Dyspnea relief: More than just the perception of a decrease in dyspnea

https://doi.org/10.1016/j.resp.2009.04.001Get rights and content

Abstract

Like relief in general, relief of dyspnea is the fundamental quite familiar subjective experience associated with the offset of, or decrease in an unpleasant stimulus associated most frequently with an emotion of pleasantness. Dyspnea relief can be experienced in normal daily life, but most often, occurs during recovery from the large number of various diseases where dyspnea is frequently the predominant symptom. In the present paper, after a brief review of current knowledge of the mechanisms of action of currently available therapeutic interventions for dyspnea, I shall address more extensively the specificity of relief in the larger framework of psychological models relative to human perception and emotion. More specifically, I show that emerging, albeit preliminary results, including personal work, support the view that dyspnea relief is a specific sensori-emotional experience involving a characteristic central processing, and that it is more complex than the mere perception of a decrease in dyspnea.

Introduction

Dyspnea is a multidimensional subjective experience of breathing discomfort encompassing sensory, affective and cognitive dimensions. Furthermore, dyspnea is mostly associated with physiological but also behavioural changes, including avoiding or adaptive strategies. As dyspnea is phylogenetically a very ancient sensation, it has presumably provided evolutionary advantages. Indeed, by its unpleasant nature, dyspnea acts as a preventative alarm signal, or at least to minimize harm to the integrity of the body by preserving it from asphyxia. Thereby, dyspnea has, like pain, potentially life-saving properties. The most popular illustration of this fact is that absent or impaired dyspnea perception may lead to severe or even life-threatening asthma exacerbation (Barnes, 1994). Most frequently however, rather than providing any advantage, dyspnea turns out to be a very distressful, and most predominant symptom in a large variety of different diseases and thereby a major cause of suffering. It follows that relief of dyspnea is a crucial concern in clinical practice, which in turn has generated an important number of clinical studies assessing the way of action, but predominantly, the outcome, in terms of decrease in dyspnea scores, of all the numerous different therapeutic interventions for dyspnea management. Much less work has been done on dyspnea relief as such i.e. a specific and highly complex construct. Indeed, like relief in general, dyspnea relief encompasses two different components, predominantly, the perception of offset of, or at least decrease in its underlying inherent unpleasant physical or mental stimulus, but also a positive valenced emotion i.e. pleasantness or euphoria and thus the perception of an hedonic switch from unpleasant to pleasant. Moreover, unlike for pain, and more recently for dyspnea, virtually nothing is currently known about central integration and more specifically, potential consequences of dyspnea relief on behaviour.

All these different aspects of relief will be addressed in the present paper. In the first part, after a brief overview and comments concerning current knowledge of the mechanisms of action of presently available and recognized therapeutic interventions for dyspnea, I shall consider relief in the larger framework of psychological models relative to human perception and emotion and current results from imaging studies. More specifically, I support the view, in the light of emerging results from specific albeit preliminary studies including personal work, that relief is a specific sensori-emotional experience, which basically is more complex than the mere perception of a decrease in dyspnea and that it involves characteristic neural substrates.

Section snippets

Dyspnea relief in the clinical context

In the first part of this section, I shall review the numerous and obvious reasons why dyspnea is a major concern, and its management an important challenge in clinical practice. In the second part, I present an integrative overview of the general mechanisms of action and impacts of current treatment strategies for dyspnea rather than to detail each of them. Indeed, both traditional and alternative interventions for dyspnea, especially regarding COPD, have been thoroughly addressed in several

General considerations about relief

Relief, basically the perception of offset of, or at least decrease in, noxious and/or unpleasant physical or mental stimuli, is a fundamental quite familiar subjective experience since it may be experienced in a large variety of different situations such as pain, moral or mental suffering, escape from danger or threat, thirst, hunger, heat or cold, and of course dyspnea. Regarding dyspnea, besides its predominant occurrence in the clinical context, relief can be easily experienced in normal

Concluding remarks

Much work remains to be done towards a more complete understanding of dyspnea relief, which given the burden of dyspnea, is before all, a major clinical concern. Yet, at the present state, new conceptual frameworks and recent, albeit preliminary results of current research suggest that dyspnea relief, despite its inherent and absolute dependence on preceding dyspnea (without dyspnea, no relief), encompasses specificity, both in terms sensori-emotional experience and neural substrates.

References (55)

  • M. Williams et al.

    The language of breathlessness differentiates between patients with COPD and age-matched adults

    Chest

    (2008)
  • F. Willoch et al.

    PET activation study. Analgesia by electrostimulation of the trigeminal ganglion in patients with trigeminopathic pain: a PET activation study

    Pain

    (2003)
  • American Thoracic Society

    Dyspnea: mechanisms, assessment, and management. A consensus statement

    Am. J. Respir. Crit. Care Med.

    (1999)
  • M.S. Angst et al.

    The relationship between the visual analog pain intensity and pain relief scale changes during analgesic drug studies in chronic pain patients

    Anesthesiology

    (1999)
  • R.B. Banzett et al.

    Breathlessness in humans activates insular cortex

    Neuroreport

    (2000)
  • P.J. Barnes

    Blunted perception and death from asthma

    N. Engl. J. Med.

    (1994)
  • U. Bingel et al.

    Imaging pain modulation in health and disease

    Curr. Opin. Neurol.

    (2007)
  • V. Bonnardel et al.

    Color vision in the comb frequency domain

    Biol. Res.

    (2003)
  • M. Cabanac

    Physiological role of pleasure

    Science

    (1971)
  • L. Carpenter et al.

    Respiratory symptoms as predictors of 27 year mortality in a representative sample of British adults

    Br. Med. J.

    (1989)
  • V. Carrieri-Kohlman

    Coping and self-management strategies for dyspnea

  • D.R. Corfield et al.

    Evidence for limbic system activation during CO2-stimulated breathing in man

    J. Physiol.

    (1995)
  • A.D. Craig

    A new view of pain as a homeostatic emotion

    Trends Neurosci.

    (2003)
  • Cuervo Pinna, M.A., Mota Vargas, R., Redondo Moralo, M.J., Sanchez Correas, M.A., Pera Blanco, G., 2008. Dyspnea—a bad...
  • M.W. Elliott et al.

    The language of breathlessness: use by patients of verbal descriptors

    Am. Rev. Respir. Dis.

    (1991)
  • K.C. Evans et al.

    BOLD fMRI identifies limbic, paralimbic, and cerebellar activation during air hunger

    J. Neurophysiol.

    (2002)
  • F.E. Gyulai et al.

    In vivo imaging of human limbic responses to nitrous oxide inhalation

    Anesth. Analg.

    (1996)
  • Cited by (13)

    View all citing articles on Scopus
    View full text