Emergency. 2017; 5 (1): e62 OR I G I N A L RE S E A RC H Relationship between Dyspnea Descriptors and Underly- ing Causes of the Symptom; a Cross-sectional Study Seyyed Mohammad Ali Sajadi1, Alireza Majidi2, Fahimeh Abdollahimajd3∗, Fatemeh jalali1 1. Department of Internal Medicine, Ali-Ebne-Abitaleb Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. 2. Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: August 2016; Accepted: March 2017; Published online: 19 March 2017 Abstract: Introduction: History taking and physical examination help clinicians identify the patient’s problem and effec- tively treat it. This study aimed to evaluate the descriptors of dyspnea in patients presenting to emergency de- partment (ED) with asthma, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Methods: This cross-sectional study was conducted on all patients presenting to ED with chief complaint of dys- pnea, during 2 years. The patients were asked to describe their dyspnea by choosing three items from the valid and reliable questionnaire or articulating their sensation. The relationship between dyspnea descriptors and underlying cause of symptom was evaluated using SPSS version 16. Results: 312 patients with the mean age of 60.96±17.01 years were evaluated (53.2% male). Most of the patients were > 65 years old (48.7%) and had basic level of education (76.9%). “My breath doesn’t go out all the way” with 83.1%, “My chest feels tight” with 45.8%, and “I feel that my airway is obstructed” with 40.7%, were the most frequent dyspnea descriptors in asthma pa- tients. “My breathing requires work” with 46.3%, “I feel that I am suffocating” with 31.5%, and "My breath doesn’t go out all the way" with 29.6%, were the most frequent dyspnea descriptors in COPD patients. “My breathing is heavy” with 74.4%, "A hunger for more air” with 24.4%, and “I cannot get enough air” with 23.2%, were the most frequent dyspnea descriptors in CHF patients. Except for “My breath does not go in all the way”, there was significant correlation between studied dyspnea descriptors and underlying disease (p = 0.001 for all analyses). Conclusion: It seems that dyspnea descriptors along with other findings from history and physical examina- tion could be helpful in differentiating the causes of the symptom in patients presenting to ED suffering from dyspnea. Keywords: Dyspnea; asthma; pulmonary disease, chronic obstructive; heart failure; symptom assessment © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Sajadi SMA, Majidi A, Abdollahimajd F, jalali F. Relationship between Dyspnea Descriptors and Underlying Causes of the Symptom; a Cross-sectional Study. Emergency. 2017; 5(1): e62. 1. Introduction H istory taking and physical examination help clin- icians detect the patient’s problem and effectively treat it. Dyspnea is a subjective perception of diffi- culty breathing, commonly seen in patients with respiratory and cardiovascular diseases. Healthy subjects may also experience it in intense emotional states and during heavy exercise (1-3). ∗Corresponding Author: Fahimeh Abdollahimajd; Skin Research Center, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Email: fabdollahi- majd@yahoo.com, Tell: 0989132914340, Fax: 098-21-22744393 Dyspnea is a multidimensional expression, which has been investigated extensively in clinical and psychological set- tings. Usually, it is identified as being unable to take a satisfying deep inspiration; moreover, it is characterized as difficulty breathing, which is described by air hunger and an uneasy awareness of breathing at rest or on exertion (4, 5). As with pain, different terms used to describe the sensa- tion of dyspnea might indicate the underlying diseases (6). Previous studies have shown that descriptors are not only different among patients with different disorders but also in those with the same disease. For instance, to describe breathlessness, patients with asthma, prefer terms as “My chest feels tight “and “I cannot get enough air in”, but pa- tients with interstitial lung disease choose the phrase “My This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com SMA. Sajadi et al. 2 breathing is rapid” (7-10). The language used to describe dyspnea may be valuable in identifying the cause of dyspnea and choosing the best treatment modality (10). However, lots of variables such as linguistic and cultural differences can affect the results (6). The present study aimed to evaluate the relationship between different descriptors of dyspnea and underlying cause of the symptom in patients presenting to emergency department (ED) suffering from dyspnea. 2. Methods 2.1. Study design and setting In this prospective cross-sectional study, all patients present- ing to ED of Ali-Ebne-Abitaleb Hospital, Rafsanjan, Iran, with chief complaint of dyspnea, during 2 years, were evaluated regarding the descriptors of dyspnea. The study protocol was approved by Ethical Committee of Rafsanjan University of Medical Sciences. The patients were informed about all as- pects of the research protocol and written informed consent was obtained from the patients. 2.2. Participants All patients aged 18 years and older presenting to ED of the mentioned hospital with chief complaint of dyspnea were enrolled using census sampling. Cases of communication disability (because of hearing problem, old age, illiteracy) and hemodynamic instability were excluded. Subjects were also excluded if an ultimate diagnosis other than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or asthma was reached. 2.3. Data gathering After initial assessment and emergency management, all pa- tients were fully examined and eligible patients were in- cluded. A prepared questionnaire containing baseline char- acteristics and descriptors of dyspnea was used for data gath- ering. The questionnaire used here has been described in a previously published study (11). The questionnaire was translated into Persian language by the researchers and was evaluated in a pilot study, interviewing 20 patients and 5 emergency physicians, to confirm its validity and reliability (Cronbach’s alpha for internal consistency = 0.86). To de- scribe dyspnea, two trained medical students asked patients to choose three items from the list. An open ended question was also included allowing patients to describe their sensa- tion if it was not represented in the questionnaire. The pa- tients were categorized into three groups of CHF, COPD, and asthma based on final diagnosis, which was made based on imaging, spirometry, and other diagnostic tests needed. Table 1: Baseline characteristics of studied patients Variable Number (%) Age (year) 18 - 30 16 (5.1) 30 - 45 36 (11.5) 45 -65 108 (34.6) ≥ 65 152 (48.7) Sex Male 166 (53.2) Female 146 (46.8) Level of education Basic 240 (76.9) High school 64 (20.5) University 8 (2.6) Final diagnosis COPD 108 (34.6) Asthma 118 (37.9) CHF 86 (27.6) CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease. 2.4. Statistical Analysis SPSS software version 16 was used for statistical analysis. Mean ± standard deviation or frequency and percentage were used for reporting the results. Chi square test was used to analyze relationships between different variables. Level of significance was 0.05 with a 95% confidence interval. 3. Results 312 patients with the mean age of 60.96±17.01 years (20 - 88) were evaluated (53.2% male). Table 1 shows the base- line characteristics of studied patients. Most of the patients were > 65 years old (48.7%) and had basic level of educa- tion (76.9%). The patients of all three groups (COPD, asthma, CHF) were similar regarding age, sex, and level of educa- tion (p > 0.05 for all analyses). "My breath doesn’t go out all the way" with 83.1%, “My chest feels tight” with 45.8%, and “I feel that my airway is obstructed” with 40.7%, were the most frequent dyspnea descriptors in asthma patients. “My breathing requires work” with 46.3%, “I feel that I am suffocating” with 31.5%, "My breath doesn’t go out all the way" with 29.6%, were the most frequent dyspnea descrip- tors in COPD patients. "My breathing is heavy" with 74.4%, “A hunger for more air” with 24.4%, and "I cannot get enough air" with 23.2%, were the most frequent dyspnea descriptors in CHF patients. Table 2 and 3 summarize the relation be- tween different dyspnea descriptors with final diagnosis and level of education, respectively. Apart from “My breath does not go in all the way”, there was a significant correlation be- tween studied dyspnea descriptors and final diagnosis (p = 0.001 for all analysis). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e62 Table 2: The relationship between different dyspnea descriptors and final diagnosis Descriptors Diagnosis n (%) P Asthma COPD CHF My breathing is shallow 0 (0) 0 (0) 0 (0) - I feel an urge to breathe More 0 (0) 22 (20.4) 16 (18.6) 0.001 My chest is constricted 2 (1.7) 24 (22.2) 16 (18.6) 0.001 My breathing requires effort 2 (1.7) 22 (20.4) 6 (7) 0.001 I feel a hunger for more air 4 (3.4) 0 (0) 21 (24.4) 0.001 I feel out of breath 4 (3.4) 4 (3.7) 14 (16.3) 0.001 I cannot get enough air 0 (0) 0 (0) 20 (23.3) 0.001 My breath does not go in all the way 4 (3.4) 2 (1.9) 4 (4.7) 0.540 My chest feels tight 54 (45.8) 2 (1.9) 0 (0) 0.001 My breathing requires work 20 (16.9) 50 (46.3) 2 (2.3) 0.001 I feel that I am suffocat- ing/smothering 40 (33.9) 34 (31.5) 12 (14) 0.004 I feel that I cannot get a deep breath 2 (1.7) 12 (11.1) 0 (0) 0.001 I feel that I am breathing more 0 (0) 2 (1.9) 8 (9.3) 0.001 My breath does not go out all the way 98 (83.1) 32 (29.6) 6 (7) 0.001 My breathing is heavy 4 (3.4) 2 (1.9) 64 (74.4) 0.001 I feel that my airway is ob- structed 48 (40.7) 4 (3.7) 2 (2.3) 0.001 CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease. Table 3: The relationship between different dyspnea descriptors and level of education Descriptors Level of education n (%) P Basic High school University My breathing is shallow 0 (0) 0 (0) 0 (0) - I feel an urge to breathe More 34 (14.2) 4 (6.2) 0 (0) 0.129 My chest is constricted 42 (17.5) 0 (0) 0 (0) 0.001 My breathing requires effort 24 (10.0) 6 (9.4) 0 (0.0) 0.639 I feel a hunger for more air 25 (10.4) 0 (0) 0 (0) 0.017 I feel out of breath 16 (6.7) 6 (9.4) 0 (0) 0.552 I cannot get enough air 16 (6.7) 4 (6.2) 0 (0) 0.749 My breath does not go in all the way 8 (3.3) 2 (3.1) 0 (0) 0.870 My chest feels tight 30 (12.5) 22 (34.4) 4 (50.0) <0.001 My breathing requires work 50 (20.8) 20 (31.2) 2 (25.0) 0.212 I feel that I am suffocat- ing/smothering 66 (27.5) 16 (25.0) 4 (50.0) 0.328 I feel that I cannot get a deep breath 12 (5.0) 2 (3.1) 0 (0) 0.670 I feel that I am breathing more 10 (4.2) 0 (0) 0 (0) 0.212 My breath does not go out all the way 86 (35.8) 42 (65.6) 8 (100.0) <0.001 My breathing is heavy 66 (27.5) 4 (6.3) 0 (0) <0.001 I feel that my airway is ob- structed 24 (10) 24 (37.5) 6 (75.0) <0.001 4. Discussion Based on the findings of the present study, patients prefer to use a variety of terminology to describe their sense of dysp- nea. There was a significant relationship between the used terms and underlying cause of dyspnea and level of educa- tion. "My breath doesn’t go out all the way”, “my breathing This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com SMA. Sajadi et al. 4 requires work” , and “my breathing is heavy”, were the most frequent phrases used by asthma, COPD, and CHF patients, respectively, for description of their respiratory problem. The leading aim of understanding a patient’s dyspnea language is better diagnosis of underlying diseases and consequently in- creasing therapeutic efficacy. Different qualities of dyspnea sensation can point to prominent afferent mechanisms un- derlying clinical dyspnea making differential diagnosis easier and potentially advocate the best symptomatic therapy. More precise definition of symptoms in patients with short- ness of breath has been looked into by researchers in the past. In a study, Williams et al. remarked that when the descrip- tors were not restricted to a single best word or phrase, indi- viduals’ description of feeling breathless could differentiate people with and without a previous diagnosis of COPD (8). Several studies have shown that dyspnea perception among people is related to diverse etiologies including physiological, psychological, and racial causes and etc. (12-15). Some re- ports have stated that race, sex, educational level and socioe- conomic class influence the perception of dyspnea (12-15). Barbaro et al. in a study designated that advanced age, air- way inflammation, depression status, and severity of asthma affect perception of dyspnea (16). The relationship between dyspnea descriptors and cause of symptom was strongly significant in the present study. In the study conducted by Mahler et al, the majority of patients with COPD applied work/effort descriptors such as “my breathing requires effort”; on the other hand, “I feel air hunger” had a lower prevalence in these patients (17). In addition, Chang et al. showed that the patients with asthma preferred “My chest feels tight” and mostly “Work/effort” descriptors were cho- sen by patients with COPD (18). In line with our findings, Rutgers et al. showed consider- able differences in dyspnea perception between COPD and asthma (19). Caroci et al. noted that stable COPD and CHF patients prefer different terms to describe their breathing distress, however, they showed that they may use some sim- ilar terms (20). It seems that dyspnea descriptors along with other findings from history and physical examination could be helpful in differentiating the causes of the symptom in pa- tients presenting to ED suffering from dyspnea. 5. Limitation The main limitation of our study was its relatively small sam- ple size, also this study was conducted in a local region of Iran and its external validity may be limited. Therefore, the results cannot be generalized to the whole of Iranian popu- lation. Hence, further investigations are recommended with larger series to validate the findings. 6. Conclusion Based on the findings of the present study, patients prefer to use a variety of terminology to describe their sense of dyspnea based on underlying cause of symptom and level of education. It seems that dyspnea descriptors along with other findings from history and physical examination could be helpful in differentiating the causes of the symptom in pa- tients presenting to ED suffering from dyspnea. 7. Appendix 7.1. Acknowledgements This article is based on the medical doctoral thesis of Dr. Fahimeh Abdollahimajd and Dr. Fatemeh Jalali in Rafsanjan University of Medical Sciences, Rafsanjan, Iran. The authors would like to thank Dr. Ali Tabatabaey (Department of Emer- gency Medicine, Qom University of Medical Sciences) for his critical comments. 7.2. Author contribution Seyyed Mohammad Ali Sajadi was the lead author and con- tributed in study design, data gathering and manuscript preparation. Alireza Majidi was involved in concept devel- opment and study design and was involved in manuscript development. Fahimeh Abdollahimajd was involved in data gathering, data analysis, interpretation, and manuscript preparation and revision. Fatemeh jalali was involved in data gathering and interpretation. 7.3. Funding/Support None. 7.4. Conflict of interest None. References 1. Mahler DA, Fierro-Carrion G, Baird JC. Evaluation of dyspnea in the elderly. 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