Effect of Perceived Dyspnea on Attitude Toward Death From the Perspective of COPD Patients.

In this study, it was aimed to examine attitudes toward dyspnea and death from the perspective of Chronic Obstructive Pulmonary Disease (COPD) patients and to determine the relationship between them. This descriptive research was carried out in the chest diseases clinic of a public hospital and with the participation of COPD patients (n = 124). The data were obtained from the Personal Information Form, Death Attitude Profile-Revised, and Medical Research Council Scale. The neutral acceptance and approach acceptance subscale is explained as believing that death is an inevitable part of life and a transition to life after death. The escape acceptance subscale is explained as believing that life will save from physical or psychological harms. It was determined that the Neutral Acceptance and Approach Acceptance sub-dimension of the predictors of dyspnea, comorbid diseases, and COPD had a significant effect at a rate of 33% (p = 0.000). Dyspnea, Comorbid diseases, and the predictors of the severity of COPD affect the Escape Acceptance sub-dimension by 57% (p = 0.000). This research has shown that fear of death is high in COPD patients with high perceived dyspnea. The psychological support provided to patients with COPD should be considered to relieve the fear of death. New studies are needed in which these should be reevaluated in the same context.

Evaluation of the Individual Activity Descriptors of the mMRC Breathlessness Scale: A Mixed Method Study.

Purpose: The modified-Medical Research Council (mMRC) breathlessness scale consists of five grades that contain of a description of different activities. It has wide utility in the assessment of disability due to breathlessness but was originally developed before the advent of modern psychometric methodology and, for example contains more than one activity per grade. We conducted an evaluation of the mMRC structure. Patients and Methods: Cognitive debriefing was conducted with COPD patients to elicit their understanding of each mMRC activity. In a cross-sectional study, patients completed the mMRC scale (grades 0-4) and an MRC-Expanded (MRC-Ex) version consisting of 10-items, each containing one mMRC activity. Each activity was then given a 4-point response scale (0 "not at all" to 4 "all of the time") and all 10 items were given to 203 patients to complete Rasch analysis and assess the pattern of MRC item severity and its hierarchical structure. Results: Cognitive debriefing with 36 patients suggested ambiguity with the term "strenuous exercise" and perceived severity differences between mMRC activities. 203 patients completed the mMRC-Ex. Strenuous exercise was located third on the ascending severity scale. Rasch identified the mildest term was "walking up a slight hill" (logit -2.76) and "too breathless to leave the house" was the most severe (logit 3.42). Conclusion: This analysis showed that items that were combined into a single mMRC grade may be widely separated in terms of perceived severity when assessed individually. This suggests that mMRC grades as a measure of individual disability related to breathlessness contain significant ambiguity due to the combination of activities of different degrees of perceived severity into a single grade.

Qualitative validation of the modified Medical Research Council (mMRC) dyspnoea scale as a patient-reported measure of breathlessness severity.

INTRODUCTION: The modified Medical Research Council (mMRC) dyspnoea scale is a measure of breathlessness severity recommended by guidelines and utilised as an inclusion criterion or endpoint for clinical trials. No studies have been conducted to validate the categorical descriptors against the dyspnoea severity grade. METHODS: This study utilised cognitive interviews (Think Aloud method) to assess the content validity of the mMRC scale among 16 participants (13 with cardiac/respiratory disease). Participants were recruited to achieve representation across a variety of demographic factors. Interviews were conducted remotely via video conferencing and participants were presented with all 5 mMRC descriptors on screen in random order then asked to rank the statements "in order from the best breathing to the worst breathing". RESULTS: Mean age of participants was 57 years (range 22-84 years). Eleven had multimorbidity (≥2 comorbidities) including COPD, asthma, lung cancer, lung infection, interstitial lung disease, heart failure, depression, and anxiety. Length of time with breathlessness ranged between 2 weeks and >25 years. The median rank of the mMRC grade descriptors was concordant for mMRC grades 0, 1 and 4 but not grades 2 and 3. Even so, substantial heterogeneity was found in the distribution of responses for mMRC grade 0. CONCLUSION: Our study found substantial heterogeneity in participant grading of the mMRC descriptors, particularly for grades 0, 2 and 3, indicating that mMRC might not be a good discriminator of difference or change in dyspnoea severity. This study demonstrates the importance of content validation even for long-established PROs like mMRC.

Dyspnea.

The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.

Evaluation of the Norwegian version of the Dyspnoea-12 questionnaire in patients with COPD.

BACKGROUND: The Dyspnoea-12 (D-12) questionnaire is widely used and tested in patients with breathing difficulties. The objective of this study was to translate and undertake the first evaluation of the measurement properties of the Norwegian version of the D-12 in patients with chronic obstructive pulmonary disease (COPD) attending a 4-week inpatient pulmonary rehabilitation programme. METHODS: Confirmatory factor analysis was used to assess structural validity. Fit to the Rasch partial credit model and differential item functioning (DIF) were assessed in relation to age, sex and comorbidity. Based on a priori hypotheses, validity was assessed through comparisons with scores for the COPD Assessment Test (CAT), Hospital Anxiety and Depression Scales (HADS) and clinical variables. RESULTS: There were 203 (86%) respondents with a mean age (SD) of 65.2 (9.0) years, and 49% were female. The D-12 showed satisfactory structural validity including presence of physical and affective domains. There was acceptable fit to Rasch model including unidimensionality for the two domains, and no evidence of DIF. Correlations with scores for the CAT, HADS and clinical variables were as hypothesised and highest for domains assessing similar aspects of health. CONCLUSIONS: The Norwegian version of the D-12 showed good evidence for validity and internal consistency in this group of patients with COPD, including support for two separate domains. Further testing for these measurement properties is recommended in other Norwegian patients with dyspnoea.

Perceptual sensitivity to sensory and affective aspects of dyspnea: Test-retest reliability and effects of fear of suffocation.

Perceptual sensitivity for dyspnea (i.e. breathlessness) is often quantified using the slope of magnitude estimations plotted against the physical stimulus intensities of respiratory loads. This study investigated whether this slope and its stability varies as a function of (1) affective versus sensory aspects of dyspnea, and (2) interindividual differences in Fear of Suffocation. Eighty-three healthy women performed a load magnitude estimation task twice one week apart. Resistive loads of increasing magnitude (0-2.4-5-7.4-12.4-20 cmH20/l/s) were repeatedly presented for a single flow-targeted inspiration. One group rated the intensity of loads, another their unpleasantness. Neither slopes nor intercepts differed between sensory versus affective aspects of dyspnea. Intercepts were lower in the second compared to the first session. Fear of Suffocation was associated with flatter slopes. Test-retest reliabilities were low to moderate suggesting that perceptual sensitivity to dyspnea is less stable than commonly assumed.

Do guidelines influence breathlessness management in advanced lung diseases? A multinational survey of respiratory medicine and palliative care physicians.

BACKGROUND: Respiratory medicine (RM) and palliative care (PC) physicians' management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey. METHODS: A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists. RESULTS: 450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018). CONCLUSIONS: These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.

Living with an ever-present breathlessness: Women's experiences of living with chronic obstructive pulmonary disease stage III or IV.

BACKGROUND: Living with chronic obstructive pulmonary disease stage III or IV has a major impact on a person's everyday life. This qualitative study focuses on women with chronic obstructive pulmonary disease stage III or IV. AIM: The aim of this study was to describe women's experiences of living with chronic obstructive pulmonary disease stage III or IV. METHOD: A purposive sample of fifteen women with chronic obstructive pulmonary disease stage III or IV participated in the study. Data were collected through individual semi-structured interviews that were subjected to qualitative content analysis. FINDINGS: One theme was identified, stabilizing an ever-present breathlessness by restoring strength, and three categories are as follows: managing a restricted everyday life as an expert of their illness, being afraid of contracting infections leading to suffocation and suffering and importance of continuous help and support from significant others and digital media. Breathlessness restricted women with chronic obstructive pulmonary disease, living with a body they have to wait for. Managing everyday life was adapted to their limited abilities and energy. This required detailed planning, good knowledge of their breathing and body. Women were afraid of contracting life-threatening infections that caused suffering, especially COVID-19. The fear leads to isolation and digital media was described as an important means of communication. Significant others gave support and help that was practical and emotional. Women with chronic obstructive pulmonary disease experienced lack of continuous help and support from healthcare professionals. CONCLUSION: Stabilizing an ever-present breathlessness by restoring strength required women with chronic obstructive pulmonary disease stage III or IV to conduct detailed planning to manage everyday life. Being afraid of contracting infections and the consequences of suffocation had increased since the pandemic COVID-19 outbreak, which led to self-isolation and an inactive everyday life. To get help, support and socialize, women used digital media.

Dyspnoea-12 and Multidimensional Dyspnea Profile: Systematic Review of Use and Properties.

CONTEXT: The Dyspnoea-12 (D-12) and Multidimensional Dyspnea Profile (MDP) were specifically developed for assessment of multiple sensations of breathlessness. OBJECTIVES: This systematic review aimed to identify the use and measurement properties of the D-12 and MDP across populations, settings and languages. METHODS: Electronic databases were searched for primary studies (2008-2020) reporting use of the D-12 or MDP in adults. Two independent reviewers completed screening and data extraction. Study and participant characteristics, instrument use, reported scores and minimal clinical important differences (MCID) were evaluated. Data on internal consistency (Cronbach's α) and test-retest reliability (intraclass correlation coefficient, ICC) were pooled using random effects models between settings and languages. RESULTS: A total 75 publications reported use of D-12 (n = 35), MDP (n = 37) or both (n = 3), reflecting 16 chronic conditions. Synthesis confirmed two factor structure, internal consistency (Cronbach's α mean, 95% CI: D-12 Total = 0.93, 0.91-0.94; MDP Immediate Perception [IP] = 0.88, 0.85-0.90; MDP Emotional Response [ER] = 0.86, 0.82-0.89) and 14 day test-rest reliability (ICC: D-12 Total = 0.91, 0.88-0.94; MDP IP = 0.85, 0.70-0.93; MDP ER = 0.84, 0.73-0.90) across settings and languages. MCID estimates for clinical interventions ranged between -3 and -6 points (D-12 Total) with small variability in scores over 2 weeks (D-12 Total 2.8 (95% CI: 2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1) and six months (D-12 Total 2.9 (2.0 to 3.7), MDP-A1 0.8 (0.6 to 1.1)). CONCLUSION: D-12 and MDP are widely used, reliable, valid and responsive across various chronic conditions, settings and languages, and could be considered standard instruments for measuring dimensions of breathlessness in international trials.

Affective Comorbidity Associated with Symptoms, Lung Function, and Differences Between Patients with COPD for Biomass and Tobacco Smoke Exposure.

Anxiety and depression are common entities in patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD). This study aimed to determine the prevalence of affective comorbidity (depression and anxiety) associated with lung function, functional capacity, dyspnea, and quality of life; as well as the differences between groups of patients diagnosed with COPD associated with biomass (COPD-BE) and patients with COPD secondary to tobacco (COPD-TS). Comparative cross-sectional observational study. Multiple hierarchical regression models, analysis of variance, and covariance were carried out. A total of 291 COPD patients were evaluated, symptoms of depression were found to be higher in patients with COPD-BE than in patients with COPD-TS (5.3 ± 4.2 versus 4.2 ± 4, 1, p = 0.016), as well as anxiety complications (4.1 ± 3.8 versus 3.8 ± 3.3, p = 0.095), although with anxiety it was not statistically significant, being adjusted for age and FEV1. Patients with COPD-BE had higher prevalence of depression, compared to COPD-TS (41.2% versus 27.7%, p = 0.028). In the multivariate regression models, the variables of dyspnea and quality of life were associated with depression and anxiety, explaining 25% and 24% of the variability, respectively. Depression is higher in COPD-BE patients compared to COPD-TE patients, it is necessary to consider affective comorbidity in routine evaluation and provide a comprehensive intervention to prevent the effects on other clinical conditions of the disease.

Experience of symptom control, anxiety and associating factors in a palliative care unit evaluated with Support Team Assessment Schedule Japanese version.

Various physical and psychosocial difficulties including anxiety affect cancer patients. Patient surroundings also have psychological effects on caregiving. Assessing the current status of palliative care intervention, specifically examining anxiety and its associated factors, is important to improve palliative care unit (PCU) patient quality of life (QOL). This study retrospectively assessed 199 patients admitted to a PCU during August 2018-June 2019. Data for symptom control, anxiety level, disease insight, and communication level obtained using Support Team Assessment Schedule Japanese version (STAS-J) were evaluated on admission and after 2 weeks. Palliative Prognostic Index (PPI) and laboratory data were collected at admission. Patient anxiety was significantly severer and more frequent in groups with severer functional impairment (p = 0.003) and those requiring symptom control (p = 0.006). Nevertheless, no relation was found between dyspnea and anxiety (p = 0.135). Patients with edema more frequently experienced anxiety (p = 0.068). Patient survival was significantly shorter when family anxiety was higher after 2 weeks (p = 0.021). Symptoms, edema, and disabilities in daily living correlate with patient anxiety. Dyspnea is associated with anxiety, but its emergence might be attributable mainly to physical factors in this population. Family members might sensitize changes reflecting worsened general conditions earlier than the patients.

Association between symptoms, affect and heart rhythm in patients with persistent or paroxysmal atrial fibrillation: an ambulatory pilot study.

Symptoms in atrial fibrillation are generally assumed to correspond to heart rhythm; however, patient affect - the experience of feelings, emotion or mood - is known to frequently modulate how patients report symptoms but this has not been studied in atrial fibrillation. In this study, we investigated the relationship between affect, symptoms and heart rhythm in patients with paroxysmal or persistent atrial fibrillation. We found that presence of negative affect portended reporting of more severe symptoms to the same or greater extent than heart rhythm.

Managing the experience of breathlessness with Tai Chi: A qualitative analysis from a randomized controlled trial in COPD.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is associated with dyspnea, decreased physical activity, and reduced quality-of-life. While pulmonary rehabilitation is helpful, maintenance of physical activity afterwards is problematic. We sought to explore qualitatively the multi-dimensional, biopsychosocial experience of patients with COPD who participated in Tai Chi (TC) vs. group walking to facilitate physical activity after pulmonary rehabilitation). METHODS: We analyzed semi-structured qualitative exit interviews (N = 81) from a randomized controlled trial comparing 6-months TC with a time-matched group walking intervention and usual care control (UC). Transcripts were reviewed by at least 2 independent reviewers utilizing a social constructivist framework and theoretical sampling approach. An in-depth analysis of an exemplar subset was performed to thematic saturation and captured emergent themes within and between groups. RESULTS: Focused analysis was conducted on 54 transcripts (N = 21 TC, N = 16 Walking, N = 17 UC). Participants were characterized by mean age 68.5 (±8.3) years, GOLD Stage = 3.0 (IQR 2.0-3.0), baseline FEV1 percent predicted 48.8% (±16.4), and 48.2% female. We identified predominant themes of breathlessness, and associated fear and embarrassment that limited physical activity across all groups. In both TC and walking, participants reported improvements in energy and endurance. Those in TC additionally shared improvements in breathing, mobility, and capacity for daily activities facilitated by body and breath awareness, emotional control and regulation of breathing, and an adaptive reframing of breathlessness. CONCLUSION: TC promoted physical and mental wellbeing by diminishing fear and embarrassment associated with breathlessness. Results highlight the multimodal characteristics of TC that may facilitate continued physical activity and improvement in quality of life.

Posttraumatic Stress Disorder Is Associated With a Decrease in Anaerobic Threshold, Oxygen Pulse, and Maximal Oxygen Uptake.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been linked to respiratory symptoms and functional limitations, but the mechanisms leading to this association are poorly defined. RESEARCH QUESTION: What is the relationship between PTSD, lung function, and the cardiopulmonary response to exercise in combat veterans presenting with chronic respiratory symptoms? STUDY DESIGN AND METHODS: This study prospectively enrolled military service members with respiratory symptoms following deployment to southwest Asia. All participants underwent a comprehensive evaluation that included pulmonary function testing and cardiopulmonary exercise testing. Pulmonary function test variables and cardiopulmonary response to exercise were compared in subjects with and without PTSD by using multivariable linear regression to adjust for confounders. RESULTS: A total of 303 participants were included (PTSD, n = 70; non-PTSD, n = 233). Those with PTSD had a greater frequency of current respiratory symptoms. There were no differences in measures for airway disease or lung volumes, but patients with PTSD had a reduction in diffusing capacity that was eliminated following adjustment for differences in hemoglobin levels. Participants with PTSD had a lower anaerobic threshold (23.9 vs 26.4 cc/kg per minute; P = .004), peak oxygen pulse (19.7 vs 18.5 cc/beat; P = .03), and peak oxygen uptake (34.5 vs 38.8 cc/kg per minute; P < .001). No significant difference was observed in gas exchange, respiratory reserve, or effort at peak exercise between participants with and without PTSD. INTERPRETATION: A diagnosis of PTSD was associated with a reduced anaerobic threshold, oxygen pulse, and peak oxygen uptake. This objective reduction in cardiopulmonary work is independent of baseline lung function, was not associated with abnormalities in gas exchange or respiratory reserve, and may be related to deconditioning.

Voice-related quality of life: Relation to objective spirometry measures in subglottic stenosis.

OBJECTIVES: The current study seeks to identify the correlation between in-office spirometry data and voice-related quality of life in patients with subglottic stenosis (SGS). METHODS: Patients with SGS of any etiology were included when in-office spirometric data was available in addition to voice-related patient-reported outcomes (PROM) data in the form of the Voice Handicap Index-10 (VHI-10) and/or the Voice-Related Quality of Life (V-RQOL) survey. Overall survey scores and individual question responses were assessed for degree of correlation to spirometric data. RESULTS: Twenty-nine patients were included in the final analysis. Overall mean total VHI-10 scores totaled 7.15 (SD 9.11), while mean overall V-RQOL scores totaled 78.41 (SD 16.45). Both PEF and PIF rates correlated to total scores on the VHI and V-RQOL surveys. This correlation was stronger with PIF than with PEF, and with the V-RQOL than with the VHI. Questions related to breathlessness most closely correlated with spirometric data. CONCLUSION: Voice-related QOL is impacted in patients with SGS in a predictable way. Breathlessness while speaking may be more impactful than inability to produce speech in this population.

Pharmacologic Interventions for Breathlessness in Patients With Advanced Cancer: A Systematic Review and Meta-analysis.

Importance: Improved survival in patients with advanced cancer has increased the need for better understanding of how to manage common symptoms that they may experience, such as breathlessness. Objective: To assess the benefits and harms associated with pharmacologic interventions for breathlessness in adults with advanced cancer. Data Sources: PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for studies published from database inception through May 31, 2020, using predefined eligibility criteria within a PICOTS (population, intervention, comparator, outcome, timing, setting) format. Study Selection: Randomized clinical trials (RCTs), non-RCTs, and observational studies with a comparison group that evaluated benefits and/or harms and cohort studies that reported harms were selected. Data Extraction and Synthesis: Two reviewers independently screened studies for eligibility, serially abstracted data, independently assessed risk of bias, and graded strength of evidence (SOE). Main Outcomes and Measures: Benefits and harms of pharmacologic interventions were compared, focusing on breathlessness, anxiety, exercise capacity, and health-related quality of life. When possible, meta-analyses were conducted and standardized mean differences (SMDs) calculated. Results: In this systematic review and meta-analysis, a total of 7729 unique citations were identified, of which 19 studies (17 RCTs and 2 retrospective studies) that included a total of 1424 patients assessed the benefits of medications for management of breathlessness in advanced cancer or reported harms. The most commonly reported type of cancer was lung cancer. Opioids were not associated with more effectiveness than placebo for improving breathlessness (SMD, -0.14; 95% CI, -0.47 to 0.18) or exercise capacity ( SMD, 0.06; 95% CI, -0.43 to 0.55) (SOE, moderate); most studies examined exertional breathlessness. Specific dose and/or route of administration of opioids did not differ in effectiveness for breathlessness (SMD, 0.15; 95% CI, -0.22 to 0.52) (SOE, low). Anxiolytics were not associated with more effectiveness than placebo for breathlessness or anxiety (reported mean between-group difference, -0.52; 95% CI, -1.045 to 0.005) (SOE, low). Evidence for other pharmacologic interventions was limited. Pharmacologic interventions demonstrated some harms compared with usual care, but dropout attributable to adverse events was minimal in these short-term studies (range 3.2%-16%). Conclusions and Relevance: Evidence did not support the association of opioids or other pharmacologic interventions with improved breathlessness. Given that studies had many limitations, pharmacologic interventions should be considered in selected patients but need to be considered in the context of potential harms and evidence of an association of nonpharmacologic interventions with improved breathlessness.

Prevalence and correlates of chronic fatigue syndrome and post-traumatic stress disorder after the outbreak of the COVID-19.

As the SARS-COV-2 becomes a global pandemic, many researchers have a concern about the long COVID-19 complications. Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a persistent, debilitating, and unexplained fatigue disorder. We investigated psychological morbidities such as CFS and post-traumatic stress disorder (PTSD) among survivors of COVID-19 over 6 months. All COVID-19 survivors from the university-affiliated hospital of Tehran, Iran, were assessed 6 months after infection onset by a previously validated questionnaire based on the Fukuda guidelines for CFS/EM and DSM-5 Checklist for PTSD (The Post-traumatic Stress Disorder Checklist for DSM-5 or PCL-5) to determine the presence of stress disorder and chronic fatigue problems. A total of 120 patients were enrolled. The prevalence rate of fatigue symptoms was 17.5%. Twelve (10%) screened positive for chronic idiopathic fatigue (CIF), 6 (5%) for CFS-like with insufficient fatigue syndrome (CFSWIFS), and 3 (2.5%) for CFS. The mean total scores in PCL-5 were 9.27 ± 10.76 (range:0-44), and the prevalence rate of PTSD was 5.8%. There was no significant association after adjusting between CFS and PTSD, gender, comorbidities, and chloroquine phosphate administration. The obtained data revealed the prevalence of CFS among patients with COVID-19, which is almost similar to CFS prevalence in the general population. Moreover, PTSD in patients with COVID-19 is not associated with the increased risk of CFS. Our study suggested that medical institutions should pay attention to the psychological consequences of the COVID-19 outbreak.

Dear Breath: using story structure to understand the value of letter writing for those living with breathlessness - a qualitative study.

Background: Despite the prevalence of dyspnoea (the pathological term for breathlessness) amongst the general population and the diagnostic importance of dyspnoea for respiratory illness, public awareness of dyspnoea is poor with an estimated two million people with undiagnosed Chronic Obstructive Pulmonary Disorder in the UK. We explore whether therapeutic letter writing is a valuable arts health approach for those living with breathlessness. Methods: Eighty (80) participants took part in 10 workshops held in community-based settings. The overall approach was qualitative. We analysed the data thematically. Results: Informed by theories of story structure, our analysis explores letters written to the breath in terms of there being a protagonist, antagonist, a process of recognition and reconciliation. Conclusions: Writing a letter to the breath facilitates new ways of relating to breathlessness. Letters create a personal narrative and workshops create a public story. Further research should explore whether therapeutic letter writing can support communication about breathlessness with clinicians.

Dyspnea, Acute Respiratory Failure, Psychological Trauma, and Post-ICU Mental Health: A Caution and a Call for Research.

Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.