Nature and Evaluation of Dyspnea in Speaking and Swallowing

ABSTRACT

Dyspnea (breathing discomfort) is a serious and pervasive problem that can have a profound impact on quality of life. It can manifest in different qualities (air hunger, physical exertion, chest/lung tightness, and mental concentration, among others) and intensities (barely noticeable to intolerable) and can influence a person's emotional state (causing anxiety, fear, and frustration, among others). Dyspnea can make it difficult to perform daily activities, including speaking and swallowing. In fact, dyspnea can cause people to change the way they speak and swallow in their attempts to relieve their breathing discomfort; in extreme cases, it can even cause people to avoid speaking and eating/drinking. This article provides an overview of dyspnea in general, describes the effects of dyspnea on speaking and swallowing, includes data from two survey studies of speaking-related dyspnea and swallowing-related dyspnea, and outlines suggested protocols for evaluating dyspnea during speaking and swallowing.

KEYWORDS

Breathing discomfort - air hunger - exertional dyspnea - respiratory disease

REFERENCES

• 1 Hammond E C. Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women.  Am J Public Health Nations Health. 1964;  54 11-23
• 2 Kroenke K, Arrington M E, Mangelsdorff A D. The prevalence of symptoms in medical outpatients and the adequacy of therapy.  Arch Intern Med. 1990;  150 (8) 1685-1689
• 3 Desbiens N A, Mueller-Rizner N, Connors Jr AF, Wenger N S, Lynn J. SUPPORT Investigators . Study to Understand Prognoses and Preferences for Outcome and Risks of Treatment. The symptom burden of seriously ill hospitalized patients.  J Pain Symptom Manage. 1999;  17 (4) 248-255
• 4 Banzett R B, Lansing R W, Brown R et al. “Air hunger” from increased PCO₂ persists after complete neuromuscular block in humans.  Respir Physiol. 1990;  81 (1) 1-17
• 5 Hill L, Flack M. The effect of excess of carbon dioxide and of want of oxygen upon the respiration and the circulation.  J Physiol. 1908;  37 (2) 77-111
• 6 Smoller J W, Pollack M H, Otto M W, Rosenbaum J F, Kradin R L. Panic anxiety, dyspnea, and respiratory disease. Theoretical and clinical considerations.  Am J Respir Crit Care Med. 1996;  154 (1) 6-17
• 7 American Thoracic Society . Dyspnea. Mechanisms, assessment, and management: a consensus statement.  Am J Respir Crit Care Med. 1999;  159 (1) 321-340
• 8 Banzett R B, Moosavi S. Dyspnea and pain: similarities and contrasts between two very unpleasant sensations.  Am Pain Soc Bull. 2001;  11 (1) 6-8
• 9 Banzett R B, Mulnier H E, Murphy K, Rosen S D, Wise R J, Adams L. Breathlessness in humans activates insular cortex.  Neuroreport. 2000;  11 (10) 2117-2120
• 10 Evans K C, Banzett R B, Adams L, McKay L, Frackowiak R S, Corfield D R. BOLD fMRI identifies limbic, paralimbic, and cerebellar activation during air hunger.  J Neurophysiol. 2002;  88 (3) 1500-1511
• 11 Peiffer C, Poline J B, Thivard L, Aubier M, Samson Y. Neural substrates for the perception of acutely induced dyspnea.  Am J Respir Crit Care Med. 2001;  163 (4) 951-957
• 12 Banzett R B, Gracely R H, Lansing R W. When it's hard to breathe, maybe pain doesn't matter. Focus on “Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans”.  J Neurophysiol. 2007;  97 (2) 959-960
• 13 Nishino T, Shimoyama N, Ide T, Isono S. Experimental pain augments experimental dyspnea, but not vice versa in human volunteers.  Anesthesiology. 1999;  91 (6) 1633-1638
• 14 Melzack R, Torgerson W S. On the language of pain.  Anesthesiology. 1971;  34 (1) 50-59
• 15 Elliott M W, Adams L, Cockcroft A, MacRae K D, Murphy K, Guz A. The language of breathlessness. Use of verbal descriptors by patients with cardiopulmonary disease.  Am Rev Respir Dis. 1991;  144 (4) 826-832
• 16 O'Driscoll M, Corner J, Bailey C. The experience of breathlessness in lung cancer.  Eur J Cancer Care (Engl). 1999;  8 (1) 37-43
• 17 Lansing R W, Gracely R H, Banzett R B. The multiple dimensions of dyspnea: review and hypotheses.  Respir Physiol Neurobiol. 2009;  167 (1) 53-60
• 18 Schwartzstein R M, Christiano L M. Qualities of respiratory sensation. In:, Adams L, Guz A, eds. Respiratory Sensation. New York, NY: Marcel Dekker; 1996: 125-154
• 19 Lansing R W, Im B S, Thwing J I, Legedza A T, Banzett R B. The perception of respiratory work and effort can be independent of the perception of air hunger.  Am J Respir Crit Care Med. 2000;  162 (5) 1690-1696
• 20 Moy M L, Woodrow J W, Sparrow D, Israel E, Schwartzstein R M. Quality of dyspnea in bronchoconstriction differs from external resistive loads.  Am J Respir Crit Care Med. 2000;  162 (2 Pt 1) 451-455
• 21 Simon P M, Schwartzstein R M, Weiss J W et al. Distinguishable sensations of breathlessness induced in normal volunteers.  Am Rev Respir Dis. 1989;  140 (4) 1021-1027
• 22 Simon P M, Schwartzstein R M, Weiss J W, Fencl V, Teghtsoonian M, Weinberger S E. Distinguishable types of dyspnea in patients with shortness of breath.  Am Rev Respir Dis. 1990;  142 (5) 1009-1014
• 23 Wright G W, Branscomb B V. The origin of the sensations of dyspnea.  Trans Am Clin Climatol Assoc. 1954;  66 116-125
• 24 Banzett R B, Lansing R W, Reid M B, Adams L, Brown R. “Air hunger” arising from increased PCO2 in mechanically ventilated quadriplegics.  Respir Physiol. 1989;  76 (1) 53-67
• 25 Banzett R B, Lansing R W. Respiratory sensations arising from chemoreceptors and pulmonary receptors: air hunger and lung volume. In:, Adams L, Guz A, eds. Respiratory Sensation. New York, NY: Marcel Dekker; 1996: 155-180
• 26 O'Donnell D E, Banzett R B, Carrieri-Kohlman V et al. Pathophysiology of dyspnea in chronic obstructive pulmonary disease: a roundtable.  Proc Am Thorac Soc. 2007;  4 (2) 145-168
• 27 Harty H R, Mummery C J, Adams L et al. Ventilatory relief of the sensation of the urge to breathe in humans: are pulmonary receptors important?.  J Physiol. 1996;  490 (Pt 3) 805-815
• 28 Manning H L, Shea S A, Schwartzstein R M, Lansing R W, Brown R, Banzett R B. Reduced tidal volume increases “air hunger” at fixed PCO₂ in ventilated quadriplegics.  Respir Physiol. 1992;  90 (1) 19-30
• 29 Opie L H, Smith A C, Spalding J MK. Conscious appreciation of the effects produced by independent changes of ventilation volume and of end-tidal pCO2 in paralysed patients.  J Physiol. 1959;  149 494-499
• 30 Remmers J E, Brooks III JE, Tenney S M. Effect of controlled ventilation on the tolerable limit of hypercapnia.  Respir Physiol. 1968;  4 (1) 78-90
• 31 Vovk A, Binks A P. Raising end-expiratory volume relieves air hunger in mechanically ventilated healthy adults.  J Appl Physiol. 2007;  103 (3) 779-786
• 32 Chonan T, Mulholland M B, Leitner J, Altose M D, Cherniack N S. Sensation of dyspnea during hypercapnia, exercise, and voluntary hyperventilation.  J Appl Physiol. 1990;  68 (5) 2100-2106
• 33 Gandevia S C, Killian K J, Campbell E J. The effect of respiratory muscle fatigue on respiratory sensations.  Clin Sci (Lond). 1981;  60 (4) 463-466
• 34 Killian K J, Gandevia S C, Summers E, Campbell E J. Effect of increased lung volume on perception of breathlessness, effort, and tension.  J Appl Physiol. 1984;  57 (3) 686-691
• 35 Moosavi S H, Topulos G P, Hafer A et al. Acute partial paralysis alters perceptions of air hunger, work and effort at constant PCO₂ and V_E .  Respir Physiol. 2000;  122 (1) 45-60
• 36 Campbell E JM, Gandevia S C, Killian K J, Mahutte C K, Rigg J R. Changes in the perception of inspiratory resistive loads during partial curarization.  J Physiol. 1980;  309 93-100
• 37 Price D D, Harkins S W. The affective-motivational dimension of pain: a two stage model.  Am Pain Soc J. 1992;  1 229-239
• 38 Banzett R B, Pedersen S H, Schwartzstein R M, Lansing R W. The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort.  Am J Respir Crit Care Med. 2008;  177 (12) 1384-1390
• 39 Gift A G. Psychologic and physiologic aspects of acute dyspnea in asthmatics.  Nurs Res. 1991;  40 (4) 196-199
• 40 Janson-Bjerklie S, Ruma S S, Stulbarg M, Carrieri V K. Predictors of dyspnea intensity in asthma.  Nurs Res. 1987;  36 (3) 179-183
• 41 Carrieri-Kohlman V, Donesky-Cuenco D, Park S K, Mackin L, Nguyen H Q, Paul S M. Additional evidence for the affective dimension of dyspnea in patients with COPD.  Res Nurs Health. 2010;  33 (1) 4-19
• 42 von Leupoldt A, Seemann N, Gugleva T, Dahme B. Attentional distraction reduces the affective but not the sensory dimension of perceived dyspnea.  Respir Med. 2007;  101 (4) 839-844
• 43 Dorman S, Byrne A, Edwards A. Which measurement scales should we use to measure breathlessness in palliative care? A systematic review.  Palliat Med. 2007;  21 (3) 177-191
• 44 Bausewein C, Booth S, Higginson I J. Measurement of dyspnoea in the clinical rather than the research setting.  Curr Opin Support Palliat Care. 2008;  2 (2) 95-99
• 45 Gift A G. Validation of a vertical visual analogue scale as a measure of clinical dyspnea.  Rehabil Nurs. 1989;  14 (6) 323-325
• 46 Mador M J, Kufel T J. Reproducibility of visual analog scale measurements of dyspnea in patients with chronic obstructive pulmonary disease.  Am Rev Respir Dis. 1992;  146 (1) 82-87
• 47 Lansing R W, Banzett R B. The use of psychophysical methods in the study of respiratory sensation. In:, Adams L, Guz A, eds. Respiratory Sensation. New York, NY: Marcel Dekker; 1996: 69-100
• 48 Borg G AV. A category scale with ratio properties for intermodal and interindividual comparisons. In:, Geisler H, Petzold P, eds. Psychophysical Judgement and the Process of Perception. Amsterdam, The Netherlands; 1982: 25-34
• 49 Lansing R W, Moosavi S H, Banzett R B. Measurement of dyspnea: word labeled visual analog scale vs. verbal ordinal scale.  Respir Physiol Neurobiol. 2003;  134 (2) 77-83
• 50 Jones P W, Baveystock C M, Littlejohns P. Relationships between general health measured with the sickness impact profile and respiratory symptoms, physiological measures, and mood in patients with chronic airflow limitation.  Am Rev Respir Dis. 1989;  140 (6) 1538-1543
• 51 Hodgev V, Kostianev S, Marinov B. University of Cincinnati Dyspnea Questionnaire for Evaluation of Dyspnoea during physical and speech activities in patients with chronic obstructive pulmonary disease: a validation analysis.  Clin Physiol Funct Imaging. 2003;  23 (5) 269-274
• 52 Guyatt G H, Berman L B, Townsend M, Pugsley S O, Chambers L W. A measure of quality of life for clinical trials in chronic lung disease.  Thorax. 1987;  42 (10) 773-778
• 53 Pitta F, Troosters T, Spruit M A, Decramer M, Gosselink R. Activity monitoring for assessment of physical activities in daily life in patients with chronic obstructive pulmonary disease.  Arch Phys Med Rehabil. 2005;  86 (10) 1979-1985
• 54 Sanders S H. Automated versus self-monitoring of “up-time” in chronic low-back pain patients: a comparative study.  Pain. 1983;  15 (4) 399-405
• 55 Shephard R J. Limits to the measurement of habitual physical activity by questionnaires.  Br J Sports Med. 2003;  37 (3) 197-206 discussion 206
• 56 White C S, Humm J H, Armstrong E D, Lundgren N P. Human tolerance to acute exposure to carbon dioxide. Report No. 1: Six per cent carbon dioxide in air and in oxygen.  J Aviat Med. 1952;  23 (5) 439-455
• 57 Otis A B, Clark R G. Ventilatory implications of phonation and phonatory implications for ventilation.  Ann N Y Acad Sci. 1968;  155 122-128
• 58 Bunn J C, Mead J. Control of ventilation during speech.  J Appl Physiol. 1971;  31 (6) 870-872
• 59 Phillipson E A, McClean P A, Sullivan C E, Zamel N. Interaction of metabolic and behavioral respiratory control during hypercapnia and speech.  Am Rev Respir Dis. 1978;  117 (5) 903-909
• 60 Doust J H, Patrick J M. The limitation of exercise ventilation during speech.  Respir Physiol. 1981;  46 (2) 137-147
• 61 Bailey E F, Hoit J D. Speaking and breathing in high respiratory drive.  J Speech Lang Hear Res. 2002;  45 (1) 89-99
• 62 Hoit J D, Lansing R W, Perona K E. Speaking-related dyspnea in healthy adults.  J Speech Lang Hear Res. 2007;  50 (2) 361-374
• 63 Loudon R G, Lee L, Holcomb B J. Volumes and breathing patterns during speech in healthy and asthmatic subjects.  J Speech Hear Res. 1988;  31 (2) 219-227
• 64 Lee L, Friesen M, Lambert I R, Loudon R G. Evaluation of dyspnea during physical and speech activities in patients with pulmonary diseases.  Chest. 1998;  113 (3) 625-632
• 65 Martin B J, Logemann J A, Shaker R, Dodds W J. Coordination between respiration and swallowing: respiratory phase relationships and temporal integration.  J Appl Physiol. 1994;  76 (2) 714-723
• 66 Nishino T, Yonezawa T, Honda Y. Effects of swallowing on the pattern of continuous respiration in human adults.  Am Rev Respir Dis. 1985;  132 (6) 1219-1222
• 67 Selley W G, Flack F C, Ellis R E, Brooks W A. Respiratory patterns associated with swallowing: Part 1. The normal adult pattern and changes with age.  Age Ageing. 1989;  18 (3) 168-172
• 68 Smith J, Wolkove N, Colacone A, Kreisman H. Coordination of eating, drinking and breathing in adults.  Chest. 1989;  96 (3) 578-582
• 69 Perlman A L, Ettema S L, Barkmeier J. Respiratory and acoustic signals associated with bolus passage during swallowing.  Dysphagia. 2000;  15 (2) 89-94
• 70 Preiksaitis H G, Mills C A. Coordination of breathing and swallowing: effects of bolus consistency and presentation in normal adults.  J Appl Physiol. 1996;  81 (4) 1707-1714
• 71 Klahn M S, Perlman A L. Temporal and durational patterns associating respiration and swallowing.  Dysphagia. 1999;  14 (3) 131-138
• 72 Palmer J B, Hiiemae K M. Eating and breathing: interactions between respiration and feeding on solid food.  Dysphagia. 2003;  18 (3) 169-178
• 73 Martin-Harris B, Brodsky M B, Price C C, Michel Y, Walters B. Temporal coordination of pharyngeal and laryngeal dynamics with breathing during swallowing: single liquid swallows.  J Appl Physiol. 2003;  94 (5) 1735-1743
• 74 Martin-Harris B, Brodsky M B, Michel Y, Ford C L, Walters B, Heffner J. Breathing and swallowing dynamics across the adult lifespan.  Arch Otolaryngol Head Neck Surg. 2005;  131 (9) 762-770
• 75 Leslie P, Drinnan M J, Ford G A, Wilson J A. Swallow respiratory patterns and aging: presbyphagia or dysphagia?.  J Gerontol A Biol Sci Med Sci. 2005;  60 (3) 391-395
• 76 Dozier T S, Brodsky M B, Michel Y, Walters Jr BC, Martin-Harris B. Coordination of swallowing and respiration in normal sequential cup swallows.  Laryngoscope. 2006;  116 (8) 1489-1493
• 77 Lederle A, Hoit J D, Barkmeier-Kraemer J M. Effects of sequential drinking tasks on breathing and dyspnea. Paper presented at: American Speech-Language-Hearing Association Convention; November, 2009; New Orleans, LA
• 78 Gross R D, Atwood Jr CW, Ross S B, Olszewski J W, Eichhorn K A. The coordination of breathing and swallowing in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2009;  179 (7) 559-565
• 79 Good-Fratturelli M D, Curlee R F, Holle J L. Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic swallow examination.  J Commun Disord. 2000;  33 (2) 93-110