Development and testing of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ).

OBJECTIVE: To develop and test the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) that measures both intensity of dyspnea with activities and changes (reductions or improvements) in the ability of patients with chronic obstructive pulmonary, disease to perform daily activities. DESIGN: Instrument development and initial testing for validity and reliability. SETTING: Hospital-based pulmonary rehabilitation program. PATIENTS: One hundred thirty-one adult male patients with chronic obstructive pulmonary disease. Mean age was 63.7 +/- 6.2 years. OUTCOME MEASURES: Pulmonary Functional Status and Dyspnea Questionnaire, pulmonary function and exercise parameters. RESULTS: The PFSDQ is a 164-item paper and pencil self-administered questionnaire and consists of two components measuring dyspnea intensity with activities and changes in functional ability related to 79 activities of daily living. Activities are grouped into scales of self-care, mobility, eating, home management, social, and recreational. The dyspnea component measures the level of dyspnea patients report with these activities. The functional abilities component evaluates the degree to which the performance of activities has changed as the result of chronic obstructive pulmonary disease. The activities are relevant for adults of both sexes and reflect various energy workload requirements. Normative data for both components were described. Content and initial construct validity of the PFSDQ was supported by clinical experts and findings related related to expected theoretical relationships. Internal consistency reliability for both the dyspnea and functional abilities components was 0.91. The alpha coefficients for the scales ranged from 0.88 to 0.94. A case study was used to describe the clinical application of the PFSDQ. CONCLUSION: The PFSDQ can be used clinically and in research studies to assess dyspnea and changes in the functional ability of patients with pulmonary disease. Although further testing is warranted, initial evaluation supports the validity and reliability of the PFSDQ.

Comparison of breathing comfort during weaning with two ventilatory modes.

In twenty-one patients ventilated for > or = 3 days, we compared similar levels of partial support provided by synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV) in terms of breathing comfort. On a single day, eligible subjects experienced, in random order, both SIMV and PSV weaning protocols (sequential 20% reductions in support at timed intervals) separated by a 1 to 3 h rest. Breathing comfort was defined by subjective ratings of dyspnea and anxiety. Subjects reported significant levels of preweaning dyspnea and anxiety despite resting for at least 6 h. Dyspnea and anxiety were not significantly different between the two methods at any level of support. Our findings suggest that dyspnea and anxiety are higher than expected on "full" ventilator support, and that comfort may not differ between PSV and SIMV during active withdrawal of machine support.

The effects of activity and bed rest on tissue oxygen tension, perfusion, and plasma volume.

An experimental study with a crossover design was used to compare the effects of activity and bed rest on subcutaneous oxygen (PscO2), perfusion (BFsc), and plasma volume, and to explore the relationship of cardiovascular fitness to these variables. Fifteen healthy males were randomized to bed rest or activity and later completed the remaining protocol. Exercise prescription for the activity protocol and cardiovascular fitness were based on a treadmill performance test. Repeated measurements were made of subcutaneous oxygen and temperature using an optode in upper arm subcutaneous tonometers. Perfusion and PscO2 were greater during bed rest (p < .05). Post hoc analysis revealed a trend toward higher heart rates and diastolic blood pressure during the activity protocol. Change in plasma volume did not differ between protocols, and cardiovascular fitness was unrelated to PscO2 or BFsc. Findings suggest that in uninjured individuals, higher levels of activity intensity reduce oxygen levels and blood flow in peripheral tissues.

Predicting the outcomes of living with asthma.

The purpose of this study was to explore the impact of person and disease predictors on psychosocial and morbidity outcomes in adults with chronic asthma. Ninety-five asthmatic adults were followed for 60 days with standardized questionnaires and three interviews. Amount of distress during an asthma episode, perceived danger from asthma, and appraisal of social support were predictors of emergency room visits. Self-care, perceived life stress, nocturnal symptoms, and amount of distress during an asthma episode were predictors of depression. Financial status and the absence of nocturnal symptoms of asthma predicted life satisfaction.

The dilemma of seeking urgent care: asthma episodes and emergency service use.

Asthma is an invisible and unpredictable chronic illness characterized by recurrent episodes of airflow obstruction and airway inflammation. Until recently, psychological factors were thought to play a major role in this condition. The notion of an emotionally-based illness serves to discredit asthma as a 'real' illness among health professionals and patients alike, contributes to the sense of stigma that persons who have asthma experience, and impedes effective management. Findings from research with a sample of 95 adults with physician diagnosed and documented asthma indicate that persons who have asthma walk a tightrope between delaying formal medical intervention and seeking treatment too soon. Uncertainty about the quality and speed of care available in an emergency department shapes, in part, the nature of the lived experience of asthma and affects feelings of control over the illness. These concerns create a push-pull dynamic, as individuals struggle to make decisions about emergency department use that will provide relief, ensure autonomy, deter the experience of stigma, and diminish the threat of death.

Disappearance of eosinophils from bronchoalveolar lavage fluid after patient education and high-dose inhaled corticosteroids: a case report.

Inhaled steroid therapy is being emphasized in the treatment of asthma but requires patient adherence to regular dosing regimens and skilled inhalation techniques for treatment to be effective. If used correctly, high-dose inhaled corticosteroids may eradicate specific types of inflammatory cells from the airway, whereas use of systemic corticosteroids in chronic asthma may not significantly reduce airway inflammation or clinical symptoms. We report a case in which reduction in inflammatory cells in the airway was confirmed by bronchoalveolar lavage after individual patient education, training in self-monitoring, and treatment with inhaled corticosteroids. Clinical symptoms were reduced after conversion of this patient from systemic to inhaled corticosteroids.

The HIV quality audit marker (HIV-QAM): an outcome measure for hospitalized AIDS patients.

The development and validation of the HIV-Quality Audit Marker (HIV-QAM), an instrument designed to measure changes in the status of hospitalized AIDS patients due to nursing care, is reported. The HIV-QAM is designed to capture the nurse data-collector's judgment of the status of the patient based upon observations, interviews, record reviews, and listening to inter-shift report. The final version of the 10 item HIV-QAM includes three scales, Self-care (six items; Cronbach's alpha = 0.89), Ambulation (two items, alpha = 0.88), and Psychological Distress (two items, alpha = 0.84). Content validity was supported by selection of items from pre-existing scales, generation of items based on care plans for HIV/AIDS patients, and review and critique of items by a panel of nurse experts. Construct validity was supported by principal components factor analysis and multi-trait scaling analysis. Convergent and divergent concurrent validity with patient symptoms and intensity of nursing care required was demonstrated. The predictive validity of the HIV-QAM for mortality at 3 and 6 months after hospital treatment for Pneumocystis carinii pneumonia was also shown.

Assessment and management of adults with asthma: guidelines for nurse practitioners.

Asthma is a potentially life-threatening chronic disease requiring consistent and careful management. NPs play a prominent role in diagnosing, managing, and teaching people with asthma. Understanding current theories of pathogenesis, principals of therapeutic management, and patient education is critical to reduce rising asthma morbidity and mortality. When the patient, family members, and the clinician work together in partnership, an optimal individualized treatment plan can be established.

Patients' perceptions of pulmonary problems and nursing interventions during hospitalization for Pneumocystis carinii pneumonia.

BACKGROUND AND METHODS: The descriptive, correlational study examined patients' perceptions of pulmonary problems and nursing interventions in a sample (n = 201) of persons living with AIDS hospitalized for Pneumocystis carinii. Additionally, the study assessed differences in physiological variables, patient symptoms, and functional status based on the type of problems identified: dyspnea, pulmonary problems without dyspnea, and nonpulmonary problems. RESULTS: A total of 601 problems was identified including 61 instances of dyspnea and 83 reports of other pulmonary problems. The remainder of the problems was nonpulmonary. Nursing interventions associated with dyspnea and pulmonary problems other than dyspnea were mainly broadly defined interventions such as oxygen and medication administration. When patients were placed into three groups based on identification of dyspnea, pulmonary problems without dyspnea, or only nonpulmonary problems, there were no differences between groups in functional status or patient symptoms of pain, nausea, or fatigue as measured by the Quality Audit Marker. CONCLUSIONS: This study demonstrated that hospitalized patients with Pneumocystis carinii present with a broad array of problems. Contrary to expectations, dyspnea was not ubiquitous but was reported by less than one-third of this sample. When dyspnea was present there were few independent nursing interventions that patients identified. Studies are needed to test effective strategies for the nursing management of dyspnea and a large variety of other patient problems associated with HIV infection.

Clinical markers of asthma severity and risk: importance of subjective as well as objective factors.

The purpose of this study was to explore patient perceptions of asthma severity and danger from asthma, correlate them with objective measures, and assess the impact of psychologic variables on the perception of severity. Recognition of patients at greatest risk for fatal attacks requires identifying those with severe asthma. In our study of 95 adults with asthma, we found that the subjective factors of perceived severity and perceived danger and the objective factors of medications, hospitalizations, history of intubation, and pulmonary function were important markers of asthma severity and risk. Our findings indicate that asthmatic adults make independent self-assessments that generally correlate with objective markers of increased risk of mortality and increased severity of the asthma. The perception of high severity was significantly correlated with depression, panic-fear, frequency of emergency department visits, and with an objective index of risk of death. The latter includes variables obtainable from history alone (number of medications to control symptoms, need for prednisone, prior intubation, and prior recent hospitalization) and is correlated with spirometric indexes of airflow obstruction, occurrence of nocturnal symptoms, and number of emergency department visits.

The sensation of pulmonary dyspnea in school-age children.

The purpose of this investigation was to describe the sensation of dyspnea in a sample of 39 school-age children with asthma and to identify strategies used to cope with the symptom. In addition, three methods to measure dyspnea intensity in children were tested and compared. Breathing on a "bad breathing day" was used as a proxy variable to represent dyspnea. The most frequent description of how breathing feels on a bad day was "it is hard to breathe." Words chosen most frequently from a checklist of sensations were "wheezy," "short of breath," "tight," and physical sensations such as "throwing up," "hurting," and "stuffiness." The children's feelings on a bad breathing day were categorized as negative moods or emotions, a wish for change, or physical symptoms. Ratings of breathing on "good", "bad," and "usual breathing" days on word descriptor, visual analogue, and color scales provided evidence of concurrent validity for the three measures of dyspnea intensity. The most frequent strategies used to cope with dyspnea were medications, change in position, decreased activity, fluids, relaxation, distraction, and social support. The findings were very similar to those previously described for an adult sample.

Dyspnea in the ventilator-assisted patient.

Our purpose in this study was to investigate the factors coincident with the occurrence of dyspnea in ventilator-assisted patients. Five alert and oriented patients with pulmonary disease that was restrictive, obstructive, or both, who were receiving mechanical ventilation, participated in this descriptive study. At 4-hour intervals and at complaint of dyspnea, patients quantified the severity of their dyspnea using the visual analogue and modified Borg scales. At each measurement of dyspnea, nurses observed concomitant physiologic and environmental variables. A moderate correlation (r = 0.51, p less than 0.001) was found between the number of events and activities occurring in the intensive care unit environment and the occurrence and severity of dyspnea. The visual analogue scale and modified Borg scale measures of dyspnea were highly correlated (r = 0.92, p less than 0.001) and may be useful tools for assessing dyspnea in patients undergoing mechanical ventilation.

Effect of peak flow information on patterns of self-care in adult asthma.

Self-care is an important issue in the management of adults with asthma. Little is known about the specific strategies used by people with asthma to control symptoms and abort asthma attacks. The purpose of this study was to identify self-care strategies used to control asthma symptoms and to determine the effect of peak expiratory flow rate (PEFR) information on selection of self-care strategies. Thirty adult subjects with asthma were randomly assigned to either a control or an experimental group; 28 completed the study. All subjects recorded episodes of dyspnea, wheezing, and chest tightness and self-care actions in an asthma symptom diary. The experimental group recorded PEFR at the beginning and end of each symptom episode. Reported strategies were categorized into problem-focused, emotion-focused, or mixed self-care strategies. The experimental group, with access to PEFR information, used medication significantly less often than the control group. The experimental group also reported fewer and less frequent uses of alternative nondrug strategies.

Predictors of dyspnea intensity in asthma.

Predictors of dyspnea were studied during induced airflow obstruction or cough in an attempt to increase understanding of factors related to observed variability in the descriptions of the experience of dyspnea. Thirty-one adult subjects with asthma participated in a 2-day protocol using a laboratory analog of asthma. Air flow obstruction and dyspnea were induced on Day 1 with inhalations of methacholine in doubling concentrations from 0.063 to 2.0 mg/ml. Cough was induced on Day 2 with inhalations of 3% sodium gluconate solution. Dyspnea was assessed on both days by a visual analog technique. The magnitude of dyspnea was not related to airway caliber. There was a significant negative relationship between age and magnitude of dyspnea and between cigarette pack years and dyspnea intensity. Dyspnea at baseline was positively related to dyspnea intensity during induced bronchoconstriction. Dyspnea during cough was not related to airway caliber, but there was a significant difference between males and females in the intensity of dyspnea at cough threshold. These findings may explain some of the variability observed in the experience of dyspnea in asthma.

Emotionally triggered asthma as a predictor of airway response to suggestion.

Twenty-nine male and female adults with asthma were tested to determine the relationship between perceived response to emotional triggers of asthma and bronchoconstrictive suggestion. Subjects were told that they were inhaling a bronchoconstricting agent in four increasingly potent concentrations, when in fact the solution the subjects inhaled was nebulized isotonic saline. Ten subjects responded to suggestion with a greater than 20% increase in specific airway resistance, but this response could not be predicted by the report of perceived emotional triggers of asthma. The finding that perception of asthmatic response to emotional arousal does not predict airway response to bronchoconstrictive suggestion may mean that suggestion is an invalid proxy variable for studying the role of psychological factors in provocation of asthma.

The sensations of pulmonary dyspnea.

This study compared recalled physical and emotional sensations during episodes of acute dyspnea across pulmonary disease groups. The convenience sample consisted of 68 subjects with emphysema-bronchitis, asthma, vascular, and restrictive disease. Temporal patterns of physical and emotional sensations before and during episodes of dyspnea were identified. The frequency of sensations was remarkably similar across disease categories with few significant differences identified. Rather than the disease category, the frequency, intensity, and periodicity of the symptom of dyspnea had the greatest effect on the quality and frequency of sensations reported. The intensity of usual dyspnea reported on a visual analog scale varied significantly among groups, p = .026, with asthmatics having the lowest mean score and vascular subjects the highest. Females reported significantly greater usual dyspnea than males, p = .005. The variables of pulmonary disease group, gender, fatigue, and total network of social support were significantly related to usual dyspnea, and pulmonary group, gender, and attendance at Better Breathers classes were significantly related to worst dyspnea.