Breathlessness is a common and distressing symptom in advanced stages of malignant and non-malignant disease [1–4]. Breathlessness is highly prevalent, occurring in up to 80% of patients with advanced cancer, in around 56–98% of patients with chronic obstructive pulmonary disease (COPD) and in up to 90% of patients with chronic heart failure (CHF) [5, 6]. Patients with chronic breathlessness resulting from advanced disease report high symptom burden, palliative care needs [7–9] and suffer from anxiety and depression [10]. Negative consequences on health and quality of life (QoL) have been shown, e.g. for COPD patients [11]. Breathlessness is one of the most common reasons for emergency department visits and hospital admissions in cancer patients [12–14].

Footnotes 

This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article.

Conflict of interest: Dr. Schunk reports grants from BMBF (German Federal Ministry of Education and Research), during the conduct of the study;.

Conflict of interest: Dr. Le has nothing to disclose.

Conflict of interest: Dr. Syunyaeva has nothing to disclose.

Conflict of interest: Dr. Haberland has nothing to disclose.

Conflict of interest: Dr. Dr. med. Tanzler has nothing to disclose.

Conflict of interest: Dr. Mansmann has nothing to disclose.

Conflict of interest: Dr. Schwarzkopf has nothing to disclose.

Conflict of interest: Dr. Seidl has nothing to disclose.

Conflict of interest: Dr. Streitwieser has nothing to disclose.

Conflict of interest: M. Hofmann has nothing to disclose.

Conflict of interest: Dr. Mueller has nothing to disclose.

Conflict of interest: Dr. Weis has nothing to disclose.

Conflict of interest: Dr. Morawietz has nothing to disclose.

Conflict of interest: Dr. Rehfuess has nothing to disclose.

Conflict of interest: Dr. Huber reports grants from German Ministry of Education and Research, during the conduct of the study;.

Conflict of interest: Dr. Berger reports grants from Federal Ministry of Education and Research Germany (BMBF), during the conduct of the study;.

Conflict of interest: Dr. Bausewein reports grants from German Ministry of Research and Education, during the conduct of the study;.

Effectiveness of a specialised breathlessness service for patients with advanced disease in Germany: a pragmatic fast-track randomised controlled trial (BreathEase).

Purpose of review Breathlessness is a multidimensional sensation for which a range of instruments exists for children, youth and adults, capable or unable to self-report distress with breathing. This review presents developments and applications of multidimensional assessments of breathlessness. Recent findings Excluding unidimensional measures and instruments assessing the impact of breathlessness, at least eight psychometrically robust instruments exist, which comprehensively assess one or more specific domains of the sensation of breathlessness (intensity, sensory quality, affective distress). These instruments have evolved from modest beginnings (describing breathlessness in various patient cohorts) to a growing use as primary or secondary outcomes in observational, clinical, and experimental trials exploring breathlessness mechanisms and intervention effects. For adults and children unable to autonomously communicate breathing discomfort, instruments include combinations of physiological and behavioural markers of distress. Nonverbal (graphic scales) have potential use beyond paediatric applications. Summary Traditionally, breathlessness has been considered as a 'black box' with unidimensional measures reflecting box size (intensity, unpleasantness). Multidimensional instruments reveal the composition of the black box of breathlessness allowing detailed descriptions of an individual's breathlessness experience, quantification of sensory qualities, affective distress, and emotional responses with the potential to capture change over time and treatment effects in each dimension.

Multidimensional measurement of breathlessness: recent advances.

Purpose of review Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion. Recent findings Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time. Summary To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus.

Standardized measurement of breathlessness during exercise.

Well-designed nonpharmacological interventions can harness treatment responses seen in the placebo armhttp://ow.ly/EgoM30o7k1v

https://erj.ersjournals.com/content/erj/53/4/1900156.full.pdf

The importance of differentiating behavioural and psychological treatment effects from placebo in respiratory interventions.

Effectiveness of personalized air curtain in reducing exposure to airborne cough droplets

Dyspnoea-targeted interventions should probably combine multiple approaches (multidirectional) and their evaluation should take the complex nature of dyspnoea into account (multidimensional)http://ow.ly/tLaM30ndprk

https://erj.ersjournals.com/content/erj/53/1/1802471.full.pdf

Lessons from negative dyspnoea studies: arguments for the multidimensional evaluation of multidirectional therapeutic approaches.

Question addressed In contrast with pain, dyspnoea is not visible to the general public who lack the corresponding experiential baggage. We tested the hypotheses that the generalised use of face masks to fight SARS-CoV2 dissemination could change this and sensitise people to respiratory health. Methods General population polling (1012-person panel demographically representative of the adult French population –quota sampling method–; 517 women, 51%). 860 (85%) answered “no” to “treated for a chronic respiratory disease” (“respiratory healthy”, RH) and 152 “yes” (“respiratory disease”, RD). 14% of RH respondents reported having a close family member treated for a chronic respiratory disease (RH-family+ and RH-family−). Respondents described mask-related attitudes, beliefs, inconveniencies, dyspnoea, and changes in their respiratory health vision. Results Compliance with masks was high (94.7%). Dyspnoea ranked first among mask inconveniencies (RD 79.3%, RH 67.3%, p=0.013). “Air hunger” was the main sensory dyspnoea descriptor. Mask-related dyspnoea was independently associated with belonging to RH-family+ (Odds Ratio [OR] [95% confidence interval (CI)]: 1.85 [1.16–2.98]) and removing masks to improve breathing (OR 5.21 [3.73–7.28]). It was negatively associated with considering masks effective to protect others (OR]: 0.42 [0.25–0.75]). Half the respondents were more concerned with their respiratory health since wearing masks; 41% reported better understanding patients’ experiences. Answer to the question Wearing protective face masks leads to the mass discovery of breathing discomfort. It raises the public9s awareness of what respiratory diseases involve and sensitises to the importance of breathing. These data should be used as the fulcrum of respiratory-health-oriented communication actions.

Lifting dyspnoea invisibility: COVID-19 face masks, the experience of breathing discomfort, and improved lung health perception - a French nationwide survey.

In healthy humans, inspiratory threshold loading deteriorates cognitive performances. This can result from motor-cognitive interference (activation of motor respiratory-related cortical networks vs...

Impact of inspiratory threshold loading on brain activity and cognitive performances in healthy humans.

The mere expectation of dyspnoea contributes to shape the lives of patients with chronic respiratory diseases: approaches addressing anticipatory mechanisms will provide new therapeutic avenues for persistent dyspnoea in the near future https://bit.ly/3mkv6US

Harnessing the power of anticipation to manage respiratory-related brain suffering and ensuing dyspnoea: insights from the neurobiology of the respiratory nocebo effect

Laure Serresse

Papers

Lessons from negative dyspnoea studies: arguments for the multidimensional evaluation of multidirectional therapeutic approaches.

Lifting dyspnoea invisibility: COVID-19 face masks, the experience of breathing discomfort, and improved lung health perception - a French nationwide survey.

Impact of inspiratory threshold loading on brain activity and cognitive performances in healthy humans.

Harnessing the power of anticipation to manage respiratory-related brain suffering and ensuing dyspnoea: insights from the neurobiology of the respiratory nocebo effect