Tests to uncover and assess breathlessness: a proposed framework

Abstract

Purpose of ReviewBreathlessness is a common, distressing, and limiting symptom that many people avoid by reducing their activity. This review discusses exertional tests that can be used for uncovering and assessing breathlessness depending on the person's severity of illness, function, the setting, and aim of the assessment. Recent FindingsStandardized exertional tests are useful to uncover 'hidden' breathlessness earlier in people who may have adapted their physical activity to limit their breathing discomfort. In 'more fit' ambulatory people and outpatients, cardiopulmonary exercise testing is the gold standard for assessing symptom severity, underlying conditions, and mechanisms and treatment effects. Among field tests, the 6-min walk test is not useful for assessing breathlessness. Instead, the 3-min step test and walk test are validated for measuring breathlessness change in chronic obstructive pulmonary disease. In people with more severe illness (who are most often not breathless at rest), reported tests include upper limb exercise or counting numbers aloud, but a valid and useful test for this population is lacking. SummaryA framework for selecting the most appropriate test to assess breathlessness validly is proposed, and research needs are identified.

Abnormal breathlessness during cardiopulmonary exercise testing - validation in people with chronic airflow limitation

“…These findings have several important implications. First, they reinforce the use of CPET as the gold standard method to evaluate exertional breathlessness in terms of underlying mechanisms, treatment effects 8,[33][34][35] , and also the presence and level of abnormal exertional breathlessness. Second, the CPET normative reference equations provide the first valid benchmark for defining abnormal exertional breathlessness.…”

“It's like a forgotten issue sometimes …”: Qualitative study of individuals living and caring for people with chronic breathlessness

“…Develop standardised exertional tests to uncover “hidden” breathlessness in individuals who have reduced physically demanding activities to avoid breathlessness 5 …”

Editorial: Advancing the management of respiratory problems

“…Breathlessness is highly prevalent in people with serious life-limiting conditions; it is the most common symptom of chronic respiratory diseases, but also prevalent in cardiac and neurological conditions, and some advanced cancers. Ekstro ¨m [2] explores exertional tests for both uncovering and assessing breathlessness and considers these in relation to key factors such as the person's severity of illness, function, the setting and aim of the assessment. To overcome the challenges of recall and reduced physical activity, the review recommends standardized testing to uncover under-reported or ''hidden'' breathlessness in people with reduced activity (which may be reduced in response to the breathing distress at exertion) and to provide valid assessment of breathlessness severity across people and for the individuals over time.…”

“…Each of these contributions to this issue show how the field has progressed in the last year but each contribution also clearly identifies key areas for future research. Improved measurement of breathlessness in relation to standardized exertional testing is needed including reference equations for normal breathlessness for different levels of exertion, validation of breathlessness tests for people with conditions other than COPD, and the development of tests to evaluate severity and change in breathlessness in people with more severe illness for use at point of care [2]. More research is needed on cough mechanisms and how they differ between different diseases, as well as whether cough treatment affects cough-associated symptoms such as fatigue, anxiety, pain and social isolation [3].…”