Editorial: Dyspnoea and pain: an interesting analogy
Article first published online: 5 MAR 2008
© 2008 The Author
Journal of Clinical Nursing
Volume 17, Issue 7, pages 841–842, April 2008
How to Cite
Yorke, J. (2008), Editorial: Dyspnoea and pain: an interesting analogy. Journal of Clinical Nursing, 17: 841–842. doi: 10.1111/j.1365-2702.2008.02299.x
- Issue published online: 5 MAR 2008
- Article first published online: 5 MAR 2008
Recent evidence suggests that dyspnoea is analogous to pain in terms of both sensory quality and affective dimensions. Dyspnoea, the sensation of breathing discomfort, and pain are two very unpleasant sensations: both can be unyielding and substantially affect quality of life. However, the prevalence of dyspnoea is under appreciated. In a study of over 1500 seriously ill patients admitted to hospital, half complained of dyspnoea, equalling the number complaining of pain (Desbiens et al. 1999). In the final stages of terminal illness, the severity and frequency of dyspnoea increase while pain decreases (Mercadante et al. 2000). However, our knowledge of the mechanisms of dyspnoea and its assessment and treatment is decades behind that of pain.
The similarities between dyspnoea and pain are apparent when reviewing widely accepted definitions for each. The American Thoracic Society (1999) definition states that dyspnoea is ‘a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations’. The International Association for the Study of Pain (1979) define pain as ‘an unpleasant sensory and emotional process associated with actual or potential tissue damage, or described in such terms’. These definitions highlight the multidimensionality of dyspnoea and pain, consisting of at least two common elements; a sensory perception and an unpleasant emotional feeling accompanying this sensory perception.
The ATS (1999) also stresses that breathlessness is a subjective symptom, which can only be described and interpreted by the patient. Likewise, McCaffery (1979) describes the pain experience as whatever the experiencing person says it is, existing whenever the experiencing person says it does. Both dyspnoea and pain vary in intensity between individuals and within the same individual at different times; this is, in part, a consequence of subjective interpretation. It is the subjective nature of dyspnoea and pain that makes the pursuit for appropriate assessment techniques challenging. How can we know if a treatment is beneficial for the patient unless the individual’s experiences can somehow be quantified? This is particularly pertinent for nurses who often lead interventions, such as pulmonary rehabilitation, that attempt to ameliorate the effect of breathlessness (Woo 2000).
Pain multidimensionality has long been recognized (Melzack & Wall 1965), and has directed further pain research and its clinical assessment and management. Melzack developed multidimensional assessment of pain over 30 years ago with the McGill Pain Questionnaire (1971), which consists of representative words that describe pain quality and affect. We have all experienced different qualities of pain, such as sharp, aching, cramping or burning. These pain descriptors, among others, are used by health professionals and patients alike because they offer a common language with which the cause of the problem can often be identified. Similarly, we can probably all identify with the emotive aspect of pain and can adapt our response to the experience depending on the situation at hand and our memory of previous pain experiences. Attempting to assess pain without consideration of the contribution of psychological factors is inappropriate and the affective descriptor words of the McGill Pain Questionnaire (e.g. tiring-exhausting, fearful, sickening and cruel-punishing) attempt to capture this dimension.
In many respects, it is the concept of multidimensional pain assessment, developed by Melzack et al., that researchers have used to guide the study of dyspnoea. In particular, studies concerning the semantics of breathlessness follow similar work on the language of pain and the development of instruments such as the McGilll Pain Questionnaire. This work has seen a common language for breathlessness emerge. The vast majority of research, however, relates to dyspnoea intensity and quality. There is a relative paucity of work relating to patients’ affective response to breathlessness.
A number of phrases are used to describe the quality of dyspnoea that form at least three separable qualities referred to as ‘air hunger’, ‘effort or work’ and ‘tightness’. This classification is based on studies that analysed subjective descriptions of dyspnoea evoked by different respiratory stimuli or by different clinical conditions (Elliot et al. 1991). These distinguishable sensations most likely arise from different afferent sources. Air hunger, associated with hypercapnia, is likened to the perception at the end of a long breathe hold and described as ‘not getting enough air’ or ‘uncomfortable urge to breath’ (Schwartzstein et al. 1989). A perception of the ‘effort’ or ‘work’ of breathing is evoked when the work of breathing is increased by high ventilation or external loads (Moosavi et al. 2000). The sensation of chest tightness or chest constriction occurs during episodes of bronchcoconstriction and is fairly specific to asthma (Binks et al. 2002). The association between the descriptors of dyspnoea quality and underlying physiological disorders has gained much interest although the relationship does not appear to be robust enough to aid differential diagnosis (Wilcock et al. 2002). Interestingly, verbal descriptors of dyspnoea appear to be related to the intensity level of dyspnoea. For example, in patients with chronic obstructive pulmonary disease (COPD) the clusters of heavy/fast breathing and work/effort seem to be particularly sensitive descriptors of dyspnoea during exercise (von Leupoldt & Dahme 2007). In mild asthma, the sensation of chest tightness is distinct from the sensation of work and effort; at mild degrees of airway obstruction, ‘chest tightness’ or ‘constriction’ was the primary sensation and at intense levels of bronchoconstriction, the sense of ‘work’ or ‘effort’ was used to characterise breathing discomfort. Therefore, quality descriptors may be beneficial in tracking patients’ clinical condition and response to therapy (Moy et al. 1998).
The similarities between pain and dyspnoea are the most prominent in relation to affect. Both are unpleasant and evoke emotions that motivate behaviour. The separation of unpleasantness from discriminative intensity responses to pain has provoked a great deal of study. The separation of sensory intensity and affect in the study of dyspnoea has received less attention. Wilson and Jones (1991) demonstrated that, like pain, distress and intensity could be separately measured; they were scaled as if they were different aspects of breathlessness. Their results supported the notion suggested by Comroe (1966), that the experience of breathlessness involves the perception of a sensation and the reaction to the sensation. Breathlessness unpleasantness has been described with words such as ‘panic’, ‘fear’ and ‘helplessness’. More recent evidence indicates that sensory-intensity and affect can be separately manipulated; distraction blunts the affective-intensity, and negative emotions enhance the affective-intensity, while sensory-intensity is unaffected by these interventions (von Leupoldt et al. 2006). Furthermore, the relationship of these different components to each other probably varies greatly between individuals. It has been postulated that ‘poor perceivers’ of breathlessness may not seek life-saving treatment, as may be the case in fatal asthma (Barreiro et al. 2004). Likewise, the severity and frequency of exacerbations and the patient’s ability to cope in COPD and chronic heart failure (and most likely other diseases associated with breathlessness) may be highly dependent on the affective component of breathlessness. For example, ‘over perceivers’ may seek costly, inappropriate treatment (Smoller et al. 1996), but this concept requires further investigation.
There is a high prevalence of panic and anxiety in respiratory disease (Smoller et al. 1999). A recent phenomenological study revealed valuable insights, from the patient’s perspective, into the impact of COPD (Barnett 2005) with breathlessness being identified as the most troublesome symptom leading to anxiety, panic and fear. It is surprising, if not disappointing, that more research has not been done relating to breathlessness affect. Studies that have investigated the language used by patients to describe breathing distress have yielded similar results in that emotive words (e.g. helplessness, anxiety and irritability) form unique clusters (Yorke et al. 2007). With recognition that dyspnoea comprises multiple component sensations and has distinguishable sensory and affective dimensions, it is now possible and necessary to develop an instrument for multidimensional dyspnoea assessment. Because breathlessness is multidimensional, there are different therapeutic targets. Reducing breathlessness intensity is a key approach although not always possible. However, it may be possible to alter breathlessness character to a less distressing type and mitigate the affective component. An instrument that will capture these different components will further enable therapies that focus on all aspects of breathlessness to be developed and assessed. Work to develop such an instrument for the evaluation and quantification of dyspnoea is underway (Yorke et al. 2007).
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