Abe Guz Fellowship – Assessment

Introduction

• Breathlessness is a subjective experience and thus the gold standard for breathlessness assessment is based on patient self­report.[1]
• Breathlessness is intimately related to physical and emotional exertion and patients usually avoid activity causing a vicious cycle of deconditioning. The response to ‘are you short of breath’ is often therefore ‘no’, rendering the breathlessness ‘invisible’.[2]
• Enquiry should include the activities that the patient has reduced or given up because of breathlessness.
• Commonly used objective physiological measures such as respiratory rate or oxygen saturations only have a weak association with subjective sensations of breathlessness. In general, lung function tests correlate poorly with the sensation of breathlessness and relatively normal values should not preclude enquiring about breathlessness.
• The European Society of Medical Oncology (ESMO) recommends that:
  • Breathlessness assessment should include a unidimensional measure of severity, a measure of multi-dimensional functional impact, and patient interview.[2]
• The revised Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria requires symptoms, broader impact, and exacerbations to be assessed along with spirometry, to classify stage of disease, guide COPD management, and monitor progress.[3]
• A comprehensive review of breathlessness should therefore include:
  • A measure of how severe the patient feels their breathlessness is
  • A measure of how their breathlessness impacts on their daily functioning

Self-reported

• Modified Medical Research Council Dyspnoea scale (mMRC)
  • Used to assess the degree of baseline functional disability due to dyspnoea.
  • Useful for characterising baseline dyspnoea in patients with respiratory diseases
  • Correlates with healthcare-associated quality of life, morbidity, and possibly mortality for patients with respiratory diseases
  • This does not capture patient effort
• Visual Analogue Scale (VAS) / Numeric Rating Scale (NRS)
  • Two similar ways of measuring patient reported severity of breathlessness, both are quick and simple to administer.
  • Ekstrom et al found that an improvement of ∼10 mm on a 100-mm VAS is likely to be clinically meaningful across commonly used measures of chronic breathlessness (current intensity, unpleasantness, and average, best and worst intensity over the past 24 h) to evaluate clinical benefit and effects in therapeutic trials.[4]
  • VAS
    • Using horizontal line, 100 mm in length, anchored by word descriptors at each end that represent the severity of symptoms from 0 “no breathlessness” to 10 “very severe breathlessness.”
    • The patient marks on the line the point that the patient believes represents his or her perception of his or her current state.
    • The VAS score is determined by measuring in millimeters from the left-hand end of the line to the point that the patient marks.
    • These scales are most useful when looking at change within individuals and are of less value for comparing across a group of individuals at one time point.
  • NRS
    • Similar to the VAS in that it is bounded at the left-most end with “no breathlessness” and at the right-most end with “very severe breathlessness”.
    • Instead of a line without marks, numbers from 0 to 10 are spaced evenly across the page.
    • Patients are instructed to circle the number that represents the amount of breathlessness that they are experiencing at the time of the evaluation.
    • A variation of this scale is the verbal numeric scale (VNS), in which patients are asked to verbally state a number between 0 and 10 that corresponds to their present pain intensity.
  • The Borg Rating of Perceived Exertion (RPE) scale/modified Borg scale
    • A tool for measuring an individual’s effort and exertion, breathlessness and fatigue during physical work – it provides a measure of how hard it feels that the body is working based on the physical sensations that the subject experiences, including increased heart rate, increased respiration or breathing rate, increased sweating and muscle fatigue.