Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency

Objectives: Patients with chronic respiratory insufficiency suffer from advanced disease, but their overall symptom burden is poorly described. We evaluated the symptoms and screening of depression in subjects with chronic respiratory insufficiency by using the Edmonton symptom assessment system (ESAS). Methods: In this retrospective study, 226 subjects with chronic respiratory insufficiency answered the ESAS questionnaire measuring symptoms on a scale from 0 (no symptoms) to 10 (worst possible symptom), and the depression scale (DEPS) questionnaire, in which the cut-off point for depressive symptoms is 9. Results: The most severe symptoms measured with ESAS (median [interquartile range]) were shortness of breath 4.0 (1.0-7.0), dry mouth 3.0 (1.0-7.0), tiredness 3.0 (1.0-6.0), and pain on movement 3.0 (0.0-6.0). Subjects with a chronic obstructive pulmonary disease as a cause for chronic respiratory insufficiency had significantly higher scores for shortness of breath, dry mouth, and loss of appetite compared to others. Subjects with DEPS ≥9 reported significantly higher symptom scores in all ESAS categories than subjects with DEPS <9. The area under the receiver operating characteristic curve for ESAS depression score predicting DEPS ≥9 was 0.840 ( P < .001). If the ESAS depression score was 0, there was an 89% probability of the DEPS being <9, and if the ESAS depression score was ≥4, there was an 89% probability of the DEPS being ≥9. The relation between ESAS depression score and DEPS was independent of subjects’ characteristics and other ESAS items. Conclusions: Subjects with chronic respiratory insufficiency suffer from a high symptom burden due to their advanced disease. The severity of symptoms increases with depression and 4 or more points in the depression question of ESAS should lead to a closer diagnostic evaluation of depression. Symptom-centered palliative care including psychosocial aspects should be early integrated into the treatment of respiratory insufficiency.

Validation of the Arabic Severe Respiratory Insufficiency Questionnaire

Background/objectives Assessment of Health-Related Quality of Life (HRQL) in patients with chronic respiratory insufficiency requiring Home Mechanical Ventilation (HMV) requires a valid measurement tool. The Severe Respiratory Insufficiency (SRI) questionnaire, originally developed in German, has been translated into different languages and tested in different contexts, but has so far not been in use in Arabic-speaking populations. The objective of this study is to validate the Arabic version of the SRI questionnaire in a sample of Arabic-speaking patients from Lebanon. Methods Following forward/backward translations, the finalized Arabic version was administered to 149 patients (53 males–96 females, age 69.80 ± 10 years) receiving HMV. Patients were recruited from outpatient clinics and visited at home. The Arabic SRI and the 36-Item Short-Form Health Survey (SF-36) were administered, in addition to questions on sociodemographics and medical history. Exploratory Factor Analysis (EFA) was used to explore dimensionality; internal consistency reliability of the unidimensional scale and its subscales was assessed using Cronbach’s alpha. External nomological validity was examined by assessing the correlation between the SRI and SF-36 scores. Results The 49-item Arabic SRI scale showed a high internal consistency reliability (Cronbach alpha for the total scale was 0.897 and ranged between 0.73 and 0.87 for all subscales). Correlations between the SF-36-Mental Health Component MHC and SF-36-Physical Health Component with SRI-Summary Scale were 0.57 and 0.66, respectively, with higher correlations observed between the SF-36 and specific sub-scales such as the Physical Functioning and the Social Functioning subscales [r = 0.81 and r = 0.74 (P < 0.01), respectively]. Conclusion and recommendations The Arabic SRI is a reliable and valid tool for assessing HRQL in patients with chronic respiratory insufficiency receiving home mechanical ventilation.

Endobronchial Mucoepidermoid Carcinoma in a child

Endobronchial mucoepidermoid tumors are rare neoplasms but most cases are reported in children. Due to nonspecific symptoms, diagnosis can be challenging, but early diagnosis and treatment are crucial for prognosis. We present the case of a boy, with chronic respiratory insufficiency due to bronchiolitis obliterans, that presented worsening exertional dyspnea at 12 years. Spirometry showed a frank deterioration of respiratory function and CT scan revealed an obstructive polypoid mass in the intermediate bronchus. Given the severe basal ventilatory compromise and risk associated with surgical treatment, rigid bronchoscopy and laser excision, and photocoagulation were performed, with clinical and functional improvement. The histological examination revealed a low-grade mucoepidermoid carcinoma. The option for a minimally invasive procedure requires careful follow-up due to the risk of tumor recurrence.

Psychometric properties of the Arabic-validated Severe Respiratory Insufficiency Questionnaire for the assessment of Health-Related Quality of Life in patients on home mechanical ventilation

Background/objectives:Assessment of Health-Related Quality of Life (HRQL) in patients with chronic respiratory insufficiency requiring Home Mechanical Ventilation (HMV) needs a valid measurement tool. The Severe Respiratory Insufficiency (SRI) questionnaire, originally developed in German, has been translated into different languages and tested in different contexts, except in Arabic-speaking populations of Arab world. The objective of this study is to validate the Arabic version of the SRI questionnaire from its original German version.Methods:Forward/backward translations between German and Arabic were conducted. The final Arabic version was administered to 149 patients (53 males - 96 females, age 69.8±10 years) receiving HMV recruited from outpatient clinics. Patients were scheduled for a home visit during which the Arabic SRI and the 36-Item Short-Form Health Survey (SF-36) questionnaires were administered; data on sociodemographic and medical history were also collected. Dimensionality internal construct validity were assessed using exploratory factor analysis; internal consistency of the unidimensional scale and its subscales was also assessed using Cronbach’s alpha. External nomological validity was tested by assessing correlation between the SRI and SF-36 questionnaires.Results:PCA scree plot indicated the presence of only one factor that explained 63% of the total variability. The Cronbach alpha for the total scale was 0.897 (ranged between 0.73 and 0.87 for all subscales). Correlation between the SRI and SF-36 was highest amongst comparable subscales yielding r=0.81 and r=0.74 (P < 0.01).Conclusion & Recommendations:The Arabic SRI is a reliable and valid tool for assessing HRQL in patients with chronic respiratory insufficiency receiving home mechanical ventilation.

Paediatric invasive long-term ventilation -- A ten-year review

Background and objective: The number of children with complex physical and developmental pathologies, including chronic respiratory insufficiency, surviving and growing beyond early childhood continues to rise. No study has examined the clinical pathway of children on invasive LTMV in an Irish setting. Our data over a 10-year period was reviewed to see if our demographics and outcomes are in line with global trends. Methods: Children’s Health Ireland (CHI) at Crumlin, Dublin is Ireland’s largest tertiary paediatric hospital. A retrospective review analysed data from children in our centre commenced on LTMV via a tracheostomy over 10 years (2009 – 2018). This data was subdivided into two epochs for statistical analysis of longitudinal trends. Results: Forty-six children were commenced on LTMV from 2009 to 2018. Many had complex medical diagnoses with associated co-morbidities. Far less children, 30.4% (n=14) commenced on LTMV in the latter half of the 10-year period, they also fared better in all aspects of their treatment course. Focusing solely on children who have needed LTMV over this timeframe has enabled us to isolate trends specific to this cohort. Less patients commenced LTMV on a year on year basis, and for those that require tracheostomy and LTMV, their journey to decannulation tends to be shorter. Conclusion: Over the period reviewed, less patients over time necessitated long-term invasive therapy and those patients are being weaned and decannulated with ever more success. This has implications in terms of predicting numbers transitioning to adult services and allocation of hospital and community care resources.

Dyspnea is associated with overall symptom burden in patients with chronic respiratory insufficiency

Objective Patients with chronic respiratory insufficiency suffer from many symptoms together with dyspnea. We evaluated the association of dyspnea with other symptoms in patients with chronic respiratory insufficiency due to chronic obstructive pulmonary disease or interstitial lung disease. Results This retrospective study included 101 patients. Dyspnea was assessed with modified Medical Research Council dyspnea questionnaire (mMRC) and other symptoms with Edmonton Symptom Assessment System (ESAS) and Depression Scale (DEPS). Patients with mMRC 4 (most severe dyspnea) compared to those with mMRC 0–3 reported higher median (IQR) symptom scores on ESAS in e.g. dry mouth (7.0 (4.0–8.0) vs. 3.0 (1.0–6.0), P < 0.001), tiredness (6.0 (3.0–7.0) vs. 3.0 (1.0–5.0), P < 0.001) and anxiety (3.0 (0.0-5.5) vs. 1.0 (0.0–3.0), P = 0.007). Patients with mMRC 4 were more likely to reach the DEPS threshold for depression compared to those with mMRC 0–3 (42.1% vs. 20.8%, P = 0.028). In conclusion, patients with chronic respiratory insufficiency need comprehensive symptom screening with relevant treatment, as they suffer from many severe symptoms worsening with increased dyspnea.