influence intrapartal outcomes in nulliparas. Labor environment, at home and in the hospital, is recognized as an important component of the first childbirth experience.

Effective management of dyspnea in chronic obstructive pulmonary disease (COPD) requires a clearer understanding of its underlying mechanisms. This roundtable reviews what is currently known about the neurophysiology of dyspnea with the aim of applying this knowledge to the clinical setting. Dyspnea is not a single sensation, having multiple qualitative descriptors. Primary sources of dyspnea include: (1) inputs from multiple somatic proprioceptive and bronchopulmonary afferents, and (2) centrally generated signals related to inspiratory motor command output or effort. Respiratory disruption that causes a mismatch between medullary respiratory motor discharge and peripheral mechanosensor afferent feedback gives rise to a distressing urge to breathe which is independent of muscular effort. Recent brain imaging studies have shown increased limbic system activation in response to various dyspneogenic stimuli and emphasize the affective dimension of this symptom. All of these mechanisms are likely instrumental in exertional dyspnea causation in COPD. Increased central motor drive (and effort) is required to increase ventilation during activity because the inspiratory muscles become acutely overloaded and functionally weakened. Abnormal dynamic ventilatory mechanics and excessive chemostimulation during exercise also result in a widening disparity between escalating central neural drive and restricted thoracic volume displacement. This neuromechanical uncoupling may form the basis for the distressing sensation of unsatisfied inspiration. Interventions that alleviate dyspnea in COPD do so by improving ventilatory mechanics, reducing central neural drive, or both-thereby partially restoring neuromechanical coupling of the respiratory system. Self-management strategies address the affective aspect of dyspnea and are essential to successful treatment.

Purpose To evaluate the differences in the long-term outcomes of dyspnea, exercise performance, health-related quality of life, and health resource utilization following a dyspnea self-management program with 3 different "doses" of supervised exercise. Patients and methods In a prospective, randomized, single-blind, 1-year trial, patients with stable chronic obstructive pulmonary disease (N = 103; age 66 +/- 8, females 57; FEV1 44.8% +/- 14% predicted) were randomly assigned to either: (1) Dyspnea self-management program (DM); (2) DM plus 4 supervised exercise sessions (DM-exposure); or (3) DM plus 24 supervised exercise sessions (DM-training). The dyspnea self-management program included individualized education and demonstration of dyspnea self-management strategies, an individualized home walking prescription, and biweekly nurse telephone calls. Outcomes were measured at baseline and every 2 months for 1 year. Results The DM-training group had significantly greater improvements in dyspnea during incremental treadmill test and in exercise performance on the incremental and endurance treadmill tests at 6 and 12 months compared with the other 2 groups. Dyspnea with activities of daily living and self-reported physical functioning significantly improved for all groups over time. The dose-response relationship between supervised exercise and improvement in dyspnea present at 2 months was not sustained over the year. Conclusion Consistent with previous findings from evaluation studies of pulmonary rehabilitation programs, the greater number of supervised exercise training sessions improved laboratory dyspnea and performance more than the other two doses of exercise. In the long term, the improvement in dyspnea with activities of daily living and physical functioning was similar for all 3 groups.

The Internet provides patients, families, and health providers with unparalleled opportunities to learn, inform, and communicate with one another. This paper is a review of studies that have evaluated the impact of professionally facilitated Internet-based programs for diverse clinical populations on health outcomes, utilization, and user satisfaction. The findings suggest that some outcomes in certain groups can be moderately improved and that user satisfaction has been generally positive. Given the increasing need to provide timely and effective patient-centered care, a stronger evidence base for eHealth applications must be established before broader deployment of such programs will take place.

The primary purpose of this study was to determine if there are three distinct factors representing ratings of dyspnea during laboratory exercise, clinical ratings of dyspnea, and pulmonary function in patients with moderate to severe chronic obstructive pulmonary disease (COPD) (n = 92) using factor analysis. Subjects (mean age 66 ± 7 yrs; FEV1% predicted 44.7 ± 14.0) were randomly assigned to one of three treatment groups to test the effects of three education and exercise training programs. Outcomes were evaluated at baseline and at 2 months after the intervention. Dyspnea ratings with laboratory exercise (SOB) were measured during incremental (ITT) and endurance (ETT) treadmill tests, and a six-minute walk (6MW) using the modified Borg scale. Clinical measures of dyspnea were measured with the Baseline and Transitional Dyspnea Index (BDI/TDI), UCSD Shortness of Breath Questionnaire (SOBQ), Medical Research Council Dyspnea Scale (MRC), Dyspnea subscale of the Chronic Respiratory Questionnaire (CRQ-D), and a global dyspnea question. Pulmonary function parameters included FEV1% predicted, FEV1/FVC, and RV/TLC. The factor analysis yielded three factors that accounted for 58.7% of the total variance in the data: Factor 1, “Dyspnea with Laboratory Exercise” comprised ETT SOB end, ETT SOB isotime, ITTSOB end, ITT SOB isotime, ITT SOB/Time and ETT SOB/Time. Factor 2, “Clinical Dyspnea,” comprised 6MW SOB, 6MW SOB/Feet, BDI, SOBQ, MRC, Global SOB, CRQ-D. Measures of airway resistance (FEV1% predicted, FEV1/FVC) and hyperinflation (RV/TLC) loaded on a third factor, “Pulmonary Function.” An additional post hoc factor analysis with post-intervention data provided similar results. The Global SOB question and ITT SOB isostage variables were relatively more sensitive to change compared to the other outcome variables. We conclude that pulmonary function, clinical ratings of dyspnea, and laboratory ratings of dyspnea are three separate and independent factors and should be included in the routine clinical evaluation of patients with COPD.

PURPOSE: The purpose of this study was twofold: (1) to determine whether exercise training adds to the benefit of a dyspnea self-management (DM) program; and (2) to determine if there is a “dose response” to supervised exercise training (0, 4, or 24 sessions) in dyspnea, exercise performance, and health-related quality of life. METHODS: Subjects with chronic obstructive pulmonary disease (n = 103, 46 men, 57 women; age 66 ± 8 years; forced expiratory volume in 1 second 44.8 ± 14% predicted) were randomized to DM, DM-exposure, or DM-training. Dyspnea self-management included individualized education about dyspnea management strategies, a home-walking prescription, and daily logs. Outcomes were measured at baseline and 2 months as part of a 1-year longitudinal randomized clinical trial. Outcomes included dyspnea during laboratory exercise and with activities of daily living (Chronic Respiratory Questionnaire [CRQ]), Shortness of Breath Questionnaire, Baseline/Transitional Dyspnea Index), exercise performance (incremental treadmill tests (ITTs) and endurance treadmill tests (ETTs), 6-minute walk (6MW), and health-related quality of life (SF-36). RESULTS: The DM-training group had significantly greater improvements than the DM-exposure and the DM groups in dyspnea at isotime during ITT (P = .006); exercise performance during ITT (P = .005), ETT (P = .003), and 6MW (P = .01); SF-36 Vitality (P = .031); and CRQ mastery (P = .007). There was a dose-dependent improvement in CRQ dyspnea scores (P < .05) with significant improvements only in the DM-training and DM-exposure groups. CONCLUSION: Exercise training substantially improved the impact of a dyspnea self-management program with a home walking prescription (DM). This impact tended to be dependent on the “dose” of exercise.

The way, or ways, in which asthmatics recognize specific symptom(s) with varying degrees of their airway obstruction, or asthma severity, is poorly understood. Our purpose was to gain a better understanding of how asthma patients during acute episodes, based on their symptom perception, decide when to seek symptom relief. A cross-sectional design was used to study 32, 16 per group, African Americans and Caucasians with a mean age of 34.5 years. All had mild, stable asthma (FEV1 > or = 70%), were non-smokers, atopic, and had not used inhaled or oral steroids for 3 months. Their mean baseline FEV1 was 97.5% predicted; all were controlled with intermittent use of a beta agonist inhaler. All had a bronchoconstrictor challenge using a provocative concentration of methacholine to achieve a 30% fall (PC30) in their FEV1. After achieving a PC30 and before their first dose of a bronchodilator was given, all subjects were asked: "If you felt this way at home would you take your inhaler?" Subjects were blinded to the fact that the yes/no question was asked when their FEV1 was reduced by 30%. In both groups, 44% responded "no" that they would not use their inhaler at that point in time. This finding suggests that those subjects, the 44% who failed to associate a change in their symptoms with increased airflow obstruction, may be at risk for life-threatening episodes.

BackgroundSelf-management education for cardiopulmonary diseases is primarily provided through time-limited, face-to-face programs, with access limited to a small percentage of patients. Telecommunication tools will increasingly be an important component of future health care delivery. ObjectiveThe purpose of this study was to describe the patterns of technology use in patients attending a cardiopulmonary clinic in an academic medical center. MethodsA prevalence survey was developed to collect data on participant demographics (age in years, sex, and socioeconomic status); access to computers, Internet, and mobile phones; and use of current online health support sites or programs. Surveys were offered by reception staff to all patients attending the outpatient clinic. ResultsA total of 123 surveys were collected between March and April 2014. Technological devices were a pervasive part of everyday life with respondents engaged in regular computer (102/123, 82.9%), mobile telephone (115/117, 98.3%), and Internet (104/121, 86.0%) use. Emailing (101/121, 83.4%), researching and reading news articles (93/121, 76.9%), social media (71/121, 58.7%), and day-to-day activities (65/121, 53.7%) were the most common telecommunication activities. The majority of respondents reported that access to health support programs and assistance through the Internet (82/111, 73.9%) would be of use, with benefits reported as better understanding of health information (16/111, 22.5%), avoidance of difficult travel requirements and time-consuming face-to-face appointments (13/111, 18.3%), convenient and easily accessible help and information (12/111, 16.9%), and access to peer support and sharing (9/111, 12.7%). The majority of patients did not have concerns over participating in the online environment (87/111, 78.4%); the few concerns noted related to privacy and security (10/15), information accuracy (2/15), and computer literacy and access (2/15). ConclusionsChronic disease burden and long-term self-management tasks provide a compelling argument for accessible and convenient avenues to obtaining ongoing treatment and peer support. Online access to health support programs and assistance was reported as useful and perceived as providing convenient, timely, and easily accessible health support and information. Distance from the health care facility and a lack of information provision through traditional health sources were both barriers and enablers to telehealth. This is particularly important in the context of a cardiopulmonary clinic that attracts patients from a large geographical area, and in patients who are most likely to have high health care utilization needs in the future. Telecommunication interfaces will be an increasingly important adjunct to traditional forms of health care delivery.

BACKGROUND Dyspnea (SOB), dyspnea-related anxiety (DA), and exercise performance have been shown to improve after exercise training in patients with Chronic Obstructive Pulmonary Disease (COPD). However, there are no published descriptions of the changes in dyspnea intensity or dyspnea-related anxiety during or across the exercise training sessions. OBJECTIVES To describe and compare the differences in the patterns of change in SOB, DA, and exercise performance during 12 exercise training sessions with and without nurse coaching. METHODS Forty-five dyspnea-limited patients with COPD were randomly assigned to nurse-monitored (ME) or nurse-coached exercise (CE). SOB and DA were rated on a 200 mm VAS every 2 minutes during each of 12 treadmill training sessions. RESULTS Warm-up, peak, cool-down, mean SOB, and peak SOB/stage remained constant over the exercise sessions, with increasing exercise performance for both groups over the 12 sessions (p < .001). There was a significant difference in the pattern of mean SOB over time between the ME and CE group (p < . 05). Mean, peak DA, and peak DA/stage showed a rapid decrease within the first 4 sessions (p < . 05) with no significant differences between the groups. Warm-up and cool-down DA remained constant. There were large intra- and inter-subject variations in the rating of dyspnea and dyspnea-related anxiety within and across sessions. CONCLUSIONS As theoretically proposed, both groups significantly decreased their DA over the training sessions. This decrease was early in the sessions and was not accompanied by a decrease in the SOB. In contrast, subjects maintained a nearly constant mean and peak SOB with increasing exercise performance, suggesting that people may have a dyspnea threshold above which they are unable to tolerate greater dyspnea. Description of the changes in dyspnea and the affective response during training need to be expanded, while studying the type and timing of strategies to enhance the improvement in dyspnea and dyspnea-related anxiety.

Study objectives To determine if African-American and white patients with asthma (1) differ in the words they use to describe their breathlessness, and (2) differ in their perception of breathlessness. Design Descriptive cross-sectional design. Setting and participants The study setting was located in Northern California, an ethnically and economically diverse area. A total of 32 subjects, 16 per group, completed the study. Measurements All had a provocation concentration of methacholine chloride causing a 30% fall in FEV 1 (PC 30 ) of ≤ 8 mg/mL. Serial pulmonary function testing was performed. Breathlessness was measured using the Borg scale and the visual analog scale. Word descriptors were measured by an open-ended word descriptor questionnaire. Results Significant ethnic differences in the words used to describe the sensation of breathlessness were present at PC 30 . African Americans used upper airway word descriptors: tight throat (p scared-agitated (p voice tight (p itchy throat (p tough breath (p deep breath (p lightheaded (p out of air (p aware of breathing (p hurts to breathe (p 30 (p Conclusion This study provides valuable new information about ethnicity and the words used to describe breathlessness during airflow obstruction. Asthmatic African Americans used primarily upper airway word descriptors; whites used lower airway or chest-wall word descriptors. Effective symptom monitoring requires asking the correct question and awareness that ethnic differences in the words used to describe breathlessness may exist.

In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.

This study investigated whether people with chronic obstructive pulmonary disease (COPD) can differentiate distress and anxiety associated with dyspnea from the intensity of dyspnea and the perceived effort of breathing. Fifty-two subjects with COPD rated their perception of the individual components of dyspnea on a 200 mm visual analog scale at rest, after a 6-min walk (6MD), and every 2 min during an incremental treadmill test (ET). Subjects differentiated among the four dyspnea components at the end of the 6MD (p

Study objective To determine whether exercise training with coaching is more effective than exercise training alone in reducing dyspnea and the anxiety and distress associated with it and improving exercise performance, self-efficacy for walking, and dyspnea with activities of daily living. Design Randomized clinical trial of 51 dyspnea-limited patients with COPD assigned to monitored (n=27) or coached (n=24) exercise groups. Setting Outpatient area of university teaching hospital. Intervention Both groups completed 12 supervised treadmill training sessions (phase 1) over 4 weeks followed by 8 weeks of home walking (phase 2). The CE group also received coaching during training. Measurements Perceived work of breathing, dyspnea intensity, distress associated with dyspnea, and anxiety associated with dyspnea were rated on a visual analog scale during incremental treadmill testing and after 6-min walks before and after phase 1. Dyspnea with activities of daily living, self-efficacy for walking, state anxiety, and 6-min walks were measured before and after both phases. Results Dyspnea and the associated distress and anxiety improved significantly for both groups relative to work performed and in relation to ventilation (p Conclusions Coaching with exercise training was no more effective than exercise training alone in improving exercise performance, dyspnea, and the anxiety and distress associated with it, dyspnea with activities, and self-efficacy for walking.

Objective To describe the frequency, manifestations, and correlates of impaired healing of saphenous vein (SV) harvest incisions in hospitalized patients who had undergone coronary artery bypass grafting (CABG). Design Prospective, descriptive, correlational. Setting West Coast university-affiliated medical center. Patients Thirty-two English-speaking adults who had undergone CABG. Outcome Measures Impaired wound healing of SV-harvest incisions. Results The overall indidence of impaired healing was 43.8%. The most frequent manifestations of impaired wound healing at discharge were prolonged erythema (8/32), prolonged drainage (8/32), and both prolonged erythema and drainage (2/32). Correlates of impaired healing of SV-harvest incisions were body mass index (product-moment correlation=0.39, p=0.026) and preoperative use of diuretics (point biserial correlation=0.42, p=0.016). Conclusions Impaired healing of SV-harvest incisions in this sample occurred more frequently than previously indicated in the literature. Although severe wound infections were infrequent, a high degree of impaired healing occurred (43.8% of patients who had undergone CABG). Future studies need to explore the long-term effects of impaired healing and test interventions to mitigate impaired healing in this population.

Context The perception of dyspnea includes both sensory and affective dimensions that are shaped by emotions and psychological, social, and environmental experiences. Previous investigators have studied either measurement or strategies to decrease the affective dimension with laboratory-induced dyspnea. Few have reported the effect of a therapeutic clinical intervention on the affective dimension of dyspnea. Objectives 1) To evaluate the effects of three different versions of a dyspnea self-management program (DM) on the affective dimension of dyspnea, measured by dyspnea-related anxiety (DA) and dyspnea-related distress (DD); and 2) to determine the stability of DA and DD over two baseline incremental treadmill tests (ITTs). Methods Participants with chronic obstructive pulmonary disease were randomly assigned to three 12 month DMs with varying doses of supervised exercise (DM, DM-Exposure, and DM-Training). The measurements of the affective dimension, DA and DD, were rated during ITTs on two baseline days and at two, six, and 12 months. Changes over time in DA and DD were analyzed using linear mixed-effects models. Results Participants in the DM-Training group who received 24 nurse-coached exercise sessions had significantly greater reductions in DA and DD compared with those who had four exercise sessions (DM-Exposure) or only received a home-walking program (DM). Reductions in DA and DD in the DM-Training group were only maintained through six months. There were no significant differences in ratings of DA and DD at end between the two baseline ITTs. Conclusion These findings provide initial support for the positive impact of a self-management program with nurse-coached exercise on the affective dimension of dyspnea. Further investigation of interventions that target the affective dimension in addition to the sensory dimension of dyspnea should be encouraged.

Traditional approaches to patient-reported outcomes diaries have been largely paper based. However, paper-based approaches have inherent inefficiencies such as an inability to communicate the entries in real time to the healthcare team, issues related to transport and mobility, and no tailored output related to what is entered. Traditional paper-based approaches also lack the ability to prompt users at regular intervals to record data. This lack of prompting may lead to delays in entering symptoms and exercises (diary hoarding). Electronic mobile devices have addressed some of these limitations. However, until recently these electronic devices have not been able to deliver the data in real time, thus limiting the ability of the care team to interact and respond. With the emergence of wireless mobile devices, which provide real-time linkages between the patient and the researchers, these limitations are largely eliminated. Yet, it is unclear (whether diary hoarding still occurs and) whether prompts are effective in reducing hoarding over the course of many months. The purpose of this analysis was to conduct a summative evaluation of 7474 automated prompts sent to participants with chronic obstructive pulmonary disease (n = 19). These participants were provided with mobile devices for logging exercise and symptom data over a 6-month period as part of a clinical trial. We found a marginal association between length in the study and delay in submission of exercise and symptom data in response to electronic prompts. Factors associated with delayed response to the prompts included older age, limited computer skills, and reports of no exercise. We recommend that future investigators who are using mobile devices in their research pay careful attention to usability issues as well as strategies that might keep patients engaged and motivated.

As part of a larger ongoing study of nurse-coached practice with dyspnea, 52 subjects (25 men, 27 women) with moderate to severe COPD exercised on a treadmill three times a week for 4 weeks. Subjects were randomized into a coached exercise group, which received nurse coaching during exercise, and a

The purpose of this study was to identify determinants of frequency (days per week), duration (minutes per session), and continuity (persistence over 1 year) of home walking in 103 patients with chronic obstructive pulmonary disease (COPD) who participated in a dyspnea self-management program. Dimensions of home walking exercise were measured by logs and reports of biweekly telephone calls with the intervention nurse. The selection of personal, cognitive, and environmental determinants of home walking was guided by social cognitive theory. Participants walked more frequently if they were exercising before they entered the study, had less depressive symptoms, and were living with friends or family. Duration of walks was influenced by supervised exercise training; living with spouse, friends, or family; and physical conditioning. Participants who walked most consistently over the course of the year had more supervised exercise sessions as part of the dyspnea self-management program, exercised regularly before entering the program, and perceived a gain in social support over the year. These findings can be used to tailor exercise interventions to the specific needs of patients and improve the likelihood of consistent exercise participation.

Little is understood about the characteristics of dyspnea in patients with interstitial lung disease (ILD), and its severity is likely influenced by multiple factors. Depression and functional status are known to influence dyspnea in patients with COPD. The aim of this study was to determine the relationship of dyspnea with clinical parameters, including depression and functional status, in patients with ILD.Dyspnea was measured with the Baseline Dyspnea Index and the University of California San Diego Shortness of Breath Questionnaire. Clinical parameters were recorded. Regression analysis was performed to determine independent correlates of dyspnea.Fifty-two subjects were enrolled. The two dyspnea scales were strongly correlated (r=-0.79; P.00005). The mean levels of dyspnea were 6.5 and 41.0, representing a moderate degree of dyspnea. Clinically meaningful depressive symptoms were found in 23% of subjects. Independent correlates of dyspnea severity for each dyspnea scale were depression score (P=.002 and P.0005), 4-m walk time (P=.001 and P=.06), FVC (P=.07 and P=.004), and diffusing capacity of the lung for carbon monoxide (P=.007). BMI had borderline significant association with the Baseline Dyspnea Index (P=.10).In patients with ILD, dyspnea is associated with depression score, functional status, and pulmonary function. These results suggest that attention to depression and functional status is important in these patients and that treatment directed at these comorbidities may improve dyspnea and quality of life.ClinicalTrials.gov; No.: NCT00611182 ; URL: www. clinicaltrials.gov.

Rationale: Previous research has shown that patients with chronic obstructive pulmonary disease (COPD) desire conversations about end-of-life wishes. However, most clinicians do not initiate these discussions. We explored whether educating patients via Web conferencing (webinar) would equip them with knowledge and skills to engage in conversations about end-of-life care. Results: Prewebinar, 6 of the 7 patients had completed advanced care planning forms but only half had shared these with their clinicians. Most patients felt confident about discussing end-of-life preferences. At 3 months, all participants had taken further action on end-of-life planning. Five felt the webinar was an acceptable option if unable to participate in person. All patients voiced that adding a video stream would have promoted interaction in the context of these sensitive conversations. Conclusions: This pilot project demonstrated that a webinar to educate patients on end-of-life communication was acceptable for the majority of patients. Improvements in audio and video bandwidth may facilitate more interaction among virtual participants. This may be particularly useful for patient education on sensitive topics.

Background This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea. Methods A panel of experts was convened. After a literature review, the panel developed 23 statements covering five domains that were considered relevant to the topic condition. Endorsement of these statements was assessed by levels of agreement or disagreement on a five-point Likert scale using two rounds of the Delphi method. Results The panel defined the topic condition as "dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease." The five domains were: measurement of patient-reported dyspnea, oxygen therapy, other therapies, opioid medications, and ethical issues. In the second round of the Delphi method, 34 of 56 individuals (61%) responded, and agreement of at least 70% was achieved for 20 of the 23 statements. Conclusions For patients with advanced lung or heart disease, we suggest that: health-care professionals are ethically obligated to treat dyspnea, patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, both the patient and clinician should reassess whether specific treatments are serving the goal of palliating dyspnea without causing adverse effects, and it is important for clinicians to communicate about palliative and end-of-life care with their patients.

The primary purpose of this secondary analysis was to determine whether 103 participants with chronic obstructive pulmonary disease rated the affective dimension of dyspnea (dyspnea-related anxiety and dyspnea-related distress) separately from the sensory dimension (intensity) during baseline exercise testing conducted as part of a randomized clinical trial. A secondary purpose was to determine if dyspnea-related anxiety and distress were rated distinctly different from other measurements of anxiety. At the end of a 6-minute walk and an incremental treadmill test, participant ratings of the magnitude of dyspnea-related anxiety and distress on the Modified Borg Scale were significantly different from their ratings of the intensity of dyspnea. Dyspnea-related anxiety and distress also appeared to be concepts independent from measures of state anxiety, negative affect, and anxiety before a treadmill test.