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Prospective Observation of Air Hunger in Severely Ill Patients

Walter Reed Army Medical Center, Washington, DC

PURPOSE: Air hunger near end-of-life is poorly studied. We performed a prospective survey of dyspnea in severely ill patients to expand our understanding of this problem.

METHODS: Consecutive admissions to general medicine and oncology at our tertiary care hospital were surveyed for severe illness using a tool to identify patients at high-risk for short term death. Patients who met screening criteria were asked if they had difficulty breathing. Patients with dyspnea who consented completed a questionnaire including modified Borg scale, American Thoracic Society (ATS) shortness of breath scale, and visual analog scale (VAS). Surveys were administered on day of admission and on the subsequent hospital day. Physician estimates were solicited on day of admission.

RESULTS: For 198 consecutive patients, mean age was 62 yrs (range 19-97 yrs). 78/198 (39%) met screening criteria and 60/78 were able to participate. 32/60 participants (53%) reported difficult breathing. Diagnoses of cardiac or pulmonary disease were more commonly associated with dyspnea than diagnosis of malignancy (p=0.035). On admission median Borg, VAS, and ATS scores were 4/10, 4/10, and 3/4 respectively. The three dyspnea scales all had statistically significant agreement. Borg and VAS had excellent agreement (Spearman’s r=0.80, p < 0.0005, n=32). Borg-ATS correlation was moderate (r=0.49, p=0.005), and ATS-VAS association was weak (r=0.35, p=0.051). Physician impression differed from patient scores by 3 points or more in Borg 11/32 (34%) and in VAS 16/32 (50%). On Day #2 Borg improved 2.6 points (p=0.007), VAS improved 3.6 points (p<0.0005), and ATS improved 2.6 points (p=0.008).

CONCLUSION: Dyspnea is common near end-of-life, involving approximately 50% of severely ill patients. Cardiac or pulmonary diagnoses are more likely associated with dyspnea than admission diagnosis of malignancy. Borg and VAS scales have the best agreement among dyspnea questionnaires used. Physicians estimated severity of dyspnea poorly.

CLINICAL IMPLICATIONS: Dyspnea is a prevalent symptom that deserves further study. Objective survey tools such as the Borg or VAS scales appear to be useful in the assessment of dyspnea near end-of-life.

DISCLOSURE: N.M. Shumway, None.