treatmentof dyspnea in copd* - semantic scholar · 2017-06-26 · ofeffort exertedto...

Treatment of Dyspnea in COPD*

A Controlled Clinical Trial of Dyspnea ManagementStrategies

Dawn E. Sassi-Dambron, BSN, RN; Elizabeth G. Eakin, BA;Andrew L. Ries, MD, MPH, FCCP; and Robert M. Kaplan, PhD

We conducted a randomized clinical trial to evaluate a

limited pulmonary rehabilitation program focused on

coping strategies for shortness of breath but withoutexercise training. Eighty-nine patients with COPD were

randomly assigned to either 6-week treatment or generalhealth education control groups. Treatment consisted ofinstruction and practice in techniques of progressivemuscle relaxation, breathing retraining, pacing, self-talk, and panic control. Tests of 6-min walk distance,quality of well-being, and psychological function as wellas six dyspnea measures were administered at baseline,posttreatment, and 6 months after the intervention.Baseline pulmonary function tests also were obtained.At the end of the 6-week treatment, there were no sig-nificant differences between the treatment and controlgroups on any outcome measure. At the 6-month follow-up, a significant group difference was seen on only one

variable, Mahler's transition dyspnea index. The results

COPD is a major health problem and leading cause

of morbidity and mortality in the United States.Dyspnea, one of the disabling symptoms of COPD, isan uncomfortable, subjective sensation of breathless-ness. It encompasses not only the perception ofbreathlessness, but also the individual's reaction tothe sensation.1 The mechanisms of dyspnea are notclearly understood, and there is no universal theorythat completely explains its physiologic basis.2

Pulmonary rehabilitation provides an importanttreatment option for patients with shortness of breathrelated to COPD.3 Comprehensive pulmonary reha-bilitation programs generally include components ofeducation, instruction in self-care techniques, exer-

cise training, and psychosocial group support. Such

*From the Division of Pulmonary and Critical Care Medicine(Ms. Sassi-Dambron and Dr. Ries) and the Department ofFamily and Preventive Medicine (Dr. Kaplan), University ofCalifornia, San Diego; and the University of California, SanDiego/San Diego State University Joint Doctoral Program inClinical Psychology (Ms. Eakin).This research was supported by grant 2RT0268 from the Uni-versity of California Tobacco Related Disease Research Programand grant R01 HL34732 from the National Heart, Lung & BloodInstitute.

Manuscript received October 4, 1993; revision accepted August17.Reprint requests: Dr. Sassi-Dambron, UCSD Medical Center,200 W. Arbor Drive, San Diego, CA 92103-8377

of this evaluation suggest that a treatment program ofdyspnea management strategies, without structured ex-

ercise training or other components of a comprehensivepulmonary rehabilitation program, is not sufficient toproduce significant improvement in dyspnea, exercisetolerance, health-related quality of well-being, anxiety,or depression. (Chest 1995; 107:724-29)

programs include but are not limited to symptom-control treatment strategies. Previous research stud-ies have focused on the effectiveness of comprehen-sive pulmonary rehabilitation or of individual strat-egies, but none has evaluated a specific multi-component program directed specifically at controlof dyspnea. Since dyspnea is the symptom mostassociated with dysfunction for patients with COPD,a reasonable hypothesis is that treatment of dyspneawill result in improved functional outcomes. Thepurpose of this study was to evaluate the effectivenessof a treatment program utilizing various copingstrategies for dyspnea management in patients withCOPD.

METHODSSubjects

Patients were recruited from local newspaper advertisements,community physicians and clinics, and the local Better BreathersClubs of the American Lung Association. We screened 497 per-

sons for the study. Criteria for participation in the randomizedclinical trial were (1) diagnosis of COPD, (2) patient's report thatshe or he felt limited in physical functioning secondary to dysp-nea, and (3) no participation in a pulmonary rehabilitation pro-

gram during the previous 2 years. An initial power analysis indi-cated that 84 subjects would be required in the clinical trial todetect a moderate treatment effect with power of 0.80 and an

alpha level of 0.05. Ninety-eight eligible subjects agreed to be

Treatment of Dyspnea in COPD (Sassi-Dambron et al)

ATS=American Thoracic Society; BDI=baseline dyspneaindex; Borg-Hx=Borg average rating for past week; Borg-6MW=Borg rating following 6-min walk; CESD=Centerfor Epidemiologic Studies' Depression; 6MW=6-min walk;OCD=oxygen cost diagram; PMR=progressive muscle re-laxation; QWB=quality of well-being; SOBQ=shortness ofbreath questionnaire; STAI=state-trait anxiety inventory;TDI=transition dyspnea index; VAS=visual analog scale;VAS-Hx=VAS average rating for past week; VAS-6MW=VAS following 6-min walk

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randomized into the clinical trial. An additional 45 subjectscompleted the baseline assessment but did not enter the treatmentstudy either because they were unable to commit the necessarytime or were not limited by self-reported dyspnea. We usedavailable medical records and pulmonary function test evidenceof expiratory obstruction to confirm the diagnosis of COPD in allsubjects. All subjects completed a baseline assessment in which mea-sures of dyspnea, function, and psychological status were obtained.

Study Groups

Study subjects were randomly assigned into either a treatmentor an education-control group.

Treatment Group: The treatment groups were facilitatedjointly by a graduate student in psychology and a clinical nursewith more than 9 years of experience working in the field of pul-monary rehabilitation. The intervention consisted of 6 weeklysessions during which various strategies for coping with shortnessof breath were presented. Class size varied between four and eightparticipants who completed the 6 weekly sessions together. Dur-ing the sessions, one or more of the following strategies was pre-sented followed by a question-and-answer period: pulmonaryanatomy and physiology; description of COPD; a dyspnea model;progressive muscle relaxation; diaphragmatic and pursed-lipbreathing; pacing and energy-saving techniques; self-talk andpanic control; and stress management. Subjects also practiced thestrategies at activity stations, which were set up to mimic variousactivities of daily living. The activity stations included showering,vacuuming, window washing, folding laundry, packing and un-packing groceries, and stair stepping.The topics covered included some general background infor-

mation about lung disease in addition to techniques specific todyspnea management. Topic outlines are described as follows:

(1) Pulmonary anatomy and physiology: A basic description ofthe respiratory system including the diaphragm and the mechan-ics of gas exchange utilizing visual material such as posters.

(2) Description of COPD: Discussion of the cause, pathophys-iology, diagnosis, symptoms and treatment of asthma, chronicbronchitis, and emphysema. Posters illustrating and comparingnormal and diseased anatomy were utilized.

(3) Dyspnea-function model: Discussion of the role of dyspneain functional limitations. Shortness of breath is associated withdiscomfort, frustration, and sometimes panic, which lead to agradual decrease in activities. This causes physical decondition-ing which increases the likelihood of dyspnea during exertion,leading to a vicious cycle of dyspnea and inactivity (Fig 1).

(4) Progressive muscle relaxation: Progressive muscle relax-ation (PMR) involves systematically tensing and relaxing specificmuscle groups with a goal of increasing awareness of the distinc-tion between muscle tension and relaxation;4 PMR was introducedduring the first session and practiced at each subsequent session.Patients were given cassette tapes to use during daily homepractice.

(5) Breathing techniques: A review of the anatomy of the res-piratory system, highlighting the location and function of the di-aphragm, was followed by instruction in diaphragmatic andpursed-lip breathing techniques. To reinforce the therapist's in-struction, the videotape, "Learning to Breathe Better." (Ency-clopedia Britannica, Training Edge, Palatine, Ill) also was uti-lized. A practice session followed, and patients were asked topractice daily during rest and exercise.

(6) Pacing and energy-saving techniques: Methods for energyconservation and work simplification were presented with em-phasis on planning, prioritizing, and pacing. Participants wereinstructed to coordinate breathing with activities. For example,patients were instructed to exhale during the strenuous part of anactivity and were reminded not to hold their breath when exert-ing.

DYSPNEA MODEL

DYSPNEA ON EXERTION

PHYSICAL

DECONDITIONING

DECREASE IN ACTIVITIES

DISCOMFORTFRUSTRATIONANXIETY/PANIC

TREATMEJT STRATEGIES

1) Education about COPD & Eys7pnea2) Relaxation

3) Breathing Techniques

4) Pacing & Energy Saving

5) Self-Talk & Panic Control

6) Stress Managemaent

FIGURE 1. Dyspnea model.

(7) Self-talk and panic control: Discussion of the role ofthoughts ie, self-talk, in managing panic associated with dyspnea.For example, when short of breath, thoughts such as, "I can'tbreathe. I'm going to die," exacerbate panic, while thoughts suchas, "I can handle this, I just need to sit quietly and use breathingtechniques," reduce panic and help to manage dyspnea.

(8) Stress management: Discussion of the role of stress andemotional factors in shortness of breath. Patients were encouragedto identify external and internal causes of stress and physiologi-cal and behavioral responses. A number of coping strategies werediscussed: controlling the situation, opening up to others, pacingoneself, regular exercise, and relaxation.

Control Group: The control group consisted of 6 weekly gen-eral health education lectures on topics not directly related to lungdisease. Lectures were presented by professionals specializing ineach subject without specific directions for behavior change ordyspnea management. The series included exercise, generalmedications, durable power of attorney, nutrition, Alzheimer'sdisease, and medical insurance.

Although group support was not planned formally in the studydesign, it occurred spontaneously in both the treatment and thecontrol groups. In the control group, the subjects talked togetherbefore and after each lecture, and a supportive environment de-veloped during the 6 weeks. In the treatment group, theresearchers facilitated the discussion periods which often becamesupport sessions, since strategies taught the prior week were re-viewed.

Outcome Measures

A 2-h assessment was obtained at baseline, after the 6-weekintervention, and 6 months later; it included measures of dyspnea,exercise tolerance, health-related quality of well-being, anxiety,and depression. The reliability and validity of the dyspnea mea-sures used in this study were evaluated in the assessment phase ofthe study and are described in detail elsewhere in another forth-coming study.

Dyspnea Measures

There is considerable disagreement about the appropriatemethodology for measuring dyspnea.5 In order to ensure that thisconstruct was adequately captured, we applied six differentmeasures of shortness of breath and four more general healthoutcome measures. Brief descriptions of these measures follow.

Baseline and Transition Dyspnea Indexes: Mahler and col-leagues6 developed a two-part (baseline and transition), inter-viewer-administered dyspnea index used to rate dyspnea accord-ing to three categories: functional impairment attributed to dys-pnea, magnitude of task that produces dyspnea, and magnitude

CHEST / 107 / 3 / MARCH, 1995 725


of effort exerted to produce dyspnea. The baseline dyspnea index(BDI) is used to rate the severity of dyspnea at a single point intime; the transition dyspnea index (TDI) is used to assess changesfrom that baseline.6American Thoracic Society Dyspnea Scale: The American

Thoracic Society (ATS) dyspnea scale is a self-reporting respira-tory questionnaire consisting of five yes-no questions which askwhether the respondent becomes breathless during various levelsof exertion. Based on the responses to these questions, the subject'sdyspnea is rated in terms of one of five grades of severity.7Oxygen Cost Diagram: The oxygen cost diagram (OCD) is a

10-cm line along which activities are written at intervals whichcorrespond to the metabolic equivalents (or oxygen cost) requiredto perform them. Patients are asked to make a mark on the lineindicating the point above which their breathlessness would notallow them to go. 8

University of California, San Diego, Shortness of BreathQuestionnaire: The shortness of breath questionnaire (SOBQ)was developed and has been used extensively in the PulmonaryRehabilitation Program at the University of California, San Di-ego.9 A modified version of the SOBQ was used in the currentstudy. The modification clarified and expanded the dyspnea rat-ing scale of the original instrument. The modified questionnaireasks patients to indicate how frequently they experience shortnessof breath on a 7-point scale (0 = never, 1 = sometimes, 2 = halfof the time, 3 = most of the time, 4 = all of the time, 5 = activ-ity given up due to dyspnea, NA = activity not performed, un-related to dyspnea) during 21 different activities of daily livingassociated with varying levels of exertion. Three additionalquestions about limitations due to shortness of breath, fear of harmfrom overexertion, and fear of shortness of breath are included fora total of 24 items.

Visual Analog Scale: The visual analog scale (VAS) is presentedto the subject as a 10-cm vertical or horizontal line, sometimesaccompanied by anchors, such as "not at all breathless" and "verybreathless."'-0 Subjects are instructed to place a mark on the lineindicating their level of breathlessness.Borg Scale of Perceived Dyspnea: The modified Borg scale is

a 0 to 10 rating scale (0 = none, 10 = severe) on which subjectsare asked to rate their level of breathlessness." Written descrip-tors are placed so that a doubling of the numerical rating corre-sponds to a twofold increase in sensation intensity. The originalBorg scale of perceived exertion ranged from 6 to 20, also withwritten descriptors, and was revised to give this essentially cate-gorical scale the properties of a ratio scale."2 The VAS and Borgscale were administered in two ways: (1) to obtain historical re-ports of patients' VAS and Borg average level of dyspnea duringthe past week, (VAS-Hx and Borg-Hx, respectively) and (2) toobtain VAS and Borg dyspnea ratings following a 6-min walk test(VAS-6MW and Borg-6MW, respectively).

General Measures

In addition to the dyspnea measures, four general measureswere included because dyspnea has been reported to correlatewith exercise endurance, general functioning, anxiety and de-pression. It was hypothesized that reductions in dyspnea wouldresult in improvements in these domains.

Exercise ToleranceThe 6-min walk (6MW) test is a standard measure of exercise

tolerance used with lung and cardiac disease populations.'3 Thetest was conducted in an area free from distractions withstandardized encouragement provided by the experimenter.Subjects were asked to cover as much ground as possible in 6 min.The walk test has been shown to be reliable,'4 with moderate corre-lations with tests of pulmonary function and exercise capacity.8 Weperformed two walks to compensate for possible learning effect for

repeat testing. Because of time constraints in the study protocol, thetwo walks were separated by 10 min of rest. Data from the longerof the two walks was used. Subjects rated their dyspnea using theBorg scale and VAS at the end of each walk.

Health-Related Quality of Well-Being

The quality of well-being (QWB) scale is a comprehensivemeasure of health-related qualitv of life that has been usedextensively in a variety of medical and health services researchstudies.'15'6 It includes components of mobility, physical activity,social activity, and symptomatic complaints. The observed levelof function and the subjective symptomatic complaint areweighted by general population preferences. Using this system, itis possible to place the general health status of any individual onthe continuum between death (0) and optimal functioning (1) forany point in time.

Anxiety

The Spielberger state-trait anxiety inventory (STAI) is aself-reporting measure of both state and trait anxiety that is usedwidely in research. The STAI contains 40 statements to whichsubjects respond using a 4-point rating scale indicating the extentto which the statements describe the way they feel (1 = not at allto 4 = very much so).

Depression

The Center for Epidemiologic Studies' Depression (CESD)scale is a general measure of depression that has been usedextensively in epidemiologic studies. The scale includes 20 itemsand taps dimensions of depressed mood, hopelessness, appetiteloss, sleep disturbance, and energy level. Scores on the CESDrange from 0 to 60, with scores greater than 15 generally consid-ered indicative of clinically significant levels of depressivesymptoms in adults. The CESD discriminates between clinicaland normal populations, and the reliability and validity have beenreplicated across various normal and clinical samples.

RESULTS

Of the 98 subjects randomly assigned to treatment(n = 47) and control (n = 51) groups, nine droppedout before treatment, one from the treatment andeight from the control group. Reasons for droppingincluded illness (treatment = 1, control = 1), timeconflict (control = 4), and lack of interest (control =3). To evaluate the possibility of differential loss, wecompared the pretreatment drops to the remaining89 subjects at baseline on the 12 outcome measuresusing t tests. A significant difference between the twogroups was seen on only one of the 12 variables. Thepretreatment drops had slightly higher dyspneareports on the VAS 6MW (mean for pretreatmentdrops = 7.0, mean for subjects in treatment = 5.8,p<0.05). The nine pretreatment drops were not fol-lowed up subsequently. Table 1 lists the characteris-tics of the 89 subjects who entered the clinical trial.An additional nine subjects dropped out during

treatment, five from the treatment and four from thecontrol group. We compared these subjects to the 80subjects completing the study on the same 12 out-come measures at baseline using t tests. The ninetreatment drops were different from those complet-

Treatment of Dyspnea in COPD (Sassi-Dambron et al)726


Table 1-Baseline Characteristics for 89 Subjects inClinical Trial (mean ± SD)*

GroupTreatment Control

No. 46 43Sex, M/F 26/20 23/20Age, yr 67.5 (8.0) 67.3 (8.0)FRC, % predicted 170 (31) 166 (34)RV, % predicted 206 (53) 199 (60)TLC, % predicted 138 (20) 135 (20)RV/TLC, % 59 9 58 12FVC, % predicted 73 (18) 75 (22)FEVI, L 1.1 (0.5) 1.2 (0.6)FEV1, % predicted 50 (21) 50 (23)FEF25-75%, L/s 0.5 (0.3) 0.5 (0.3)MIP, cm H20 65.9 (17.6) 65.8 (22.3)MEP, cm H20 132.5 (40.9) 131.8 (38.8)

*FRC=functional residual capacity; RV=residual volume; TLC=total lung capacity; FVC=forced vital capacity; FEF25-75% =meanforced expiratory flow during the middle half of the FVC; MIP=maximum inspiratory pressure; MEP=maximum expiratory pres-sure.

ing the study on only one variable, health-relatedQWB. Subjects who dropped out of the study duringtreatment had slightly lower QWB scores (mean fortreatment drops = 0.61, mean for subjects complet-ing study = 0.64, p<0.05). We attempted to followup these subjects at the posttreatment and 6-monthfollow-up periods and included them as part of thestudy database resulting in 46 subjects in the treat-ment group and 43 subjects in the control group.However, only one subject returned to complete the6-month follow-up examination.The t tests comparing the treatment and control

groups on 12 outcome measures at baseline revealedno significant differences between the two groups(Table 2).The primary analyses in this study evaluated

whether a treatment focused on dyspnea manage-ment strategies alone produced significant improve-ment on the 12 outcome measures. A 2X3 analysis ofvariance of condition (treatment, control) versus time(baseline, posttreatment, 6-month follow-up) withrepeated measures on the second factor was con-ducted on each outcome variable. Statistical analyseswere performed by BMDP Program 4V, droppingcases with missing values. Where appropriate, Green-house-Geisser adjusted degrees of freedom were usedto correct for departures from sphericity assumptionsof the variance-covariance matrix.The outcome measures evaluated include eight

dyspnea measures, exercise tolerance, quality of life,anxiety, depression, and two pulmonary functionparameters (FEV1 and forced vital capacity). Asshown in Table 2, there were no significant differ-ences between the treatment and control groups onany dependent variable, ie, there were no significant

group by time interactions or main effects of thegroup. There was a significant time main effect forone dependent variable, the SOBQ. Subjects in bothgroups showed a reduction in SOBQ dyspnea ratingsover time. At the 6-month follow-up, the treatmentgroup showed significant improvement on the TDI ascompared with the control group. Differences be-tween groups across time on the BDI and TDI wereevaluated by independent t tests rather than repeatedmeasures analysis of variance because changes fromthe baseline BDI are evaluated using a different in-strument, the TDI.

DISCUSSION

The purpose of this study was to evaluate the ef-fectiveness of a treatment program utilizing specificcoping strategies for dyspnea management in pa-tients with COPD. After the 6-week intervention,there were no significant group differences in dysp-nea, exercise tolerance, health-related quality ofwell-being, anxiety, or depression. A significant im-provement in dyspnea across both groups was seenonly in the SOBQ. At the 6-month follow-up, therewas a significant improvement in TDI in the treat-ment group in comparison with the control group.Given the number of statistical tests, we attributethese few differences to chance.

There are a number of possible explanations forwhy a treatment effect was not seen following thedyspnea management treatment program. First, ithas been suggested by Carrieri and Janson-Bjerkliethat patients living with a chronic illness developmany coping strategies and skills on their own.17Second, in comparing the content of this treatmentprogram to the components typically included inmost comprehensive pulmonary rehabilitation pro-grams, there are some notable differences. Theintervention evaluated in this study emphasized ed-ucation and individualized symptom (dyspnea) man-agement strategies alone. Comprehensive pulmonaryrehabilitation programs, in addition, include otherkey elements, such as exercise training, psychosocialsupport, and instruction in respiratory and chestphysiotherapy techniques. We taught diaphragmaticand pursed-lip breathing but not bronchial drainage,controlled coughing, or use of respiratory medica-tions. Comprehensive pulmonary rehabilitation hasbeen shown to be beneficial as a preventive healthmeasure and an effective adjunct to standard medi-cal therapy by reducing symptoms and increasingexercise tolerance and endurance.3,18'19 These pro-grams typically include all of the components of ed-ucation, individual instruction, group support, andexercise training. Without the advantage of specificexercise training, patients in this study were lesslikely to improve not only their dyspnea ratings, but

CHEST /107/3 / MARCH, 1995 727


Table 2-Repeated Measures Analysis of Variance on Outcome Measures*

F6-Month I I

Variable Baseline Posttreatment Follow-up Group Time G X T**

No.TreatmentControl

BDITreatmentControl

TDITreatmentControl

ATSTreatmentControl

OCDTreatmentControl

VAS-6MWTreatmentControl

Borg-6MWTreatmentControl

VAS-HxTreatmentControl

Borg-HxTreatmentControl

SOBQTreatmentControl

6MWTreatmentControl

QWBTreatmentControl

STAITreatmentControl

CESDTreatmentControl

4643

4037

3838

4.5 ±2.24.5 ±2.3

0.8 ±1.40.6± 1.8

2.4± 1.52.5 ±1.4

6.5± 1.46.0+±1.7

5.5 +2.95.5 ±2.4

4.1 ±2.74.6 ±2.0

4.3± 2.33.8 + 1.8

3.4± 1.12.9+ 1.1

38.6± 19.538.4+ 16.1

402.8 +75.3397.0+ 114.5

0.65 +0.070.63 ± 0.06

33.8 ± 9.734.1 ±9.5

14.2 ±10.211.9± 7.6

2.2± 1.42.2+ 1.7

6.6± 1.56.4± 1.5

4.9 ± 2.35.4+ 2.4

3.8±1.84.5 ± 2.1

3.8 ± 1.73.0+ 2.1

2.9+ 1.12.8± 1.3

36.6 ± 18.338.5 + 20.0

411.8+ 76.0395.5 + 108.2

0.66±+0.070.66 +0.10

32.2 +±9.933.4± 11.2

11.2± 8.612.8 + 9.4

1.0 ± 2.2t-0.2 ±2.4

2.1+±1.42.1+1.6

6.5 ±1.66.4± 1.8

4.9 ±2.45.0 ±2.2

3.8 + 1.74.3 +2.0

4.0 +2.63.3 ± 2.3

2.9+±1.82.7 ±1.6

31.8 ± 17.935.7+ 19.8

408.7 + 84.6384.4 + 130.3

0.65 + 0.070.64 ± 0.08

32.1 + 11.433.1 ± 11.8

12.5 + 8.813.0 + 10.1

0.0

1.0

0.2

1.7

2.8

0.9

0.2

0.5

0.3

0.2

0.0

2.6 0.2

1.2 0.6

2.3 0.5

1.5 0.1

2.2 0.1

2.2 0.6

5.ot 0.9

0.8 1.4

2.5 0.4

0.8 0.1

0.7 2.4

*All values are expressed as mean ± SD.**GXT=GroupXTime interactionfIndependent t test (treatment vs control) at 6-month follow-up; t=2.3; p<0.05.tProbability value less than 0.01.

also their exercise endurance as measured by the6 MW test. Unfortunately, this study was not de-signed to evaluate the exercise hypothesis. Futurestudies that systematically manipulate the inclusionof exercise are needed.The design of this study, and the relatively small

number of subjects did not allow us to individualizetreatment interventions. Program time was used toteach panic control to all experimental patients,whether or not they had documented panic prob-lems. It is possible that individualized programs may

be more effective, and we encourage future researchto evaluate these questions.One concern about the lack of a statistically

significant treatment effect in this study might beinsufficient power given the sample size. In the orig-inal power estimates, we reviewed previous studieson pulmonary rehabilitation and estimated that amoderate size treatment effect for changes in symp-toms and function would be feasible. This study maynot have had sufficient power to detect a smallertreatment effect. However, we do not believe that the

Treatment of Dyspnea in COPD (Sassi-Dambron et al)728


results, even if statistically significant, would suggestthat symptom change of this small magnitude wouldbe clinically meaningful. Also, there was little tosuggest even such small treatment trends in ourresults. Most of the F values for the interaction termswere less than 1.0, which is the level expected bychance in random data.The reasons for the significant improvement across

the entire group on the SOBQ and the differencebetween groups on the TDI at the 6-month follow-upare unclear. With multiple comparisons, these sig-nificant results may have been due to chance. How-ever, the difference in the TDI is of some interest.This measure is based on the patient's subjectiveevaluation of his or her own improvement and is opento several biases. It is possible that these biasesaccount for the change and may explain why patientsoften report improvements even though there is noother evidence of benefit.

In summary, the results of this evaluation suggestthat a treatment program focused solely on dyspneamanagement strategies, without structured exercisetraining or other components typically included in acomprehensive pulmonary rehabilitation program, isnot a powerful enough intervention to produce im-provement in dyspnea, exercise tolerance, health-re-lated QWB, anxiety, or depression in patients withCOPD. Therefore, dyspnea management may be anecessary but not sufficient component of pulmonaryrehabilitation programs.

REFERENCES1 Gift AG. Dyspnea. Nurs Clin N Am 1990; 24:955-642 Carrieri VK, Janson-Bjerklie S. The sensation of dyspnea: a re-

view. Heart Lung 1984; 13:436-473 Ries AL. Position paper of the American Association of

Cardiovascular and Pulmonary Rehabilitation: scientific basisof pulmonary rehabilitation. J Cardiopulmonary Rehab 1990;

10:418-414 Jacobson E. Progressive relaxation. 2nd ed. Chicago: University

of Chicago Press, 1938: 432-765 Eakin EG, Kaplan RM, Ries AL. Measurement of dyspnoea in

chronic obstructive pulmonary disease. Quality Life Res 1993;2: 181-91

6 Mahler DA, Weinberg DH, Wells CK, et al. The measurementof dyspnea: contents, interobserver agreement, and physiologiccorrelates of two new clinical indexes. Chest 1984; 85:751-58

7 American Thoracic Society. Recommended respiratory diseasequestionnaires for use with adults and children in epidemio-logical research. Am Rev Respir Dis 1978; 118:7-35

8 McGavin CR, Artvinli M, McHardy GJR. Dyspnoea, disability,and distance walked: comparison of estimates of exercise per-formance in respiratory disease. BMJ 1978; 2:241-43

9 Archibald CJ, Guidotti TL. Degree of objectivity measuredimpairment and perceived shortness of breath with activities ofdaily living in patients with chronic obstructive pulmonarydisease. Can J Rehab 1987; 1:45-54

10 Aitken RB. A growing edge of measurement of feelings. ProcR Soc Med 1969; 62:989-93

11 Borg G. Psychophysical bases of perceived exertion. Med SciSports Exer 1982; 14:377-81

12 Borg G. Perceived exertion as an indicator of somatic stress.Scand J Rehab Med 1970; 2:92-8

13 Guyatt GH, Thompson PJ, Berman LB, et al. How should wemeasure function in patients with chronic heart and lung dis-ease? J Chronic Dis 1985; 38:517-24

14 Mungall IPF, Hainsworth R. Assessment of respiratory functionin chronic obstructive airway disease. Thorax 1979; 34:254-58

15 Kaplan RM, Anderson JP. The general health policy model: anintegrated approach. In: Spiker B, ed. Quality of life assess-ments in clinical trials. New York: Raven Press, 1990; 131-49

16 Kaplan RM, Anderson JP. The quality of well-being scale: ra-tionale for a single quality of life index. In: Walker SR, RosserRM, eds. Quality of life: assessment and application. London:MTP Press, 1988; 51-77

17 Carrieri VK, Janson-Bjerklie S. Strategies patients use to man-age the sensation of dyspnea. West J Nurs Res 1986; 8:284-305

18 Hodgkin JE, Connors GL, Bell CW. Pulmonary rehabilitation:guidelines to success. 2nd ed. Philadelphia: JB Lippincott, 1985;1-14, 587-604

19 Lertzman MM, Cherniak RM. Rehabilitation of patients withchronic obstructive pulmonary disease. Am Rev Respir Dis1976; 114:1145-65

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