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Descriptors of Dyspnea in Obstructive Lung Diseases Descrittori Di Dispnea Nelle Patologie Ostruttive Delle Vie Aeree

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Descriptors of Dyspnea in Obstructive Lung Diseases Descrittori Di Dispnea Nelle Patologie Ostruttive Delle Vie Aeree Multidisciplinary Focus on: Dyspnea edited by / a cura di Giorgio Scano Descriptors of dyspnea in obstructive lung diseases Descrittori di dispnea nelle patologie ostruttive delle vie aeree Sabina A. Antoniu University of Medicine and Pharmacy “Gr. T. Popa” Iasi, Department of Internal Medicine II - Pulmonary Disease, Pulmonary Disease University Hospital ABSTRACT descrittori) con i meccanismi fisiologici e fisiopatologici sot- In obstructive lung diseases such as asthma and COPD dysp- tostanti. Questi studi sono stati effettuati nell’asma piutto- nea is a common respiratory symptom with different charac- sto che nella BPCO ed i descrittori di dispnea sono stati ri- teristics given the different pathogenic mechanisms: in COPD scontrati utili per identificare i pazienti con asma in pericolo initially it can occur during exertion but then it increases pro- di vita. Tuttavia studi ulteriori sono necessari per esplorare ul- gressively along with the airflow obstruction, whereas in teriormente questi descrittori e la loro utilità clinica. In que- asthma it occurs episodically and is caused by transient bron- sta rassegna vengono analizzati i meccanismi della dispnea choconstriction. nei vari sottogruppi di patologie respiratorie di tipo ostrutti- The language of dyspnea includes a large range of clinical vo, come pure i descrittori di dispnea e la loro utilità nella pra- descriptors which have been evaluated for their correlation (of tica clinica. one or several descriptors) with underlying physiologic/phys- iopathologic mechanisms. These studies were done in asthma Parole chiave: Descrittori, dispnea, patologie ostruttive respi- rather than in COPD, and dyspnea descriptors were found to be ratorie, test da sforzo. useful in identifying patients with life-threatening asthma. However further studies are needed to further explore such descriptors and their clinical utility. INTRODUCTION This review discusses dyspnea mechanisms in various Obstructive lung diseases are represented mainly by obstructive lung disease subsets as well as the descriptors of dyspnea and their utility in clinical practice. asthma and by chronic obstructive pulmonary dis- ease (COPD) which are both inflammatory diseases Keywords: Descriptors, dyspnea, exercise testing, obstructive lung of the airways but with different pathogenesis and diseases. clinical manifestations: in asthma inflammation is triggered and maintained usually by allergens, ren- RIASSUNTO ders the bronchial muscle hyperreactive to various Nelle patologie ostruttive respiratorie come l’asma e la BPCO stimuli including allergens themselves, and the con- la dispnea è un sintomo molto comune, con caratteristiche sequent bronchospasms manifest clinically with differenti a seconda del meccanismo patogenetico sotteso: episodic dyspnea and wheezing subsequently nella BPCO si verifica inizialmente durante esercizio fisico per relieved with rescue bronchodilator medication. In poi incrementare progressivamente col progredire dell’ostru- zione bronchiale, mentre nell’asma insorge episodicamente COPD cigarette smoking exposure is the main risk ed è causata da un broncospasmo transitorio. factor and the airways inflammation resulting from Il linguaggio della dispnea include un’ampia varietà di descrit- such aggression is progressive, reducing the airways tori clinici di cui è stata valutata la correlazione (di uno o più lumen, and respiratory symptoms are dominated by + Sabina A. Antoniu University of Medicine and Pharmacy “Gr.T.Popa” Iasi, Department of Internal Medicine II- Pulmonary Disease, Pulmonary Disease University Hospital 30 Dr I Cihac Str, 700115 Iasi, Romania email: [email protected] Data di arrivo: 09/04/2010 – Accettato per la pubblicazione: 20/04/2010 Multidisciplinary Respiratory Medicine 2010; 5(3): 216-219 216 MRM Descriptors of dyspnea – of dyspnea Descriptors SA Antoniu dyspnea, cough and sputum production which are augmented by increased ventilatory demands increase in severity with disease progression or dur- due to ventilation perfusion mismatches, metabolic ing disease exacerbations. acidosis, hypoxemia, increased sympathetic tone, Dyspnea is a common clinical denominator in both etc. [1]. asthma and COPD and its different characteristics Gas exchange abnormalities occurring in COPD in the two diseases reflect the different pattern of patients during exercise are represented by arterial inflammation and of airways obstruction. This hypoxemia and/or hypercapnia: the former occurs review discusses separately the mechanisms of dys- in the milder COPD stages due to reduced ventila- pnea in asthma and COPD, its descriptors, and their tion and shunting, whereas in more advanced clinical utility. COPD alveolar hypoventilation adds to the above di dispnea Descrittori mentioned mechanisms. Exercise hypercapnia in COPD is due to reduced respiratory drive, breath- DYSPNEA IN COPD ing patterns altered to minimize respiratory discom- In COPD dyspnea is one of the main respiratory fort, or ventilatory muscle fatigue and has been symptoms present during stable or exacerbated shown to be associated with greater dynamic hyper- state. It manifests initially during exertion and then, inflation [3]. as the disease progresses, also during rest. It is Neuromechanical dissociation (NMD) between the caused by airflow obstruction which is secondary to attempted and actual respiratory effort which airways inflammation, airways remodelling and occurs between efferent motor neurons and afferent sputum hypersecretion; reduced lung elastic recoil fibers has been hypothesised as a physiopathogenic due to emphysema and the obstruction of small air- mechanism in chronic obstructive pulmonary dis- ways result in incomplete air expelling and dynam- eases such as COPD and asthma [1]. In a study ic hyperinflation (“air trapping”) [1]. evaluating the perception of exertional breathless- ness during symptom-limited incremental cycle Mechanisms of dyspnea in COPD exercise testing in normal subjects and in patients Overall exertional dyspnea in COPD is the result of with chronic airflow limitation, perceived inspirato- complex pathohysiological mechanisms including ry difficulty was assessed with the Borg scale dynamic hyperinflation, increased ventilatory (BorgIN), inspiratory effort was evaluated with demand relative to impaired capacity, hypoxemia, esophageal pressure expressed as a fraction of max- hypercapnia, and neuromechanical dissociation imal esophageal pressure at isovolume (Table I) [1]. [Pes/PImax]), and breathing pattern, operational During exercise the reduced pulmonary elastic lung volumes (end-expiratory/inspiratory lung vol- recoil contributes to an increase in the end-expira- umes [EELV/EILV]) were measured and compared at tory lung volume, and dynamic hyperinflation (DH) a standard V˙O2 of 50% predicted maximum. occurs. There are several adaptive mechanisms to Breathlessness descriptors chosen and reported the DH, including the reconfiguration of the rib immediately after exercise differed between normal cage in order to contain the overinflated lungs, and subjects and patients with chronic airflow obstruc- an increased activity of the respiratory muscles, in tion. Descriptors of increased ‘work/effort’ and particular of the diaphragm, in order to generate ‘heaviness’ of breathing were chosen by both nor- increased pressures able to compensate the mal subjects and patients with airflow obstruction reduced elastic recoil, but such mechanisms can whereas the latter category constantly chose usually be compensatory during resting or during descriptors such as ‘increased inspiratory difficulty’ more reduced airways inflammation (such as in sta- (75%), ‘unsatisfied inspiratory effort’ (75%), and ble disease). During exertion or increased inflam- ‘shallow breathing’ (50%). The ratio of Pes/PImax to mation (exacerbation) the increased DH impairs the VT/predicted VC was identified as the strongest cor- ability of the respiratory muscles to increase the relate with the Borg scale [4]. intrathoracic pressure in response to the increased The differences between the quality of descriptors drive of breathing. The increased breathing rate is for dyspnea among healthy subjects and patients consequent to the inability of the overinflated lung with airflow obstruction suggest that the latter cate- to maintain or increase the inspiratory capacity dur- gory receives altered peripheral sensory afferent ing exercise [2]. During exercise such abnormalities information from mechanoreceptors in the respira- tory muscles, chest wall and lungs signaling to them that the mechanical response of the ventilatory sys- tem is insufficient or inappropriate for the effort expended [5]. TABLE I: PATHOPHYSIOLOGICAL MECHANISMS OF DYSPNEA This sense of increased effort is believed to be the IN COPD result of corollary discharge relayed from the motor cortex to the sensory cortex in the forebrain. Unlike • Dynamic lung hyperinflation normal subjects, in whom respiratory effort matches • Increased ventilatory demand relative to impaired capacity the ventilator demand both at rest and during exer- • Hypoxemia cise, in patients with COPD there is increasing dis- • Hypercapnia parity between effort and ventilatory output (i.e. • Neuromechanical dissociation neuromechanical dissociation) which becomes MRM 217 more prominent as exercise progresses, because TABLE II: FACTORS AFFECTING SYMPTOMS PERCEPTION IN dynamic hyperinflation constrains tidal volume ASTHMA expansion. Consequently COPD patients experi- ence intolerable
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