[Agreement in asthmatics' perception of dyspnea during acute and chronic obstruction]. / Concordancia entre la percepción de disnea del asmático durante la obstrucción aguda y crónica.

OBJECTIVE: Three types of asthmatic patients can be identified during periods of clinical stability: "poor perceivers," "normal perceivers," and "over perceivers." When asthmatics undergo bronchial challenge in the laboratory, the same distinctions in type of perception can be observed. The aim of the present study was to determine the level of agreement between the 2 situations. PATIENTS AND METHODS: A total of 93 patients with persistent moderate asthma (36 men and 57 women; mean age 40 years) were studied. We asked them to assess their dyspnea on a modified Borg scale when stable and after each histamine dose in a bronchial provocation test. When a patient's Borg scale assessment in stable situation was below the 25th percentile, that patient was classified as a poor perceiver. Patients were considered over perceivers if their score in stable situation was in the 75th percentile. Others were labeled normal perceivers. Type of perception during acute bronchoconstriction was defined in function of the change in Borg assessment once forced expiratory volume in the first second had decreased 20%: poor perceivers were those whose change in Borg assessment was in the 25th percentile, over perceivers were in the 75th percentile, and normal perceivers in the middle percentiles. RESULTS: In stable situation, 23 patients were poor perceivers, 58 were normal perceivers, and 12 were over perceivers. During bronchoconstriction, there were 23 poor perceivers, 47 normal perceivers, and 23 over perceivers. Agreement was estimated by a kappa index of 0.0574 for poor perception, 0.1521 for over perception, and 0.3980 for normal perception. CONCLUSIONS: Asthmatics' perception of dyspnea during periods of stability and during acute bronchoconstriction are independent phenomena. It is therefore not possible to infer how a patient will perceive an asthmatic attack by evaluating only how he or she perceives breathlessness during stable periods.

Concordancia entre la percepción de disnea del asmático durante la obstrucción aguda y crónica / Agreement in asthmatics' perception of dyspnea during acute and chronic obstruction

Objetivo: Durante la estabilidad clínica se pueden distinguir 3 tipos de asmáticos: hipoperceptores, normoperceptores e hiperperceptores. Cuando a esos mismos pacientes se les provoca una broncoconstricción aguda, también existen hipo, normo e hiperperceptores de disnea. El objetivo del presente trabajo ha sido comprobar la concordancia entre ambas situaciones. Pacientes y métodos: Se ha estudiado a 93 pacientes con asma persistente moderada (36 varones y 57 mujeres; edad media de 40 años). Se les pidió que estimaran su disnea (escala modificada de Borg) en situación de estabilidad y después de cada dosis de histamina en una prueba de broncoprovocación. Cuando la puntuación de Borg en situación estable era menor del percentil 25, se consideró hipoperceptor; si era superior al percentil 75, hiperperceptor, y normoperceptor al grupo restante. En función del cambio de disnea al descender un 20% el volumen espiratorio forzado en el primer segundo se distinguieron los perceptores agudos: hipoperceptores (cambio en Borg inferior al percentil 25), hiperperceptores (cambio superior al percentil 75) y normoperceptores (cambio entre los percentiles 25 y 75). Resultados: En situación estable 23 pacientes fueron hipoperceptores, 58 normoperceptores y 12 hiperperceptores, mientras que durante la broncoconstricción hubo 23 hipoperceptores, 47 normoperceptores y 23 hiperperceptores. El análisis de concordancia mostró un índice kappa de 0,0574 para la hipopercepción, de 0,1521 para la hiperpercepción y de 0,3980 para la normopercepción. Conclusiones: Las percepciones de disnea de los asmáticos en situación estable y durante una broncoconstricción aguda son fenómenos independientes. Por ello, no es posible inferir cómo un paciente va a percibir una crisis de asma valorando únicamente cómo percibe su enfermedad durante la estabilidad clínica

Objective: Three types of asthmatic patients can be identified during periods of clinical stability: "poor perceivers," "normal perceivers," and "over perceivers." When asthmatics undergo bronchial challenge in the laboratory, the same distinctions in type of perception can be observed. The aim of the present study was to determine the level of agreement between the 2 situations. Patients and Methods: A total of 93 patients with persistent moderate asthma (36 men and 57 women; mean age 40 years) were studied. We asked them to assess their dyspnea on a modified Borg scale when stable and after each histamine dose in a bronchial provocation test. When a patient's Borg scale assessment in stable situation was below the 25th percentile, that patient was classified as a poor perceiver. Patients were considered over perceivers if their score in stable situation was in the 75th percentile. Others were labeled normal perceivers. Type of perception during acute bronchoconstriction was defined in function of the change in Borg assessment once forced expiratory volume in the first second had decreased 20%: poor perceivers were those whose change in Borg assessment was in the 25th percentile, over perceivers were in the 75th percentile, and normal perceivers in the middle percentiles. Results: In stable situation, 23 patients were poor perceivers, 58 were normal perceivers, and 12 were over perceivers. During bronchoconstriction, there were 23 poor perceivers, 47 normal perceivers, and 23 over perceivers. Agreement was estimated by a kappa index of 0.0574 for poor perception, 0.1521 for over perception, and 0.3980 for normal perception. Conclusions: Asthmatics' perception of dyspnea during periods of stability and during acute bronchoconstriction are independent phenomena. It is therefore not possible to infer how a patient will perceive an asthmatic attack by evaluating only how he or she perceives breathlessness during stable periods

[How can we assess the perception of induced dyspnea in chronic obstructive pulmonary disease?]. / Cómo valorar la percepción de la disnea inducida en la EPOC?

OBJECTIVE: To evaluate various methods for studying the perception of dyspnea in chronic obstructive pulmonary disease (COPD) using a new parameter, the change in Borg scale rating, and others already in use: the linear regression slope and the application of Stevens' law to the response perception curve--ie change in forced expiratory volume in 1 second (delta FEV1)--change in dyspnea (delta dyspnea). PATIENTS AND METHODS: A bronchial challenge test was performed on 70 patients with stable COPD and no contraindications for performing the test (European Respiratory Society criteria), during which dyspnea was measured (Borg scale) after each nebulization. Perception was analyzed using: a) the linear regression slope of delta FEV1 plotted against (delta dyspnea); b) the exponent n of Stevens' law (psi=k phi n, in which psi is delta dyspnea and phi is delta FEV1, with perception being poor when n<1 and good when n>1), and c) change in Borg: difference between dyspnea when FEV1 has fallen 20% and dyspnea after saline inhalation. Subjects were classified according to the slope and change in Borg as hypoperceivers, normal perceivers, or hyperperceivers. These 2 methods of classification were compared using the kappa statistic. RESULTS: According to the exponent n, all patients were hypoperceivers (n<1). According to the slope, there were 33 hypoperceivers, 28 normal perceivers, and 9 hyperperceivers. The change in Borg classified 37 subjects as hypoperceivers, 23 as normal perceivers, and 10 as hyperperceivers. All except 5 subjects were classified in the same way by the slope and the change in Borg (kappa=0.88). In most of the 5 cases of discrepancy, the slope classified subjects as better perceivers. CONCLUSIONS: The n exponent is not valid for evaluating the perception of dyspnea induced by a bronchial challenge test in COPD. Change in Borg is at least as useful as the slope for evaluating perception of dyspnea. The percentage of patients with this disease who are hyperperceivers is high.

[Asthma patients' perception of dyspnea during acute bronchoconstriction]. / Percepción de la disnea durante la broncoconstricción aguda en los pacientes con asma.

The aim of this study was to analyze variations in the perception of acute bronchial obstruction among asthmatics in our practice and to try to define the variables that influence inter-individual differences. We studied 153 asthmatics in stable condition, using a Borg scale to measure dyspnea perceived during a histamine bronchial challenge test. To study individual perception we analyzed both absolute magnitude of perception of dyspnea on the Borg scale when forced expiratory volume in 1 second (FEV1) fell 20% (perception score 20-PS20) and the mathematical difference between PS20 and baseline dyspnea (change in Borg, CB). The results were as follows. 1) The factors that affected PS20 according to multiple linear regression were anxiety, baseline dyspnea and the provocative concentration required to produce a 20% fall in FEV1 (PC20). 2) Within each level of asthma severity, there were differences in dyspnea perception when FEV1 fell 20% (analysis of variance of repeated measures), such that patients with mild asthma and no bronchial obstruction perceived more change in dyspnea. 3) CB during the bronchial challenge test distinguished four ways of perceiving dyspnea: 15% were dysperceivers, 13% were hypoperceivers, 48% were normoperceivers and 24% were hyperperceivers. 4) Hypoperceivers and dysperceivers were at greater risk of severe exacerbation whereas hyperperceivers requested unnecessary medical consultations. 5) Subjects with poorer quality of life were usually dysperceivers; hyperperceivers were the second most common type among those with poorer quality of life. In conclusion, a large percentage of asthmatics do not appropriately perceive acute bronchial obstruction, and the simplest way to evaluate their perception is to calculate the change in dyspnea (on a Borg scale) during the bronchial challenge test. The manner of perceiving dyspnea can not be predicted beforehand, yet it has a significant impact on the use of medical resources and patient quality of life, among other aspects.

Percepción de la disnea durante la broncoconstricción aguda en los pacientes con asma / Asthma patients' perception of dyspnea during acute bronchoconstriction

El objetivo del estudio fue analizar las variaciones de la percepción de obstrucción bronquial aguda en los asmáticos de nuestra población e intentar definir las variables que condicionan dichas diferencias interindividuales. Se estudió a 153 asmáticos en situación estable, midiendo la disnea que percibían en una escala de Borg durante la realización de una prueba de provocación bronquial con histamina. Para el análisis de la percepción individual se valoraron tanto la PS20 (disnea en la escala de Borg al caer el FEV1 un 20 per cent) como la diferencia matemática entre la PS20 y la disnea basal ("cambio en Borg" [CB]). Según nuestros resultados: a) el conjunto de factores que determinan la PS20 (regresión lineal múltiple) ha sido la ansiedad, la disnea basal y la PC20; b) dentro de cada grupo de gravedad de asma existen diferencias en la disnea percibida cuando el FEV1 desciende un 20 per cent (análisis de la varianza de medidas repetidas), de modo que los pacientes con asma leve y sin obstrucción bronquial perciben más el cambio de disnea; c) el análisis del CB durante la prueba de provocación bronquial nos ha permitido distinguir 4 formas de percibir la disnea: un 15 per cent de los pacientes son disperceptores, un 13 per cent hipoperceptores, un 48 per cent normoperceptores y el 24 per cent hiperperceptores; d) los hipoperceptores y disperceptores tienen mayor riesgo de agudizaciones graves, mientras que los hiperperceptores generan innecesarias consultas médicas, y e) los grupos con una peor calidad de vida son los disperceptores, seguidos de los hiperperceptores. En conclusión, un elevado porcentaje de asmáticos no percibe de forma adecuada la obstrucción bronquial aguda, y el método sencillo de conocer cómo es dicha percepción consiste en calcular su cambio de disnea (en la escala de Borg) durante una prueba de provocación bronquial. La forma de percibir la disnea no puede inferirse de antemano y tiene repercusiones importantes, entre otras, en la utilización de recursos médicos y en la calidad de vida de los pacientes (AU)

[Perception of improvement in asthma patients]. / Percepción de mejoría en los pacientes con asma.

The objective of this study was to investigate the ability of patients with stable asthma to recognize improvement in bronchial obstruction with treatment. We enrolled 75 stable asthmatics (44 women and 31 men, mean age 43 17 years) who reported baseline dyspnea on a modified Borg scale. Acute bronchodilation of 15% was provoked in the laboratory, after which the patients were asked if there was a change in dyspnea. Our results were as follows. 1) Overall, 19 asthmatics (25%) failed to perceive improvement in dyspnea with bronchodilation. 2) The mean change in dyspnea was 1.17 1.11, although the change was greater in patients with more severe asthma (0.60 0.5 for mild asthmatics, 1.05 1.07 for moderate asthmatics and 1.93 1.4 for severe asthmatics; p < 0.0001). 3) Perception of improvement was significantly related to level of the patient's emotional balance (anxiety-depression), quality of life, education, socioeconomic level, age, age of onset, severity, baseline dyspnea and obstruction, thoracic pressure and number of visits to the doctor in the preceding year. 4) The variables entered into the stepwise regression model were baseline dyspnea, depression, thoracic pressure and age. 5) Generally, young asthmatics whose disease appeared at a younger age and who also had less ventilatory obstruction and greater quality of life, showed a tendency to underestimate the beneficial effect of bronchodilator treatment. Moreover, when asthma was severe, non-perceptive individuals had significantly more admissions to intensive care units due to asthma exacerbation.In conclusion, 25% of our asthmatics are unable to recognize whether their bronchia dilate as a result of treatment, meaning that they would delay the start of rescue medication during an exacerbation. Such patients should be identified in order to establish therapeutic guidelines in function of objective home criteria (peak-flow monitoring).

Percepción de mejoría en los pacientes con asma / Perception of improvement in asthma patients

OBJETIVO: Investigar la capacidad de los pacientes con asma estable de reconocer la mejoría de su obstrucción bronquial con el tratamiento. MÉTODO: Seleccionamos a 75 asmáticos estables (44 mujeres y 31 varones, con una media de edad de 43 ñ 17 años), que referían sentir disnea basal en la escala modificada de Borg, y les provocamos en el laboratorio una broncodilatación aguda del 15 per cent; en esta situación los pacientes fueron interrogados acerca del cambio de disnea experimentado. RESULTADOS: 1. Globalmente, 19 asmáticos (25 per cent) no percibieron mejoría de su disnea con la broncodilatación. 2. La media del cambio en el nivel de disnea fue de 1,17 ñ 1,11; sin embargo, este cambio fue mayor en los pacientes con asma más grave: 0,60 ñ 0,5 en los asmáticos leves, 1,05 ñ 1,07 en los moderados y 1,93 ñ 1,4 en los graves (p < 0,0001). 3. La percepción de mejoría se correlacionó significativamente con el nivel de equilibrio emocional del paciente (ansiedaddepresión), la calidad de vida, la educación, el nivel económico, la edad, la edad de inicio de la enfermedad, la gravedad del asma, disnea y obstrucción basales, la opresión torácica y el número de consultas médicas realizadas en el año precedente. 4. Las variables introducidas en el modelo de regresión (pasos sucesivos) fueron: disnea basal, depresión, opresión torácica y edad. 5. En general, los asmáticos jóvenes cuya asma se inició a una edad más temprana y que, además, tienen menor obstrucción ventilatoria y mejor calidad de vida, presentan tendencia a infravalorar el efecto beneficioso del tratamiento broncodilatador. Además, cuando el asma es grave, estos individuos no perceptores de mejoría presentan significativamente más ingresos en cuidados intensivos por agudizaciones asmáticas. CONCLUSIÓN: El 25 per cent de nuestros asmáticos no es capaz de reconocer que sus bronquios se dilatan como resultado del tratamiento, motivo por el cual ante una agudización podrían retrasar el inicio de la medicación de rescate. Es aconsejable identificar a estos pacientes para establecer las pautas terapéuticas en función de criterios domiciliarios meramente objetivos (monitorización pico-flujo) (AU)